250,000 Jehovah's Witnesses have died refusing blood

by nicolaou 739 Replies latest watchtower medical

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  Marvin Shilmer

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  “Why would they 'randomly' select patients from the segregated groups?”

  Simon,

  To achieve a 1-to-1 ratio for a matched comparison study.

  “If they were dealing with such low numbers why not include them all?”

  They included all they could and have and maintain a matched comparison.

  “All this does is increase the chance that if you repeated the study you'd get very different results.”

  Not at all for purposes of gaining a ratio of deaths per capita of JWs in New Zealand. Death’s per capita means only how many deaths for how many in a given population.

  In this case the study by Beliaev established a minimum value (number) of deaths among JWs for refusing blood during years 1998 to 2007.

  We have published statistics of JWs for New Zealand over the same period hence calculating the ratio of deaths due to refusing blood becomes simple arithmetic.

  The sole liberty I took in my presentation was to prorate the number of deaths based on population distribution compared with the sources Beliaev got his data.

  For purposes of learning the number of JWs who died for refusing blood during years 1998-2007 it would not matter whether Beliaev cherry-picked his comparison group because this would not change the number of deaths in the JW group for refusing blood, and it’s the number of deaths in the JW group used in my extrapolation.

  Marvin Shilmer
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  Marvin Shilmer

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  “I think, it might have been done to eliminate researchers' bias. By using random selection, reseachers would claim that every segregaed subject in that group had a chance to be selected without bias.”

  Scott77,

  That’s correct. Once the authors had identified all patient records of treating severe anemia, and once they’d segregated for the issue of study (red cell transfusion treatment or not) then in order to achieve a matched comparison they had no choice but to segregate the red cell transfusion group into subsets to match characteristics of the control group (the JWs) and then randomly select on this basis. But the last step to achieving the 1-to-1 ratio with the control group had to be randomized in order to reduce bias and otherwise satisfy statistical rigor.

  Marvin Shilmer
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  adamah

  Obvious guy asks an obvious question (and sorry if this has been asked before and answered, i.e. not ignored), but aren't your calculations used for extrapolation Worldwide assuming that ALL JWs with severe anemia will refuse blood transfusion? Surely not, right? That would hardly be conservative, since prior studies have shown a non-zero figure?

  BTW, I found this abstract which counters the claim (and there's many more that point out the increased risk of morbidity from complications resulting from overtreatment with blood transfusions):

  J Trauma. 2008 Jul;65(1):237-47. doi: 10.1097/TA.0b013e318176cc66.

  The contemporary approach to the care of Jehovah's witnesses.

  Hughes DB , Ullery BW , Barie PS .

  Source

  Department of Surgery, Division of Critical Care and Trauma, Weill Cornell Medical College, New York, New York, USA.

  Abstract

  BACKGROUND:

  Jehovah's Witnesses are widely known for their prohibition on the acceptance of blood transfusion. Such refusal serves as a potential obstacle to optimal therapeutic intervention among critically injured Jehovah's Witnesses. As such, care of these patients requires an aggressive and multidisciplinary approach to therapy.

  METHODS:

  A review of the pertinent English language literature.

  RESULTS:

  Jehovah's Witnesses exercise the right of any adult with capacity to refuse medical treatment and often carry advance directive cards indicating their incontrovertible refusal of blood. Despite their belief regarding transfusion, Jehovah's Witnesses do not have a higher mortality rate after traumatic injury or surgery. Transfusion requirements are often overestimated. Increased morbidity and mortality is rarely observed in patients with a hemoglobin concentration >7 g/dL, and the acute hemoglobin threshold for cardiovascular collapse may be as low as 3 g/dL to 5 g/dL. There are many modalities to treat the Jehovah's Witness patient with acute blood loss. Treatment with recombinant human erythropoietin, albumin, and recombinant activated Factor VIIa have all been used with success. Autologous autotransfusion and isovolemic hemodilution can also be used to treat patients who refuse transfusion. Hemoglobin-based oxygen carriers may play a future role as intravascular volume expanders in lieu of transfusion of red blood cell concentrates.

  CONCLUSION:

  There are many treatment modalities available to assist in the care of Jehovah's Witness patients, especially since their beliefs on the intricacies of the Blood Ban appear to be in flux.

  In other words, a combination of lifting the ban on some prior treatment methodologies, as well as advancements in medical science, seems to be working.

  So much like the old adage used in medicine, if you're going to treat the patient (i.e. make a wild-ass claim about elevated deaths from "no blood" to draw attention to the problem), you'd better do it quickly before the patient improves on his own so you can take some of the credit.

  Adam
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  adamah

  Oh, and another:

  Jehovah's Witnesses: unique problems in a unique trauma population.

  Victorino G , Wisner DH .

  Source

  Department of Surgery, University of California, Davis, Medical Center, Sacramento 95817-2282, USA.

  Abstract

  BACKGROUND:

  Jehovah's Witnesses can create perplexing treatment problems by their refusal of blood transfusions. This dilemma is especially difficult for the trauma surgeon faced with critically low hemoglobin levels or life-threatening blood loss in an injured Jehovah's Witness.

  STUDY DESIGN:

  Retrospective review of the records of 58 Jehovah's Witnesses admitted to a single trauma center between July 1992 and June 1995.

  RESULTS:

  There were 53 blunt and 5 penetrating injuries. Four patients (7 percent) received blood transfusions; one received banked blood and three received autotransfusions. Two patients were sedated and paralyzed to optimize oxygen utilization; one patient received erythropoietin. Eighteen patients had a general anesthetic and underwent an operative procedure; one underwent controlled hypotensive anesthesia with normovolemic hemodilution. The records of 21 patients (36 percent) included documentation of absolute refusal of blood or blood products; the exact status of consent for blood transfusion was not documented in the records of 33 patients (57 percent). One death and six complications occurred, none of which were attributed to acute blood loss or anemia. Treatment options and special techniques for the severely anemic patient refusing blood transfusions are discussed.

  CONCLUSIONS:

  Documentation of religious status and beliefs about blood transfusion, as well as knowledge of special treatment options available for anemic Jehovah's Witnesses, is necessary to provide quality care to this unique trauma population.

  Adam
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  Marvin Shilmer

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  “Obvious guy asks an obvious question (and sorry if this has been asked before and answered, i.e. not ignored), but aren't your calculations used for extrapolation Worldwide assuming that ALL JWs with severe anemia will refuse blood transfusion?”

  No.

  My extrapolation assumes JWs in the rest of the world refuse or accept blood transfusion as frequently or infrequently as do JWs in New Zealand.

  We know all JWs do not refuse blood transfusion. But this is beside the point when it comes to learning a ratio of deaths per capita based on Beliaev’s data set. To determine a minimum amount of deaths due to refusing blood we need only assume Beliaev’s data set represents all deaths of JWs in the 2 regions of New Zealand from which his data set was extracted.

  Once we have a minimum amount of deaths we need only compare that number with the number of JWs in the same region. Then we have a ratio of deaths against a known number of JWs.

  Marvin Shilmer
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  Marvin Shilmer

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  “In other words, a combination of lifting the ban on some prior treatment methodologies, as well as advancements in medical science, seems to be working.”

  The study conducted by Beliaev was mostly of years since “lifting the ban on some prior treatment methodologies” hence to apply the resulting ratio of deaths per capita to historical numbers of JWs (prior to lifting the ban on some prior treatment methodologies) is to keep the extrapolation conservative.

  Marvin Shilmer
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  LisaRose

  MARVIN: there are loads of hospitals in the same 2 regions as the 4 whose patient records are part of this study. We’d be naïve to think none of these other hospitals in the same 2 regions had JW patients with severe anemia refusing blood who died as a result. But to keep my extrapolation conservative, for statistical purposes I assumed no such deaths at any of these many other facilities in the 2 regions.

  LISA You say you are not asumming anything, but there you go. What if there were patients in the other hospitals that refused blood, but didn't die at the same rate? What if they didn't die by a higher ratio than the ones selected in the study? The purpose of the study was to get cost/benefit ratios, not determine mortality rates, so it may not be big enough to do that. I think that is what is making every one suspicious. Of course, I am not a statistician, so it's hard for me to say.

  MARVIN:,When I was constructing the per capita deaths of JWs in New Zealand due to refusing blood I assumed the only deaths in the 2 regions were the ones reported by Beliaev.

  Does that answer your question?

  LISA: Again with the assumptions. You say there are other hospitals in the region, so why couldn't they have had other severe anemia cases and other deaths?

  MARVIN: Oh, and by the way, I’m still not sure what your earlier statistic speaks to in terms of “severe anemia” but I did find the CDC report for deaths attributed to anemia in the United States and for year 2010 the adjusted number is 4,631 of a population of 308,745,538. This represents an annual mortality of 0.0014999%, which, based on the proration I used in my presentation is more than the annual mortality among New Zealanders by a factor of 170x. This makes my extrapolation conservative by comparison.

  LISA That is what makes me uncomfortable, it's hard to believe the US rates of Anemia are that much different than NZ, so again, are the numbers from the study useful in determining mortality in the US? The discrepancy indicates maybe not. So again you feel you are being conservative, but that doesnt make it better, or make up for the fact that the study may not be big enough to make a useful extrapolation.

  The study proved people with severe anemia who refuse blood die at a higher rate, but in my mind, it does not prove that all JWs with severe anemia who refuse blood will die at exactly that particular ratio as identified in the study.
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  Marvin Shilmer

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  “LISA You say you are not asumming anything, but there you go. What if there were patients in the other hospitals that refused blood, but didn't die at the same rate? What if they didn't die by a higher ratio than the ones selected in the study? The purpose of the study was to get cost/benefit ratios, not determine mortality rates, so it may not be big enough to do that. I think that is what is making every one suspicious. Of course, I am not a statistician, so it's hard for me to say.”

  LisaRose,

  In the Beliaev study we have hard numbers from 4 large facilities and there is a mix of trauma services (advanced, district and basic).

  From this mix of trauma centers we have over 3,000 patient records to populate the control group.

  It’s hard to believe this is not representative of minimal mortality among JWs with severe anemia refusing blood.

  Both groups had the same facilities and characteristics, with the sole exception that of refusing blood. We would not expect the comparative mortality statistics at other New Zealand facilities to be different than these because within each institution the healthcare capacity is equal for both those who accept and those who reject blood. If anything the institutional rate of mortality would worsen at lesser equipped hospitals among patients refusing blood because though most would have an ability to transfusion blood equal to larger facilities most would not have an ability to equally offer more exotic responses to anemia needed for patients who refuse blood transfusion.

  Marvin Shilmer
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  Marvin Shilmer

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  “That is what makes me uncomfortable, it's hard to believe the US rates of Anemia are that much different than NZ, so again, are the numbers from the study useful in determining mortality in the US?”

  LisaRose,

  I have no reason to think mortality statistics related to severe anemia is much different between the United States and New Zealand, and you have not provided anything suggesting this.

  You offered some numbers from the CDC. I asked for bibliographic information to consult these numbers to see if they can be directly compared with the statistics we’ve been discussing from the New Zealand study. You didn’t offer it so I could make no analysis.

  I did look up the CDC records for year 2010 for deaths attributed to anemia. Those statistics are not based on the same criterion used in the New Zealand study. Hence we cannot responsibly compare one with the other.

  The numbers we find in the New Zealand study are useful against populations in the United States assuming JWs in the United States accept or refuse blood transfusion at a rate similar to JWs in New Zealand.

  Marvin Shilmer
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  LisaRose

  Well, I am not going to argue with you any more, you just keep repeating the same things, and dismissing any other concerns. I don't have confidence in your numbers, but you won't or can't imagine you are not 100% correct, so there is no point in discussing it further.

  I do appreciate the effort you put into publicizing this issue, and I hope it does some good.