C A S E ST U DY

A case study of an older adult with severe anemia refusing

blood transfusion
C. Michelle Thomas, BSN, RNC (Family Nurse Practitioner Student, Program Manager)1,
Harriet R. Coleman, BSN, RN, ACRN, NCSN, BC (Family Nurse Practitioner Student, School Nurse)2, &
Leslie-Faith Morritt Taub, ANP-C, GNP-BC, CDE, DNSc (Assistant Professor)3
1 The University Center for Bloodless Surgery and Medicine at University Hospital, The University of Medicine and Dentistry of New Jersey,
Newark, New Jersey
2 Rahway Board of Education–Franklin Elementary School, Rahway, New Jersey
3 School of Nursing, University of Medicine and Dentistry of New Jersey, Newark, New Jersey

Keywords Abstract
Anemia; iron deficiency; Jehovah’s Witness;
blood management. Purpose: To discuss the diagnosis and treatment of severe anemia in an older
adult who presents the challenge of declining blood transfusion in a real-world
Correspondence scenario where critical thinking, evidence-based care, and collaboration with
C. Michelle Thomas, BSN, RNC, other providers must come together to serve this patient’s unique needs.
150 Bergen St. C-450, Newark, NJ 07103.
Data sources: Extensive review of the scientific literature on anemia and the
Tel: 973-972-3836 (office); Fax: 973-972-0459;
situation in which a patient refuses blood transfusion presented in a case study
E-mail: [email protected]
format.
Received: January 2006; accepted: May 2006 Conclusions: A thorough physical assessment, complete health history, and
appropriate diagnostic workup should be used to distinguish the normal effects of
doi:10.1111/j.1745-7599.2006.00188.x senescence from the signs and symptoms of anemia. Common conditions that
cause anemia in the elderly include chronic disease, iron deficiency, and gastro-
intestinal bleeding. These conditions may result in profound anemia. The chal-
lenge can be compounded when, because of religious tenets, a patient does not
accept a blood transfusion. This case study challenges nurse practitioners to apply
knowledge, seek guidance, and make appropriate referrals to care for a patient
in order to render care within the parameters of the patient’s belief system.
Implications for practice: The astute primary care provider recognizes that
anemia is not an expected physiological change associated with aging but
a manifestation of an underlying disease process. Fatigue, weakness, and
dyspnea are all symptoms of anemia that may be overlooked and attributed
to the aging process. Further, in keeping with the principles of autonomy and
self-determination, it is the clinician’s duty to work with all patients to restore
them to a state of optimal health while respecting deeply held spiritual beliefs.

Case study with 175 mcg of levothyroxine sodium every day), diet-
controlled diabetes mellitus (HgbA1C normal at 5.5%),
Mrs. H. is a 65-year-old African American woman who
was in her normal state of health until she presented at her hyperlipidemia (total cholesterol level 155 mg/dL), gas-
nurse practitioner’s (NP) office with the complaints of troesophageal reflux disease, and an overactive bladder.
‘‘feeling cold and tired’’ for about a week. Mrs. H.’s medical Mrs. H. has always been conscientious about keeping her
history contains several chronic medical conditions. All of healthcare appointments and is current with her gyneco-
her known medical conditions are currently well con- logic, ophthalmologic, and podiatric care. This patient was
trolled and are as follows: hypothyroidism (controlled hospitalized for the surgical repair of a ventral hernia in

Journal of the American Academy of Nurse Practitioners 19 (2007) 43–48 ª 2007 The Author(s) 43
Journal compilation ª 2007 American Academy of Nurse Practitioners
Severe anemia in older adults C.M. Thomas et al.

2001 and of renal calculi in 2003. Her last screening round, and reactive to light bilaterally. No petechiae of the
colonoscopy was in 1998, and the findings were within skin or oral mucosa, or comma signs are noted in the
normal limits. Differential diagnoses to be considered for conjunctival vessels. Her conjunctivas are shiny and pale
this patient included the following: nutrient deficiencies, as is the nasal and oral mucosa. There is neither thyro-
mood disorders, infectious processes, metabolic disorders, megaly nor palpable lymph nodes in her neck. Respira-
hematologic disorders, and rheumatologic disease. tions are unlabored, and lungs fields are clear. The heart
rhythm is regular, and a new finding of a systolic ejection
Review of systems murmur II/VI in intensity is noted. Symmetric +1 ulnar,
femoral, posterior tibial, and dorsal pedis pulses are pal-
Mrs. H. has no paresthesias in her extremities, and she pated. The abdomen is soft, nontender, and without orga-
denies having noticed ecchymoses, or petechiae on her nomegaly. A rectal exam revealed no masses and good
skin or mucosa. Her appetite is unchanged, and she denies sphincter tone. Her stool tested negative for occult blood.
pica. She denies feeling sad or depressed. She has neither Sensation in her feet is intact to touch and vibration
noticed any glossal changes nor experienced any type of bilaterally. Her gait is unencumbered. Cranial nerves II–VII
pain. She has not had any frank loss of blood (hematuria, are grossly intact.
black tarry stools, and hematochezia), and her last men-
strual period was more than 15 years ago; she has expe-
rienced no vaginal bleeding since. Laboratory data
Mrs. H.’s lab work reveals the following: blood urea
Family history nitrogen and serum creatinine are within the normal
Mrs. H.’s family history is remarkable in that her father range, her peripheral blood smear shows no abnormal
died of colon cancer at 56 years of age. Her maternal aunt cells, and her urinalysis reveals no red blood cells. Her
died of breast cancer (age of death unknown). She has two laboratory results reveal a microcytic hypochromic ane-
siblings, one sibling with both hypothyroidism and type 2 mia. The mean corpuscular volume (MCV) is 63.5 fL
diabetes and another sibling with hypothyroidism. Mrs. H. (normal range 80–95 fL), and the mean corpuscular hemo-
has four children in good health and one with systemic globin concentration (MCHC) is 28.7 g/dL (normal range
lupus erythematosis. She denies a family history of ane- 32–36 g/dL). Mrs. H.’s hemoglobin is 4.5 g/dL (normal
mia, jaundice, bleeding disorders, or hemoglobinopathies. range for a woman is 11.5–15.0 g/dL), and her platelets are
within normal range at 273.
Social history
Mrs. H retired from her housekeeping job several years
The diagnosis
ago. She lives with her husband who is in good health. She Anemia of chronic disease (AOCD) and iron deficiency
denies alcohol or tobacco use. She denies use of any over- anemia (IDA) are the first and second most common
the-counter medications or herbal remedies and states that causes of anemia in the elderly, respectively (Eisenstaedt,
she uses only the medications that her healthcare pro- Penninx, & Woodman, 2006; Guralnik, Eisenstaedt,
viders prescribe. Medicare covers Mrs. H.’s healthcare Ferrucci, Klein, & Woodman, 2004). AOCD and IDA
costs, and she also has a supplementary plan that covers may at times coexist especially in older adults (Montoya,
her prescription drugs. She is a Jehovah’s Witness, her Wind, & Sole, 2002). The cause of anemia in the elderly
religion gives her core values that she lives by, and she is (see Table 2) is often multifactorial and may include blood
active within her congregation. loss, malnutrition, and physiological changes such as
diminished bone marrow function (Carmel, 2001). Based
on the low MCV and MCHC, the NP concludes that Mrs. H.
The physical exam
has a microcytic hypochromic anemia caused by iron
Upon physical examination, Mrs. H. is an overweight deficiency based on a ferritin level of 4 ng/mL. Smith
(body mass index 28.7), alert, and oriented African Amer- (2000) supports this diagnosis stating that when the serum
ican woman in no acute distress. Her vital signs are all ferritin is less than 15 ng/mL, iron deficiency is virtually
within normal range and present no variations from nor- certain. A diagnosis of IDA is also supported by the fact that
mal. Her skin is warm without edema, lesions, or excessive the total iron-binding capacity is high normal; this would
dryness. Her nail beds are pale; however, her nails do not be low in AOCD. Additionally, AOCD rarely progresses to
show signs of splinter hemorrhages, clubbing, koilony- a hemoglobin level below 10 g/dL (Smith). Other types
chia, or cyanosis. Her head is normocephalic and atrau- of microcytic hypochromic anemias are thalassemia, side-
matic. Her eyes are anicteric, and her pupils are equal, roblastic anemia, and anemia related to lead poisoning

44
C.M. Thomas et al. Severe anemia in older adults

most commonly found in children. These were ruled out as choice. She continued to decline blood transfusion, con-
the cause of Mrs. H.’s anemia because these disease pro- firmed that she understood the risks, and signed a release
cesses leave the patient with normal to high serum iron of liability form stating the same.
levels. This patient’s serum iron level was markedly low
(see Table 1). Working within the patient’s belief system
In order to understand the reasons for Mrs. H.’s refusal of
generally recommended treatment and to make appropri-
The treatment plan
ate alternative plans, the NP searched for information on
The next step in this process is to determine the cause of this religion. Jehovah’s Witnesses are Christians who be-
this patient’s IDA. Chronic gastrointestinal (GI) blood loss lieve that blood transfusion is forbidden. There are approx-
should be suspected as an etiology of IDA in postmeno- imately 6,613,829 Jehovah’s Witnesses in the world and
pausal women, and older patients with suspected IDA 1,035,802 in the United States. That is approximately one
should be thoroughly evaluated for GI cancers (Buttaro, Jehovah’s Witness per 282 people in the United States.
Trybulski, Bailey, & Sandberg-Cook, 2003). Also of con- Refusal of blood transfusions is based primarily on two
cern is the fact that this patient’s father died of colon cancer statements in the Bible. These are as follows: (a) God told
at the age of 56. A family history of colorectal cancer Noah and his family that blood represents the soul (or life)
increases the patient’s own risk for colorectal cancer. In and forbade them to eat it. (‘‘Every moving animal that is
general, the closer the familial relationship is to the alive may serve as food for you. As in the case of green
affected relative and the younger the age of the affected vegetation, I do give it all to you. Only flesh with its
relative, the greater is the individual’s risk for colorectal soul—its blood—you must not eat.’’ Genesis 9:3, 4) and
cancer (Read & Kodner, 1999). (b) the command given in the New Testament to abstain
Mrs. H. was admitted to the hospital due to the severity from blood (‘‘Hence my decision is not to trouble those
of her anemia (Hgb = 4.5 g/dL). The plan for Mrs. H.’s from the nations who are turning to God but to write them
hospitalization was to monitor her complete blood count to abstain from things polluted by idols and from fornica-
using micro blood sampling with specialized laboratory tion and from what is strangled and from blood.’’ Acts
equipment to test very tiny blood samples to conserve as 15:19, 20). In respect for the sanctity of blood, Jehovah’s
much of her circulating blood as possible and to treat the Witnesses do not accept blood transfusions in whole or in
anemia. Typically, a symptomatic patient with a hemoglo- components even if such a procedure would be lifesaving.
bin level this low would receive a blood transfusion; Medical alternatives acceptable to Jehovah’s Witnesses
however, blood transfusion was not an option for this have proved to be very effective. The world headquarters
patient because of her religious beliefs. Mrs. H. was, how- of Jehovah’s Witnesses is located in Brooklyn, New York,
ever, informed that her blood count is low enough that a where they have a department dedicated to the education
blood transfusion would generally be the treatment of of healthcare providers in non–blood management (for

Table 1 Laboratory results for Mrs. H

11 days 18 days 25 days 37 days

Blood test result (normal range) Ha day 1 H day 4 H day 5 H day 6 post D/C post D/C post D/C post D/C

WBC (4.0–10.5 ! 103/lL 6.6 4.7 5.1 5.7 7.9 4.8 5.0 4.8
RBC (3.8–5.1 ! 103/lL) 2.49Y 2.19Y 2.32Y 2.42Y 3.26Y 3.51Y 4.13Y 4.44Y
Hgb (11.5–15.0 g/dL) 4.5Y 4.1Y 4.5Y 4.7Y 6.7Y 7.8Y 9.3Y 11.1Y
HCT (34%–44%) 15.8Y 14.3Y 15.4Y 16.4Y 24.7Y 27.8Y 33.5Y 37.9
MCV (80–98 fL) 63.5Y 65.4Y 66.3Y 67.7Y 76Y 79Y 81 85
MCH (27–34 pg) 18.2Y 18.8Y 19.2Y 28.6 26.9Y 28 22.5Y 29.2
MCHC (32–36 g/dL) 28.7Y 28.7Y 29Y 28.6Y 26.9Y 28Y 27.7Y 29.2Y
RDW (11.7%–15%) 21.8[ 21.9[ 21.4[ 22[ 34.3[ 34[ 33.6[ 28.6[
Platelets (140–415) 273 140 188 219 245 197 152 160
Reticulocyte (0.5–3.0) 2.5 3.9[ 3.8[ 6.7[ 4.3[ 4.7[ 3.1[
Serum iron (35–150 lg/dL) 8Y
TIBC (250–400 lg/dL) 384
Ferritin (30–150 ng/mL) 4Y

Note. RBC, red blood cells; WBC, white blood cells; TIBC, total iron-binding capacity; [, abnormal high result; Y, abnormal low result.
a
H (hospital) D/C, discharge from hospital; HCT, hematocrit; MCH, mean corpuscular hemoglobin; RDW, RBC distribution width.

45
Severe anemia in older adults C.M. Thomas et al.

Table 2 Most common types of anemia ANEMIA DOCUMENTED in postmenopausal female

Type of
anemia MCV Differential diagnoses
Thorough PHYSICAL EXAM (evaluate for frank GI blood loss)
IDA Microcytic hypochromic Blood loss
Inadequate iron intake
AOCD Normocytic normochromic Chronic renal failure
Chronic inflammation No acute blood loss identified
Hepatic disease
Endocrine failure
Macrocytic Macrocytic normochromic Pernicious anemia
Check CBC with indices, reticulocyte count, & Iron studies.
anemia Folic acid deficiency
Hemolytic Normocytic normochromic Autoimmune hemolysis
anemia Lymphoproliferative
disorders LAB RESULTS:
Drug induced
Microcytic, hypochromic anemia

Low reticulocyte count

more information on Jehovah’s Witnesses’ blood man-
agement beliefs, go to http://www.watchtower.org). In Low serum iron and ferritin
line with the beliefs of this religious group, Mrs. H. did
not consent to a blood transfusion, and she had an advance
medical directive documenting this refusal and her end-of- Iron deficiency Anemia
life choices in the event that she is unable to express them
for herself (see Figure 1). (blood transfusion declined by patient)

Acceptable treatment alternatives Treat with oral iron if tolerated

Manufactured erythropoietin (EPO; available as Epo- Supplement with EPO injections

gen, Procrit, and Aranesp) is a genetically engineered form
of a hormone produced by the kidneys that regulates the
production of red blood cells (see Table 3). While it is Follow CBC, iron studies and reticulocyte count
until anemia is resolved
commonly used to treat anemic patients with end-stage
renal disease, cancer, acquired immunodeficiency syn-
drome, inflammatory conditions of rheumatoid arthritis, Refer for evaluation of the cause on the anemia
and inflammatory bowel disease, prior to elective surgery, by a gastroenterologist
experts disagree on administering this drug to treat IDA. Figure 1 Algorithm for evaluation of anemia used for Mrs. H.’s case
This is because of the high cost and insufficient evidence of study.
benefit in IDA (Montoya et al., 2002). However, in the case
of a patient declining blood transfusion because of reli-
gious beliefs, it is a reasonable choice to stimulate eryth- The recommended dose of EPO for preoperative anemia
ropoiesis. Treatment for Mrs. H. includes iron sulfate 325 is 150–300 units/kg of body weight 3 weeks, 2 weeks, and
mg tablets (see Table 4) given by mouth three times a day 1 week prior to the surgery/procedure (Kelly, 2002).
(with a stool softener to prevent constipation) along with Therefore, the appropriate dose for Mrs. H. in preparation
EPO 20,000 units subcutaneously every other day. She for her endoscopic procedures would be between 12,000
was able to tolerate the oral iron preparation. If she had not and 24,000 units for at least 3 weeks before the procedure;
been able to tolerate oral supplementation or had a history however, in consultation with the hematologist she was
of a GI disease that would limit absorption of oral prepa- given much higher doses. Kelly notes that although a max-
rations, parenteral preparations would have been pre- imum safe dose has not been established for epoetin alfa,
scribed. Parenteral therapy should be reserved until every doses of up to 1500 units/kg have been administered three
reasonable attempt at oral therapy has failed, because times a week for up to 3 weeks without toxic effects.
resolution of IDA is not more rapid when using injectable Adequate iron supplementation is imperative with EPO
iron and the potential for anaphylactic reaction is therapy to maintain adequate iron stores to form red blood
greater in parenteral forms (Fitzgerald, 2005; Montoya cells. Specific to this case, Mrs. H. is educated that she
et al.). should leave 2 h between her levothyroxine sodium and

46
C.M. Thomas et al. Severe anemia in older adults

Table 3 Dosing for synthetic EPO preparations

Medication Indication Dosing (intravenous or subcutaneous)

Procrit/Epogen (epoetin alfa) Anemia of chronic renal failure 50–100 units/kg tiw
Anemia in patients with human 100–300 units/kg tiw
immunodeficiency virus treated
with AZT (zidovudine)
Chemotherapy-induced anemia 150–300 units/kg tiw
Reduction of allogeneic blood 300 units/kg ! 10 days pre-op, on the day of
transfusions in surgical patients surgery, and 4 days post-op or 600 units/kg
once weekly starting 21 days pre-op and
ending on the day of surgery (4 doses)
Aranesp (darbepoetin alfa) Anemia of chronic renal failure 0.45 mcg/kg weekly

iron because iron salts may decrease the bioavailability of reached 11.1 g/dL; at this time her EPO dose was decreased
levothyroxine sodium (Kelly). to 20,000 units subcutaneously once every week and the
iron regimen was continued. Treatment for IDA is consid-
Monitoring the treatment plan ered successful if the hemoglobin level increases more that
1 g/dL in 1 month, and this patient exceeded that (Montoya
Once EPO injections and iron supplementation began,
et al., 2002). The patient had an esophagogastroduodeno-
the patient’s reticulocyte count increased and the hemo-
scopy (EGD) and a colonoscopy, and neither revealed any
globin and hematocrit levels followed (see Table 1). This
lesions, polyps, erosions, microangiodysplasia, or any other
confirms that there was adequate iron absorption, mini-
explanation for her anemia. The American Gastroentero-
mal if any continued blood loss, and functioning bone
logical Association guidelines (2000) state that colonoscopy
marrow (Smith, 2000).
and upper endoscopy are the cornerstones for investiga-
Mrs. H. was discharged from the hospital after 6 days
tion of occult blood loss; however, the origins of IDA and
with a stable hemoglobin level of 4.7 g/dL to continue on
positive fecal occult blood test (FOBT) results remain
her oral iron therapy and a visiting nurse was to give her
unexplained in as many as 52% of cases and typically
EPO injections every other day. She was also instructed to
require no further evaluation once the anemia is corrected.
avoid aspirin and all nonsteroidal antiinflammatory med-
Carmel (2001) recommends that a consideration for IDA
ications and to test every stool for occult blood (all have
of unknown cause would be unrecognized celiac disease
been negative thus far). An appointment was made for her
(present in approximately 10% of unexplained IDA cases).
to return to the NP’s office several times over the next few
Celiac disease is a chronic nutritional disturbance caused
weeks to monitor her anemia. All this information was
by the inability to metabolize gluten, which results in
communicated to the patient and her daughter, who is
malnutrition, a distended abdomen, muscle wasting,
very involved and reliable in coordinating her mother’s
and the passage of stools having a high fat content. This
care.
workup includes serological testing for IgG and IgA anti-
bodies and a biopsy of the intestinal mucosa that is typ-
Initiating appropriate referrals ically performed by a gastroenterologist. A biopsy of
the duodenum at the time of Mrs. H.’s EGD showed no
The evaluation of this patient’s potential GI bleeding was
evidence of celiac disease.
to be initiated once she had achieved a hemoglobin level of
Care of the patient is ongoing; prevention of anemia and
at least 7 g/dL. A referral to a gastroenterologist was made
patient education are now the goals. Mrs. H.’s hemoglobin
and a workup scheduled. On the 37th day after her
has been maintained above 12 g/dL for several weeks after
discharge from the hospital, Mrs. H.’s hemoglobin level
discontinuing the EPO injections. Her systolic murmur has
resolved, and she continues her daily iron supplementa-
Table 4 Oral iron preparation dosing tion. It is important for NPs to know that Medicare will pay
for a colonoscopy in persons at high risk for colorectal
Preparation Typical dose
cancer every 2 years. Mrs. H. should be encouraged to
Ferrous sulfate 325 mg tid continue to have these colonoscopies routinely and to
Ferrous gluconate 325 mg tid contact her NP if she has any symptoms of anemia or no-
Ferrous fumerate 325 mg tid
tices any changes in her stool indicating bleeding (Read &
Polysaccharide–iron complex 1–2 capsules qd
Kodner, 1999). This patient requires diligent monitoring to

47
Severe anemia in older adults C.M. Thomas et al.

avoid a recurrence of such a profound level of anemia. and a 200% increased risk of being admitted to a nursing
Long-term follow-up of elderly patients in whom a source home (Penninx et al., 2003).
or iron loss is not identified reveals that most often the
anemia resolves or remains stable with iron replacement
(Smith, 2000). References
Buttaro, T. M., Trybulski, J. A., Bailey, P. B., & Sandberg-Cook,
Importance of timely detection of anemia J. (2003). Primary care: A collaborative practice (2nd ed.).
in the aged population St. Louis, MO: Mosby.
Carmel, R. (2001). Anemia and aging: An overview of clinical,
As demonstrated in the case of Mrs. H., the elderly diagnostic and biological issues. Blood Reviews, 15, 9–18.
patient may present in the primary care setting with Cohen, H. J. (2003). Anemia in the elderly: Clinical impact and
a severe anemia that exhibits minimal observable signs. practical diagnosis. Journal of the American Geriatrics Society,
The astute clinician will not attribute mild symptoms to 51(3s), 1–1.
normal senescence but will perform a reasonable metic- Conrad, M. E. (2005). Iron deficiency anemia. eMedicine.
ulous workup of the older patient with anemia to avoid Retrieved October 14, 2005, from http://www.emedicine.
missing the underlying cause. Carefully executing a thor- com/med/topic1188.htm
ough assessment helps avoid the potential hazards of Eisenstaedt, R., Penninx, B. W. J. H., & Woodman, R. C. (2006).
unchecked anemia in the aged patient that can result in Anemia in the elderly: Current understanding and emerging
a decreased level of function. This diligent evaluation of concepts. Blood Reviews, 20(4), 213–226.
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healthy aging. Although it is a typical malady of the (Ed.), Pharmacotherapeutics: A primary care clinical guide
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is a fact that the prevalence of anemia increases with age Guralnik, J. M., Eisenstaedt, R. S., Ferrucci, L., Klein, H. G., &
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A root cause of anemia can usually be found in approxi- of unexplained anemia. Blood, 104(8), 2263–2268.
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Philadelphia, PA: Lippincott Williams & Wilkins.
The most common cause of anemia in the elderly is
Montoya, V. L., Wink, D., & Sole, M. L. (2002). Adult anemia:
chronic disease, followed by iron deficiency (Smith, 2000).
Determine clinical significance. Nurse Practitioner, 27(3),
AOCD is a normochromic normocytic anemia that is
38–45.
characteristically mild (hemoglobin level 9.5 g/dL) to
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ish erythropoiesis and cause the development of anemia. factors and recommendations for early detection. American
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rapidly as it is lost. Red blood cells are then produced that
are much smaller than normal and with little hemoglobin
Conflict of interest disclosure
inside. Discovering and treating anemia in the older
patient is important because anemia has been found to The authors report no conflicts of interest and no induce-
be associated with a 150% increase in hospitalization risk ments to submit this article.

48