The right to refuse treatment is one of patient’s fundamental rights. A mother who is a Jehovah’s Witness will usually refuse blood transfusion, as this "has been doctrinally forbidden for Jehovah's Witnesses since 1945" (Sacks & Koppes, 1994). Although her right, this can produce moral distress for the nurse caring for the maternal-fetal dyad. Postpartum hemorrhage occurs in approximately 4-6% of deliveries (Dildy, 2002). When the mother has lost enough blood to require transfusion, most women, after informed consent, permit replacement through transfusion. When a woman refuses blood transfusion, the nurse should advocate for best practice through alternatives acceptable to a Jehovah’s Witness (Tovarelli & Valenti, 2005).

A 34 y/o G3 P1102 with EDC of March 25, 2008 presented with complaints of decreased fetal movement and contractions at 36 weeks gestational age. Complications of this pregnancy included transverse presentation and advanced maternal age. Her prior history was remarkable for a preterm delivery, sickle cell trait and two prior caesarean sections.

She was admitted for repeat caesarean. Although the patient was counseled regarding the risk of a possible hysterectomy and need for blood products, she declined blood transfusion, stating that she was fearful due to a" bad experience" that a friend had.

During the caesarean, the patient experienced massive blood loss resulting in hysterectomy. Her hemoglobin intraoperatively fell to 3gm/dl and the patient went into cardiac arrest. CPR was initiated and the decision made to transfuse blood products.

Once the patient's family arrived, they declined further blood products as they were Jehovah’s Witnesses. The patient remained in critical condition, developed ARDS, and expired seven days later.

In order to integrate knowledge, expertise, and cultural competence, nurses must understand their own values and respect the patient’s beliefs, even if these conflict with their own values. As stated by Knuti, "It’s hard because of our overlay of what we would want for someone versus what they want for themselves." (Knuti, 2002). The ANA Code of Ethics states "Knowing how to mediate a moral dilemma empowers the nurse in caring and advocating for her patient as part of the multidisciplinary health care team."

There are many acceptable options for patients who refuse blood products, such as erythropoietin therapy, volume expansion, oral iron supplementation, or administration of antifibrinolytics. These options should be explored with patients and their families during prenatal care, or at least prior to delivery. Pre-delivery team meetings or discussions of options can facilitate identifying issues, options, and decisions in the event of an emergency. Regardless of our thoughts, beliefs, and discomforts, the patient’s right to autonomy and self determination are to be acknowledged and supported.