Vital Signs

Blinded by the Light

Discover, August 1988
By Elisabeth Rosenthal

When a Jehovah's Witness forbids a transfusion, I can only rage against the mysteries of faith.

In the New Testament (Acts 15:28-29) there is a passage that reads: "For the holy spirit and we ourselves have favored adding no further burden to you, except these necessary things, to keep abstaining from things sacrificed to idols and from blood and from things strangled and from fornication. If you carefully keep yourselves from these things, you will prosper."

Based on this text, Jehovah's Witnesses will not accept blood transfusions, I must admit that this proscription has always struck me as somewhat absurd. Placed next to "Thou shalt not kill" ad "Thou shalt honor thy father and thy mother," the notion that "Thou shalt not accept transfusion of blood and blood products" seems to lack moral force. But until one night recently, I had never had to confront the beliefs of Jehovah's Witnesses other than to say "no, thank you" to an occasional proselytizer who approached me on the street.

I have never actually spoken with Ms. Peyton, either. On the night of our only encounter I was the doctor screening patients who were being transferred to the coronary care unit. She was confused and barely conscious and her heart was dying, fiber by fiber, from lack of blood. The calls that asked me to evaluate Ms. Peyton all started with the same apology: "I'm sorry to hand you this problem, but…" The story that unfolded was a tragic mismatch between faith and disease.

Ms. Peyton was only 42 when she came to her doctor after noticing a small amount of blood in her urine. This is a fairly common complaint from women who are prone to bladder infections, but Ms. Peyton's bleeding didn't get better with antibiotics - it got worse. She was sent to a urologist for further evaluation. A fiber-optic scope threaded through the urethra into the bladder revealed that ms. Peyton had a bladder tumor.

As is usual with this type of growth, the tuner had not invaded the bladder wall, and the surgeons were able to remove it through the scope. These tumors tend to recur, however, and Ms. Peyton was told she could expect to undergo periodic procedures to remove them, but in the usual scheme of things such an illness should not be fatal. And so for several years she had repeated episodes of bloody urine followed by urologic procedures to eradicate the source of bleeding. She came, I suppose, to accept a tinged urine as a way of life. Her bone marrow, with a bit off iron supplementation, was able to match the cells that were lost, one for one. But this last time she had waited too long to see her doctor. She was bleeding more heavily than usual and was severely anemic and, as a result, was constantly weak and tired.

A woman Ms. Peyton's age normally has a hematocrit - a red blood cell measure - around 40, but hers was only 17. Her primary doctor, who had admitted her to the hospital, told her that she would require transfusion until the bleeding could be stopped. Ms. Peyton, resolute in her faith, refused. She wanted every available medical treatment - chemotherapy, surgery, cardiopulmonary resuscitation - everything, that is, except transfusion.

She was an intelligent woman, I was told, who totally understood the implications of her decision. But her judgment, it seemed to me, arose from a blind spot imposed by her faith.

Over the next week things went from bad to worse. Nothing the urologists tried could stem her bleeding, and her blood count dropped lower and lower until she was no longer a reasonable candidate for surgery. It was simply too risky to take a person with a hematocrit below 20 to the operating room. "You are probably going to die without a transfusion," her doctors reminded her daily. She was unmoved.

Gradually, as her blood count dropped further, Ms. Peyton became short of breath. The body's organs need a certain amount of oxygen to function. That oxygen is carried from the lungs to the periphery by hemoglobin molecules in the red cells. When we breathe room air, the hemoglobin molecules are not 100 percent saturated with oxygen. Their oxygen uptake can be improved by a patient's breathing oxygen-enriched vapor. The medical team gave Ms. Peyton supplemental oxygen through a mask until she was breathing virtually pure O₂. The few red cells she had were fully loaded - but there just weren't enough vehicles left to transport the fuel her body needed.

Her hunger for air increased. Her respiratory rate climbed. She became more and more groggy, and finally - inevitably - the muscle fibers of her heart declared their desperate need for oxygen. She developed crushing, severe chest pain.

A heart attack: Her perfectly healthy heart was dying because her blood was too thin to sustain it. And so, with apologies, I was called to preside over this untenable situation. By law she had to be moved to the coronary care unit since she had expressed her wishes to be resuscitated. And, also be law, we were prevented from performing the one intervention that would save her: a transfusion.

As I walked into the room, carrying my portable cardiac monitor, I was awed by the scene in front of me. At the center of everyone's attention was a large woman with an oxygen mask, gasping for air, breathing faster than seemed humanly possible. At the head of the bed were three friends, fellow church members, coaching her through her moment of wretched glory. At her side were several doctors - one monitoring her falling blood pressure, another coaxing some blood from an artery. The fluid slowly filled the syringe had the consistency of Hawaiian Punch; tests on the sample later revealed a red cell count of only 9. Hanging from the bed rail was a bag of cherry-red urine. The woman was dying. Her cardiogram tracings showed the deep valleys that signal a heart in pain. Within a matter of hours the damage they represented would become irreversible.

To bring this woman to a coronary care unit made no medical sense; and to withhold blood from her dying heart seemed opposed to my Hippocratic oath. Uncertain how to proceed, I called the hospital administrator. Since Ms. Peyton had not minors who depended on her, I was told, she had a legal right to refuse transfusion. I walked back to her room to talk with the other church members to make sure they understood the implications of their friend's decision. I felt confident they did not, I was intercepted at the door by a woman in a silk dress. "This must seem insane to you," she said, and she was right.

"Your friend is going to die," I told her. My words were direct. "I will take her up to the coronary care unit because I legally have to, but there will be nothing effective I can do. We will give her oxygen, but her blood is already carrying all the oxygen it can hold. We will giver he medicines to keep her blood pressure up, When they cease to work, we will pound on her chest to force the blood out of her thorax and into her limbs. We will shock her hear with jolts of electric current to stimulate its conduction system to fire. But without red cells to bring nutrients to her heart, nothing we can do will save her."

I recalled an old expression I learned in medical school: You can't shock hamburger meat. "You are asking us to resuscitate her with our hands tied behind out back," I went on. "It may take hours, but without a transfusion she will die tonight." By this time Ms. Peyton's other two friends were at the door, and they listened patiently, wincing as I described some of the more ghoulish aspects of the night to come.

They clearly understood my point. But this was not a rational matter. "I'm sorry, this is going to be a lot of trouble for you," one of them said. "It may not make any sense to you. But she does understand that she might die."

Two worlds collided. As I hooked Ms Peyton to the portable EKG monitor in preparation for her trip to intensive care, a flurry of emotions besieged me. First, frustration at not being able to talk to her myself when she was conscious. Second, confusion that these obviously intelligent women could be so accepting of the needless death of a friend.

As we rolled her bed out into the hall, bumping into sinks and walls and getting stuck in narrow doorways, my mood turned to anger. Without a transfusion, Ms. Peyton's chance for survival was unambiguously zero. Nonetheless, here I was in all seriousness taking her to the coronary care unit. Finally, as I rolled Ms. Peyton's body through the elevator doors, I was joined by that other chilling companion that accompanies me on every such transport: fear - the fear that Ms. Peyton could go into cardiac arrest at any second, that the doors would close with her alive on the fifth floor and open with her dead one floor below.

Once in the coronary care unit, Ms. Peyton was treated with the efficiency that the nurses display toward all patients, dead or alive. She was transferred onto a cot (weighed in the process) and hooked up to a cardiac monitor. A large catheter connected to a transducer was slipped into the artery in her groin to serve as a constant probe of her blood pressure. She did not utter a sound; I gave up my hope that she would awaken and change her mind.

The charade continued. A full EKG showed that he heart muscle was dying even faster now. We put a tube down her throat, into her lungs, in a futile attempt to improve oxygen delivery. We switched to a stronger pressure medication. Fifteen minutes later her heart was so weak, it could no longer pump effectively, and the blood pressure tracing fell flat. She was in cardiac arrest. We started cardiopulmonary resuscitation, rhythmically pushing useless fluid through her veins.

The doctor in charge was barking out orders. I placed a large intravenous line into a deep vein in Ms Peyton's thigh and then relieved the nurse doing chest compression's. One one thousand, two one thousand, three one thousand…my mind counted the hypnotic tempo as I pressed rhythmically on Ms Peyton's chest. In the background I could hear the noises of the rescue effort. A variety of cardiac stimulants were pushed into Ms. Peyton's veins and her heart was prodded with shocks.

Epinephrine, Atropine. Shock with 300 joules. We have a rhythm. Hold compressions. She's got a pulse. She's slowing again. Resume compressions. Epinephrine again. Atropine. Shock at 360. Continue CPR….

I marveled at Ms. Peyton as she lay still in the center of this desperate activity.

An hour later the floor was littered with EKG tracings, the bed with syringe tops and blood. Finally, the doctor in charge decided enough was enough. "Stop compressions. We're calling this. Thank you, everyone, for coming." It is the official way we end all failed resuscitations. I was grateful that this one had ended quickly. As I left the room to find the other Witnesses, a few surviving cells in Ms. Peyton's heart sent out their last electrical signals to the monitor.

I always feel hollow when reporting a death - even one that is inevitable. Ms. Peyton's friends were gracious and made it easy. The woman in the silk dress thank me, repeating again, "This must seem crazy." I turned to leave them, and then paused.

"No, I don't think her refusing blood is entirely crazy," I began to answer. You see, during the last hour I had given considerable thought to the question. Resuscitation efforts involve endless, repetitive, small mechanical actions - pressing 72 times a minute on a chest, squeezing a burst of air into the lungs every four seconds - and in the depths of a long resuscitation there is ample time for meditation. I could fully comprehend that there are things in life that might be worth dying for. People have risked their lives for their religion, for their family, for the thrill of winning a grand prix, for the honor of being the first to reach the South Pole.

My problem, I explained to Ms. Peyton's friends, is that if you have come to terms with death as a consequence of your belief, why not let it happen naturally? Why spend the last moments of life with people thrusting tubes down your throat and pounding their fists into your ribs? We knew she could not live without transfusion so why stage this ghoulish mock battle?

I continued my tirade, accompanied by the beeps of monitors and the whoosh of the ventilators. When I paused for air, I noticed the same patient expression on the women's faces. "This doesn't make sense to you, I know," the woman in the silk dress repeated. "You see, we believe…" She began. I saw the Watchtower peeking out from her bag.

All of a sudden I couldn't wait to leave; the gap between her world and mine yawned open. "I'm sorry Ms. Peyton died," I said. "I wish there was something we could have done." And with that I retreated back into the coronary care unit.

Elisabeth Rosenthal is a resident in internal medicine.