TRANSFUSION ALTERNATIVE HEALTH CARE
Meeting Patient Needs and Rights
Narrator: Each year in this new
millennium, pressures on health-care
systems mount. The growing number of
patients, particularly the elderly, challenges
health-care providers’ ability to meet
patient needs with available resources. At
the same time, legal and ethical voices
increasingly advocate that patients be
permitted a greater role in choosing their
treatment. These developments especially
affect one major sector of health care.
Dr. Aryeh Shander: These costs, which
are indirect and delayed, are enormous
and clearly would raise the cost of the unit
of blood substantially.
Narrator: The same holds true for
compensation totaling billions of euros or
dollars that have been paid to recipients of
tainted blood and to their surviving families.
As society faces these issues—transfusion
risks and costs—is there a better
approach? Might transfusion-alternative
health care meet patient needs and rights?
Prof. Neil Blumberg: There’s a growing
concern on the part of physicians that our
approach to blood transfusion needs to be
reevaluated.
Professors Earnshaw and Hetzer and
countless other clinicians have responded
to the requests of patients and of parents
of minors. Consider three examples of
complex surgeries performed without
transfusion. Open-heart surgery is
consistently a major challenge. In Berlin,
Professor Roland Hetzer explains why he
had to operate on the tiny heart of a tenmonth-old baby girl.
Prof. Roland Hetzer: Today at least 80
percent of the patients would strongly favor
not to have blood transfusions.
Narrator: News headlines show this, both
physicians and patients are faced with
transfusion complications, supply
shortages, and concerns about blood
product safety. As just one example, the
World Health Organization calculates that
around the globe unsafe transfusion and
injection practices cause some five million
Hepatitis-C virus infections each year.
Increased efforts by national health-care
systems to achieve a safer blood supply
have caused the cost of blood to spiral
upward.
Prof. Roland Hetzer: This child has a
congenital heart defect, which is relatively
rare. It means there is a direct
communication between the left ventricle
and the right atrium, which creates a
continuous abnormal flow between the left
heart and the right heart.
Narrator: The defect was corrected with a
heart arrest time of only 26 minutes, and
the blood flow normalized. No transfusion
was given—in fact, there was virtually no
blood loss. Another example: Liver surgery
usually involves considerable donor
transfusion. In Jena, Germany, at the
Dr. Guy Turner: Two years ago it cost us
about 63 euros per unit of transfused
blood. It now costs us 142.
Narrator: Treating transfusion-related side
effects has incurred additional costs.
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University Clinic, Professor Johannes
Scheele here removes the cancerous
portion of the liver from an elderly man.
approach is the growing evidence of
inconsistent practices leading to
unnecessary transfusions. Everyone
concerned with improving health care or
protecting the individual patient should
consider some revealing studies on blood
use. First, the Sanguis Study. As part of a
concerted action by the European
Commission Medical Research Program,
transfusion rates in 43 major teaching
hospitals across Europe were analyzed.
The ramifications of the Sanguis Study are
staggering—for the same type of operation,
there were enormous variations in the
number of units transfused, depending on
the hospital! In 1998 in Brussels, Professor
Baele published a follow-up study.
Prof. Johannes Scheele: How much was
the blood loss today? . . . 250 CCs.
Narrator: No donor blood was given, and
18 hours later, the patient is chatting with
the doctor in the ICU. Now an example of
orthopedic surgery: In London, Royal
College fellow Peter Earnshaw
successfully performs a total knee
replacement on an elderly woman, typically
a high-blood-loss operation. All three
successful operations were accomplished
by surgical teams committed to respecting
the patient’s or parent’s preference that
donor blood not be given. Were these
experimental operations by three
pioneering surgeons? There are more than
100,000 physicians and surgeons in 150
countries who routinely treat patients
without donor transfusion. Some experts
feel . . .
Prof. Philippe Baele: All types of hospitals
were included in the Belgium Biomed
Transfusion Study for Surgery. And we
found exactly the same range of variability.
Prof. Lawrence T. Goodnough: So we
are left with the conclusion that variability
implies that a lot of these blood transfusion
components are being given unnecessarily.
Dr. Linda Stehling: Every anesthesiologist
and surgeon should be interested in bloodconservation strategies because it’s good
patient care.
Narrator: A comparison of the two studies
revealed another significant fact.
Narrator: When physicians who turn to
transfusion-alternative health care are
asked why, they often cite as a major
reason—respect for their patient’s decision.
Professor Blumberg, director of a
transfusion medicine unit and blood bank:
Prof. Philippe Baele: There were two
centers which participated both in the
Sanguis Study and in the Biomed Study.
Prof. Neil Blumberg: Well, I think there
are a growing number of patients who are
interested in being treated with either no
transfusion or the minimum amount of
transfusion possible, and there are some
folks who strictly don’t want to be
transfused under any circumstances.
Prof. Philippe Baele: They had somehow
managed to reduce their blood
consumption for major surgery. The
mortality was the same before and after the
changes. The hospital stay was shorter.
The new procedures they adopted weren’t
very difficult to adopt, although they took
time and took a considerable educational
effort, but they didn’t result in increased
costs.
Narrator: Based on their findings in the
Sanguis Study:
Narrator: Another area motivating
physicians and surgeons to change their
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Prof. Neil Blumberg: We’ve estimated
that, approximately, in the United States,
we can expect that 10,000 to 50,000
patients a year may be dying from
transfusion-immunomodulation related
causes.
Narrator: Soon after, in Canada, Dr.
Hébert did a large-scale study of critically ill
patients in intensive care. Professor Spahn
evaluates the results.
Prof. Donat R. Spahn: I talk about the
Hébert paper, where they showed in more
than 800 patients that less transfusion
results in an improved outcome.
Narrator: Likely the most surprising and
least recognized medical risk is human
error—giving blood of an incompatible type
can cause a reaction ranging from mild to
fatal. Professor Spence, a director of
surgical education, acknowledges:
Narrator: The obvious conclusion is that
unnecessary transfusion translates into
unnecessary labor and unnecessary cost.
Besides patient demand and
overtransfusion, many physicians cite as
motivation to implement transfusionalternative health care the desire to avoid
medical risks.
Prof. Richard K. Spence: We can mix the
blood up and cause catastrophe. Patients
have died and do die from getting the
wrong blood.
Prof. Lawrence T. Goodnough: There’s
the risk of bacterial contamination in a
stored unit of blood.
Narrator: In fact, reports indicate that
human error causes up to one half of all
transfusion-triggered deaths! In the light of
such realities—patient decision,
unnecessary transfusions, medical risks,
as well as shrinking blood inventories and
soaring blood costs—Professor van der
Linden summarizes what many experts
have concluded:
Narrator: Bacterial contamination, whether
occurring at donation or subsequently from
improper storage, can cause infections
having fatal consequences. In another
arena, despite improved testing viral
infections continue to pose a serious
threat. Experts are concerned about what
the future holds.
Prof. Philippe van der Linden: In view of
the potential for a better patient-care and a
reduced health-care cost, blood
conservation is not an option, it’s a must.
Dr. Howard L. Zauder: Will existing
viruses mutate and produce disease?
There’s no reason to believe that they
won’t.
Narrator: The good news is that safe,
practical, and cost-effective therapies
already exist.
Prof. Peter H. Earnshaw: The problem
with contamination of transfusions, it
always seems to be one step ahead of us.
Dr. Aryeh Shander: The best medical care
can be delivered without the use of
allogeneic blood.
Prof. Donat R. Spahn: In addition, blood
transfusions induce a immunosuppressive
state with the recipient, and that results in
increased postoperative infections as well
as earlier and more often recurrence of
tumors.
Prof. Peter H. Earnshaw: There are some
very simple, very cheap things you can do,
which would help the majority of people,
and this could be done in the smallest of
hospitals.
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before administering a transfusion. Thus,
Professor Earnshaw notes his first step in
implementing a transfusion-alternative
program:
Prof. Johannes Scheele: Blood
conservation is a very simple method,
which make things rather smooth, less
expensive, and with a better outlook for the
patient.
Prof. Peter H. Earnshaw: I halved our
transfusion rate by simply saying, ‘could we
lower our triggers from 10 to 8?’ And just
taking a little more control over the
decision. That was very easy. That cost
nothing.
Narrator: The transfusion-alternative
techniques used by these surgical teams
can be grouped within one of three basic
principles, or pillars. The first is “tolerance
of anemia.” Racing through the arteries,
red cells carry life-sustaining oxygen to all
parts of the body. The anemic patient has a
low number of red cells in relation to his
blood volume. If a person suffers extensive
blood loss during surgery or as the result of
an accident, the body can tolerate anemia
to a considerable degree. Professor Moore,
an acknowledged pioneer in trauma
surgery:
Narrator: Simply implementing the first
pillar would cut out millions of transfusions
and save billions of euros or dollars
annually! The second important principle in
transfusion-alternative strategies involves
stimulating red-cell production in the
patient’s body. This is important for an
anemic patient before surgery, and it can
speed recovery after extensive blood loss.
Studies directed by Professor of Obstetrics
Albert Huch have shown:
Prof. Ernest E. Moore: Studies have
shown, physiologically, that the human
being can tolerate much lower hemoglobin
levels than previously assumed safe.
Prof. Albert Huch speaking German:
Sufficient iron supplementation can already
normalize the blood count to a large extent
and at relatively little expense.
Dr. Aryeh Shander: The medical
community is starting to realize that
tolerance of a significant anemia is doable
for patients.
Narrator: In selected cases, the genetically
engineered drug erythropoietin, commonly
called epo, can be used. Professor
Mercuriali, a director of transfusion
services, explains:
Narrator: However, anemia is tolerable
only when the body has sufficient
circulatory volume to continue to function.
Prof. Francesco Mercuriali: Stimulated by
the administration of erythropoietin, there is
an acceleration of production of new red
blood cells.
Prof. Richard K. Spence: We also know
that with that anemia, we can compensate
with volume, because volume is the critical
component here to maintaining blood
pressure.
Narrator: The third principle, or pillar, is to
minimize blood loss.
Narrator: With low-cost blood volume
expanders being available, current medical
opinion increasingly abandons the arbitrary
rule, proposed back in 1942, that a
hemoglobin level of 10 was the transfusion
trigger, or the lowest acceptable figure
Prof. Johannes Scheele: The most
important technique to control bleeding is
to avoid bleeding.
Narrator: Meticulous surgery is practical
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and cost-effective. A variety of tools can be
used to assist. For example, electrocautery
devices enable surgeons to cut rapidly and
to seal blood vessels immediately. There
are also modern drugs that can reduce
bleeding. Some are applied directly to the
bleeding area. Here a fibrin glue pad is
used to stop blood from oozing out of a
dissected liver. Professor Baron notes
about the cost-effectiveness of such
agents:
Once again, for the second procedure,
there were both skilled personnel and the
appropriate equipment, including a cellsalvage machine. The meticulous surgery,
utilizing electrocautery, took two hours, and
Luana lost only 100 milliliters of blood! Her
parents were delighted, and the medical
team was pleased with the outcome.
Prof. Carlo F. Marcelletti: We have
performed the operation without the use of
a blood transfusion, as we try to perform
with all of our children.
Prof. Jean-François Baron: The decrease
in the intraoperative bleeding and the
decrease in the use of blood products
compensates for the cost of the drug.
Dr. Nicoletta Salviato: I think all these
little babies deserve not to be transfused
and not to take the risk of a blood
transfusion.
Narrator: Another effective technique to
minimize loss in instances of heavy
bleeding is to salvage the patient’s own
blood. Recovery of as much as 50 percent
of the blood otherwise lost has become a
reality. This technique also meets the
ethical needs of many who absolutely
refuse donor transfusions. For instance,
some of Jehovah’s Witnesses have
allowed cell salvage to be used. There are
even such machines designed for small
children.
Narrator: Further proof of the effectiveness
of heart surgery without transfusion is
provided by Dr. Rosengart:
Dr. Todd K. Rosengart: When we looked
at a series of 50 Jehovah’s Witnesses
patients and 100 patients in the general
population, we found a shorter length of
stay and a lower cost using our bloodconservation strategy.
Prof. Donat R. Spahn: Cell salvage is a
very important technique because when
you use cell salvage, the blood lost by the
surgeon is not lost for the patient.
Narrator: While many clinicians would hold
that some situations absolutely require
blood, what is the view of those
experienced in the use of transfusion
alternatives in life-threatening
emergencies? First, an anesthesiologist’s
perspective:
Narrator: Many other beneficial strategies
are available. All assist in avoiding the risks
and societal costs of millions of
transfusions. To illustrate the impact of
properly combined techniques, consider
the task faced by the medical team of fouryear-old Luana in Modena, Italy. She was
born with a serious heart defect. Her team,
headed by Professor Marcelletti, chief of
cardiovascular surgery, had to perform a
series of complex operations. As requested
by Luana’s parents, the first operation was
successfully done without donor blood.
Dr. Aryeh Shander: The cessation of
bleeding, whether surgically or by other
means, must be the first principle. It’s
important to act quickly, and to keep in
mind that modalities are still available even
in a trauma situation.
Narrator: Next, a surgeon’s perspective:
Prof. Johannes Scheele: In any trauma
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patient with a significant blood loss, I would
always prepare the cell-saver system.
care honors the patient’s freedom of choice
to accept or reject a certain treatment.
Narrator: In one of the busiest trauma
centers in the United States, Professor
Cohn, chief of Trauma and Surgical Critical
Care, notes about patients declining donor
blood:
Prof. Neil Blumberg: One of the primary
principles of good medical care is being
concerned about what the patient wants.
Narrator: Professor Harding, who teaches
ethics to medical and law students:
Prof. Stephen M. Cohn: We see more
than 3,000 patients a year here that are
Jehovah’s Witnesses, and we do about
250 to 275 major operations on them each
year. And what we have seen in our
population is no increased length of stay,
no increased mortality. In fact, it appears to
be somewhat decreased.
Prof. Timothy W. Harding: Today one
would link that ethical duty not to do harm,
to seek the best possible outcome for one’s
patient, with another duty, which is to
respect the autonomy of the patient, to
respect the patient’s own views and
decisions.
Narrator: On the basis of such experience,
many physicians conclude that, overall,
transfusion-alternative health care is costeffective:
Narrator: At Glasgow University, Professor
of Law and Ethics in Medicine Sheila
McLean summarizes:
Prof. Sheila A. M. McLean: Doctors have
virtually an absolute obligation, both legally
and ethically, to respect the patient’s
choice.
Prof. Richard K. Spence: One of the
beauties of transfusion alternatives is that
the most effective alternatives are
generally the cheapest.
Narrator: Concerning the advancing legal
view generally designated “patient rights,”
Professor Guillod, founder of the Health
Law Institute at Neuchatel University:
Prof. Stephen G. Pollard: There’s no
doubt that blood is a costly product. We’ve
been able to reduce our blood-transfusion
bill for the liver-transplant program here by
70 percent since we started adopting new
techniques. And that equates to hundreds
of thousands of pounds in a year, and it’s
far more than the cost of the drugs and the
other therapies we use and the mechanical
methods we use for reducing blood loss.
Prof. Olivier Guillod: I believe the basic
element of patients’ rights is the right of
self-determination, that is, the right of any
patient to decide what shall be done with
his or her own body.
Prof. Sheila A. M. McLean: Patients have
a right to be told that there are alternatives
and, more than that there are alternatives,
what are the respective risks and benefits
expected to be associated with those.
Prof. Philippe Baele: It takes more
dedication than technical means. Similar
results can be achieved without the use of
costly machinery.
Narrator: And transfusion-alternative
health care has a benefit beyond saving
money and meeting patients’ physical
needs. There is an ethical benefit. This
Narrator: Concerning the evolution of
patient rights, Professor Weissauer
explains:
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Prof. Walther Weissauer speaking
German: Earlier, the doctor determined
how to proceed and thereby shouldered
the entire responsibility. In the course of
time, the relationship has changed more
and more into a partnership, doctor and
patient meeting each other with full equal
rights.
colleagues or to another institution or
health-care facility where this alternative is
really practiced.
Narrator: But what about emergencies
where the victim may not be able to speak,
to convey personal conviction?
Prof. Timothy W. Harding: It’s now
recognized that people have the right to
indicate treatment choices in advance. And
this takes the form of a written document
where the patient shows that they have
considered certain situations and they have
taken a clear position about a treatment
choice.
Narrator: Recognizing patient rights
accords with the UN’s universal declaration
of human rights. In fact, these legal issues
have become so important that in 1997 the
Council of Europe formulated the
Convention on Human Rights and
Biomedicine. Article 5 proclaims: “An
intervention . . . may only be carried out
after the person concerned has given free
and informed consent to it.”
Prof. Walther Weissauer speaking
German: In an emergency, one would
always also search for an advance
directive or a durable power of attorney, for
instance, in the wallet of the patient.
Prof. Olivier Guillod: The doctrine of
informed choice says that it is up to the
patient to accept or to refuse any kind of
medical act, for instance, a blood
transfusion.
Narrator: Respecting patient rights also
has health-care benefits.
Narrator: Addressing a sensitive issue,
Article 6 states: “The opinion of the minor
shall be taken into consideration as an
increasingly determining factor in
proportion to his or her age and degree of
maturity.”
Prof. Sheila A. M. McLean: There is
empirical evidence that patients who feel
engaged in their treatment are likely to get
better quicker.
Narrator: Consider, for example, a case at
St. Richard’s Hospital in Chichester in
southern England.
Prof. Timothy W. Harding: There’s no
doubt that minors, in a legal sense, can
and very often are able as adolescents to
take decisions about their own treatment
and their own health.
Dr. Vipul Patel: Mrs. Whittington had
arthritis of her hip, which was so advanced
that she required a total hip replacement.
She is a Jehovah’s Witness and therefore
declined to have a blood transfusion.
Narrator: How does freedom of choice for
patients and parents work out in practical
terms?
Mrs. Whittington: Well, I do believe that
God’s word is against taking blood, and we
should appreciate that God’s word is the
truth. Mr. Patel was quite happy to do it
without blood.
Prof. Olivier Guillod: Well, if the physician
cannot think of finding a way of
accommodating a patient’s desire about
alternatives to blood transfusion, he should
try to refer the patient to one of his
Dr. Guy Turner: It is the doctor’s
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responsibility to listen to patients’
demands, listen to what they have to say,
and give them an informed choice of
alternatives.
care uniquely meets both patient needs
and rights.
Dr. Vipul Patel: I can foresee that in the
future, patients will almost expect that any
surgery which is necessary is carried out
without blood transfusion.
Narrator: In frank dialogue between
physician and patient, the question of
whether she would accept cell salvage
arose:
Prof. Olivier Guillod: Patient
empowerment is important, not only to
better respect autonomy but to promote
good medical treatment.
Mrs. Whittington: When I knew more
about the machine and it was explained to
me, I said I would accept having the
machine.
Prof. Roland Hetzer: The various steps to
reduce the need of blood transfusion,
nowadays, are very well established, well
tested, and they are certainly safe.
Jo Light: The relationship between the
patients and the medical staff is excellent
here. We have a very open culture and a
good learning environment.
Dr. Aryeh Shander: This is universal, can
be practiced in any institution, in any part of
the world.
Narrator: What was the outcome of this
cooperative approach?
Prof. Philippe van der Linden: Blood
conservation is safe, effective, and
progressive medicine.
Dr. Vipul Patel: The strategies that we
used intraoperatively during Mrs.
Whittington’s operation were meticulous
hemostasis, salvage of blood using a cellsaver system, as well as using a cemented
hip replacement. She tells me that she is
delighted with the operation in terms of the
pain relief.
Dr. Aryeh Shander: This is the best way
of treating patients and clearly should be a
standard of care.
Narrator: As earth’s population continues
to grow and age, their medical needs will
be a greater challenge to health-care
structures, many of which are already
struggling. In this regard, transfusionalternative health care offers a promising
direction.
Prof. Philippe van der Linden: A welladopted blood-conservation program
means a decrease in the total cost for the
patient but also a decreased cost for
society.
Narrator: While all medical interventions
involve risks, transfusion-alternative health
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