Barriers to rehabilitation in a Jehovah's Witness post-bilateral lung transplant

This case report describes the physiotherapeutic management of a 63-year-old female Jehovah's Witness with familial idiopathic pulmonary fibrosis who underwent bilateral lung transplantation. The refusal of blood transfusions imposed major clinical, ethical, and physiological challenges, requiring individualized multidisciplinary planning. The surgery, performed in May 2024, involved anatomical adjustments and intraoperative blood conservation techniques, including Cell Saver use and veno-arterial extracorporeal membrane oxygenation (ECMO). Postoperatively, the patient developed primary graft dysfunction, severe anemia (minimum hemoglobin (Hb) 4.9 g/dL), respiratory infections (Candida glabrata, Klebsiella pneumoniae), septic shock, and acute kidney injury, demanding prolonged ventilatory support, early tracheostomy, and renal replacement therapy. Physiotherapy interventions were focused on respiratory and motor rehabilitation, guided by objective parameters such as maximal inspiratory pressure (-26 cmH₂O; 36.18% predicted), diaphragmatic ultrasound, and the Perme Intensive Care Unit Mobility Score (Perme ICU). Early mobilization was limited by critical Hb levels (< 7 g/dL) and was progressively advanced from passive mobilization and postural control to upright positioning, neuromuscular electrical stimulation, and cycle ergometer exercises as tolerance improved. The case highlights two main barriers to early mobilization-hemodynamic instability and cultural factors related to limited understanding of mobilization safety during anemia-and reinforces the importance of individualized, data-driven physiotherapy approaches. Despite significant medical complexity and ethical restrictions, the case demonstrates the feasibility and safety of structured rehabilitation in transfusion-restricted post-lung transplant patients, contributing to evidence-based practice in physiotherapy and critical care.