What to Do When You Can't Transfuse: Update on Optimizing Outcomes for Jehovah's Witness Patients

Patients who decline allogeneic blood transfusion for religious reasons, most commonly Jehovah's Witnesses, represent a growing population requiring specialized perioperative and inpatient care. Over the past decade, comprehensive "bloodless medicine" programs have emerged to safely manage these patients using principles of patient blood management, including preoperative anemia diagnosis and treatment with oral or intravenous iron and erythropoiesis-stimulating agents, intraoperative blood conservation techniques such as cell salvage, acute normovolemic hemodilution, antifibrinolytics, controlled hypotension, and meticulous surgical technique, and postoperative strategies to minimize iatrogenic blood loss from phlebotomy. This review synthesizes evidence from a large single-institution experience, encompassing propensity-matched cohort studies of adult, pediatric, and surgical/medical subgroups, alongside novel tools such as a preoperative hemoglobin target algorithm and comparative data on intravenous iron versus red cell transfusion. We also discuss a March 2026 update to Jehovah's Witness doctrine permitting preoperative autologous blood donation as a matter of personal conscience, and its practical implications for clinical teams. Across these studies, patients receiving bloodless care demonstrated morbidity, mortality, and length of stay comparable to or better than those receiving standard transfusion-inclusive care, with some analyses showing reduced hospital-acquired infection rates and consistently lower hospital costs and charges. A 10-year financial analysis further demonstrated that a comprehensive blood management program generated a greater than sevenfold return on investment while maintaining equivalent clinical outcomes. Collectively, these findings support bloodless medicine as a safe, cost-effective, and increasingly generalizable model of high-value perioperative care.