Form Part I Durable Power Of Attorney For Health Care Choices: Fill & Download for Free

When do the rights of a terminally ill patient end?When they die.That being said, someone will have to make decisions on thier behalf when they can no longer voice those decisions on their own. That person should be chosen by the individual and is their health care proxy or durable power of attorney, or legal guardian. Even if the person dying has told someone what they do or do not want to happen, legally, the person assigned to speak for them, DOES NOT HAVE TO FOLLOW THEIR WISHES unless this is written as part of a legal document.Be very very careful about who you decide to have speak for you.Make very certain they not only know what you want but will abide by that even if they don’t agree with it. Often, family is NOT the best choice. Make sure all your choices are legal and in writing .Ideally, they will have their wishes for what happens after in writing but if it’s not in the form of a legal will, the family does not have to abide by them.I highly recommend that everyone of adult age have a living will. It can be changed as circumstances do, but you have a place to start. To make your own wishes known if things should happen and not have someone arbitrarily assigned to speak for you if you’re in an accident, have a sudden debilitating illness etc. Crap happens. Be prepared!

“Guardians from Hell” is a term coined by Tablet Magazine regarding “The completely legal, utterly grotesque system for undermining the rights of the elderly.”Tablet Magazine caters to stories about Jewish life. For Jews, predatory guardianship, in which a person loses all of his or her civil rights, bank accounts, properties, and is placed in a nursing home against his or her will, is particularly scary — a reminder of what transpired in Nazi Germany.The latest Guardianship Nightmare story was published in The Tablet on June 21, 2018. Here it is: (I have written extensively about the guardianship nightmare. Please read my other posts about this topic.)******By Gretchen Rachel HammondAt 92-years-old,Virginia Jean Wahab hadn’t lost any of the vitality and health she maintained throughout her life. She raised two daughters as a single mom and made a home for them in the Detroit, Michigan suburb of Oak Park. Wahab worked on her feet and didn’t retire from her job at a local family restaurant until she was 88.Fiercely independent, Wahab was quite happy living at home after retirement. She had a healthy social life. She did her own grocery shopping and chores. She so rarely needed to pay a visit to a hospital that her health insurance was barely touched.Her eldest daughter Mimi Brun converted to Judaism at the age of 18. She went on to become a prolific Jewish artist, who sold her work all over the world. In 2010, she began to establish art schools for children under 12 in France and then Chicago. Although Brun was estranged from her younger sister, she and her mother were extremely close. Wahab was Catholic, but Brun noted that she had the fastidious nature of a Jewish mother.Wahab’s legal affairs were in order including a durable power of attorney she had signed in January, 2016 which named Brun as a patient advocate (the handler of her medical needs) as well as giving her daughter charge of her financial affairs should she ever become incapacitated. Wahab’s home was also registered in Brun’s name in a quit claim deed signed by Wahab on December 29, 2014.The two talked on the phone every day. Brun particularly relished visits with her mother during which she would gift her a piece of art. Wahab was an eager collector of Brun’s work.That was two years ago. Everything has changed since then.In 2016, after a fall at her home, Wahab was diagnosed with a slight cognitive problem but otherwise deemed healthy. Wahab’s doctor recommended that Brun find her a short-term rehab facility.“I looked for a Jewish one,” Brun said. “They were all full. I found Lourdes because it had a five-star reputation.”On February 23, that year, with the approval of her HMO, Wahab was admitted for short-term rehabilitation at Lourdes Senior Community in Waterford, Michigan—a nonprofit elder care facility founded by Dominican nuns in 1948. According to the organization’s 2016 I-990s, Lourdes listed end of year assets of $22,096,166.00. Expenses totaled $14,476,851.00Brun said she made her mother’s meals and went to each of her physical and occupational therapy sessions.“The insurance granted her up to 120 days,” Brun remembered. “She was excelling like a champ but the therapist at Lourdes started telling me she suspected Mom should not live alone. Mom and I decided that I was going to go back to France and Chicago, put my businesses on hold, rent out my homes and move my work and studio to Mom’s. It was what she had dreamed about—to spend the end of her life living with me.”Brun left for France, placing her aunt and sister in charge of caring for Wahab while she was in rehab.“I called Lourdes every day,” Brun said. “Then the insurance cut off.”Brun asserted that she spoke to Lourdes social worker Sara Van Acker and pledged that she would enter into a payment plan. Shortly thereafter, however, she received an email from a Lourdes administrator which stated “Your payment plan with Sara Van Acker was not approved by me. I cannot receive partial payment nor be patient for your payment plan time frame.”On June 6, Lourdes filed a petition for guardianship on the grounds of a $31,416.65 past-due bill. Brun said that the petition notice was sent to an address that was not hers. The petition shows that the address used to serve Brun belongs to an apartment complex in Harper Woods Michigan—one hour’s drive from Lourdes and 30 minutes from Oak Park. On the address, no apartment number is listed. It is also not the address listed on the Power of Attorney paperwork Brun says she provided to Lourdes.Brun rushed back to Michigan. On the morning of June 29, 2016, she attended a hearing presided over by Oakland County Probate Judge Linda Hallmark, one of four judges serving there. Hallmark vacated Wahab’s power of attorney and appointed a local attorney Jon Munger as Wahab’s guardian. According to Brun, neither she nor her mother ever requested Munger’s services.Also appointed by the court was a man named Matthew Jason Brown, another local lawyer. Brown was named as Wahab’s guardian ad litem (GAL)—a person entrusted with investigating what course of action is in the best interest of a person unable to care for themselves. The June 29 hearing was also attended by two representatives from Lourdes: Van Acker and Lisa Hibbert from the organization’s accounts receivable department.According to court transcripts from that morning, Van Acker stated that she had filed the petition for guardianship because “there’s a concern about the nursing home being paid.”Brown wanted to know if an application for Medicare benefits for Wahab had been made.“Not to my knowledge,” Van Acker replied.“Are you familiar with [Wahab’s] medical condition?” Brown wondered, to which Van Acker answered “slightly.”When Brown asked Brun if she had any objection to the petition, Brun replied “I am contesting this hearing because I was not served. I’ve had no time to get a lawyer.”“Well, you’re here Ma’am,” Hallmark replied, “and it’s a guardianship so there is some urgency about it, so we’re going to proceed.”When Brun protested that she had been appointed as Wahab’s guardian through a power of attorney, Hallmark quickly rebuked her.“That’s different than an appointment by the court,” Hallmark said. “Has any court appointed you guardian?”“No, but I haven’t applied for it yet,” Brun replied. “I’d like to petition for it, but I need time.”Hallmark did not respond to this request.In delivering his report to the court, Brown went on to state that he had visited Wahab at Lourdes only two days earlier. During that visit, he said, he “explained to Wahab her rights and gave her a copy of [the petition].”“She didn’t have any objection to the appointment of a public administrator at that time,” he added. “But I would note that she was not oriented to date, time, and place.”Brown also stated that he “went over [Wahab’s] medical condition with Ms. Van Acker and she went over with me sheets that said she was suffering from dementia, unspecified lack of coordination, osteoarthritis, two…type two diabetes, muscle weakness and hypertension.”Transcripts from that day indicate that Hallmark never asked for medical reports to prove Brown’s assertions.Brun told Hallmark that she had witnesses who would speak on her and Wahab’s behalf. Those witnesses, however, were never called.“My Mom needs love,” Brun went on to tell Hallmark. “No one loves my Mom more than me. When I asked my mom ‘what’s your greatest desire?’ she said ‘I want to go home. I want to go home with you.’”“I want to take her home,” Brun begged Hallmark.“I’m going to grant the petition,” Hallmark said. “I would like to appoint Mr. Munger [as guardian]. If he thinks that an independent medical or some other action is required that’s fine. I’m also going to appoint [Munger] as special fiduciary to make sure we have the Medicaid application on track. I’ll revoke the power of attorney today. If it’s appropriate that [Brun] should serve, if you want to get counsel and bring the matter in, we’ll consider that.”“She hasn’t lost any of her rights…” Hallmark added, speaking of Wahab. “She has a guardian and it’s Mr. Munger…”Brun made one last desperate plea. “Is there a reason why?”“Yes,” Hallmark replied. “Because she’s in need of a guardian and I’m appointing Mr. Munger. That’s why.”Hallmark never mentioned the grounds by which she was revoking the power of attorney.The court adjourned.Brun’s fight to have her mom released from Lourdes would eventually result in Hallmark issuing an injunction restraining her from entering Lourdes premises, denial of her visitation rights (even when chaperoned by a nun and a locally renowned, retired judge) and a bench warrant from Hallmark’s court for Brun’s arrest.Two days after Munger had been assigned, Brun received an email from his office which stated “It will be necessary to close [Wahab’s] bank accounts and locate all assets in order to apply for Medicaid. I understand that there is at least one account at ****** Bank with both of your names on it. It would be more efficient if you cooperate with the closing of the account(s). I will need proof of closure for the Medicaid application. I will then open a guardianship account at ******** for your mother, pay her bills, and apply for Medicaid.”Even though Wahab was originally admitted for a short-term rehab at Lourdes, on July 1, 2016, according to his own accounting, Munger completed a long-term medical assistance application that entitled Lourdes to three months of retroactive disbursement, faxing the application to Michigan State’s Department of Human Services. Five days later, Munger completed and mailed another admissions packet to Lourdes for Wahab.A July 17, 2016 affidavit, signed by Wahab and filed in court, read “I want to go home with my daughter Mimi.”On August 15, 2016 Brun’s then-attorney sent a letter to Lourdes CEO Sr. Maureen Comer stating “Ms. Brun has not and has never been opposed to negotiating the payment of the outstanding bill. Ms. Brun has made arrangements to take Ms. Wahab home and Ms. Wahab has even signed an affidavit stating she wants to return home.”Two days later, Brun, her attorney and Lourdes received an email from Munger which stated that he was clarifying “for both Lourdes and for yourself, that I am not authorizing either Mimi Brun or yourself to discuss, negotiate or otherwise become involved in any potential discharge plan nor payment.”Munger also went on to say “there have already been repeated complaints about your client’s behavior while at Lourdes facility. I have not yet taken full steps to curtail your client’s visitation, but we may need to revisit that issue.”In a subsequent series of emails Brun’s then-attorney called Munger’s actions “highly inappropriate. You are needlessly dragging on this litigation so you can keep billing and billing.”Munger replied “You and your client will cease any communication with Lourdes administration or management. Your failure to abide by this requirement will simply force me to place the matter before Judge Hallmark, where I will ask that both you and your client be sanctioned for this grossly unprofessional, abusive and threatening behavior. I simply will not allow either of you to interfere with Virginia’s care.”On August 18, 2016, Munger billed Wahab $245 for his drafting “of a petition to limit visitation.”An email that day from Munger to Brun’s attorney stated that it was “due to your attempts to pay Lourdes.” It makes no mention of any complaints about Brun’s behavior.Because he was Wahab’s guardian, Munger was legally permitted to bill his ward for any work on her behalf. A 2017 statement of other fees and services billed to Wahab by Munger and Associates shows that in little over a three-month span, Munger billed Wahab a total of $6,097.00 in fees and services.Brun filed an emergency petition to have Wahab released from Lourdes. In an October 5 hearing in Hallmark’s courtroom, Munger was represented by attorney Joseph Ehrlich.Munger billed Wahab $450 to “attend hearing on court motions and “[a] conference with judicial staff attorney.”Following the hearing, Ehrlich secured an order from Hallmark compelling Brun to pay $25,000 to Lourdes and gave her 25 days to come up with the cash.Brun told me that, because it did not include the provision for her mother to be released, she refused to pay it.A subsequent motion Brun filed to vacate the order stated that “upon review of the transcript of this hearing, at no point did Brun ever agree to pay $25,000 to Lourdes. It does not comport with the settlement placed on record.”Lourdes retained attorney Mary Lyneis to represent them.A November 2016 letter from Lyneis to Brun accused her of violating “Court Orders entered into the Probate Court.”While it did not mention which of those orders Brun was supposed to have violated, it went on to accuse her of “Threatening conduct toward the staff at Lourdes. In addition, you upset your mother with unfounded allegations the staff at Lourdes. As a result, you are hereby notified that you are no longer permitted on the premises. Should you attempt to enter the premises, appropriate law enforcement will be contacted.”The letter offered no evidence of any court order sanctioning a decision to bar Brun from the premises.In a February 2, 2017 email, Lyneis told Brun “We want to be paid. You cannot expect to show up to see your mother when you have not paid for the privilege and you have disappeared since November.”A subsequent email from Munger to Brun stated “If you want to visit your mother and or even remain in contact with her, you would be better served by complying with the existing court order than by continuing to harass everyone trying to see your mother. In particular, pay the $25,000.”Concerned about being able to pay her legal fees, Brun sold her and her mother’s home to Michigan banker Bradley Silverstein on the proviso that he draft a lease for her and Wahab to live there. A lease with that condition was drafted on February 28, 2017.Two days later on March 1, 2017, Ehrlich, Lyneis, and Munger appeared before Hallmark and asked for a series of ex parte orders against Brun.Ex parte orders are issued without the presence of or even notification of the parties it affects. Since due process is Constitutionally guaranteed, these orders are supposed to be temporary while allowing ample room for them to be contested.Brun was not present at the hearing when the ex parte orders were issued. At the time, with the support of her doctor and with his medical order in the court file, she had requested a two-month medical leave from the court.Hallmark also issued a permanent injunction against Brun restraining her from entering Lourdes premises, and a bench warrant for arrest alleging that her refusal to pay the $25,000.00 was in contempt of court.Regardless, Munger and Ehrlich requested that the house be transferred back to Wahab’s name “and then [to] permit Jon Munger to sell the house in order to pay for her care, so that [Wahab] would then qualify for needs-based benefits.” The court issued this order on June 28, 2016.Brun told me that, in the months that followed, Munger attempted to force his way into the house. On August 8, 2017, she filed a police report, complaining that Munger had attempted to enter the house on three separate occasions.When Brun replied that she had never received such an order, Munger wrote “A hearing was held on June 21 in front of Judge Linda Hallmark, and you received notice of that. I have every legal right to enter your mother’s home, and I have done so.”A June 30 email from Munger to Brun read “As you are aware, Judge Hallmark entered an order in the eviction case requiring you to vacate your mother’s home by Wednesday, June 28th 2017. I went to the home with several others on the following day, June 29th, and it was apparent that no one was residing in the home. Accordingly, we had the locks changed and the home secured. Upon our entry into the home, it was apparent that you had left a great deal of valuable personal property behind, including artwork. We deem this to be abandoned property under the law. For the time being, we are holding that personal property and artwork as security for repayment of the $25,000 you were ordered to pay on October 5.”Brun has filed criminal police reports for larceny home invasion and theft against Munger with the Oak Park Police. The police took no subsequent action.On August 30, Munger billed Wahab $245 for “a hearing to set aside deed” and $119 for calls to the real estate agent and the locksmith.Brun said she was not present at any such hearing.Brun’s attorney Phillip Strehle would later tell Hallmark “In October ’16 [Munger] filed a forwarding address card with the post office which has Mimi’s name on top and Munger’s address on it. So, he already knew, as of October ’16, that whatever mail he sent to the house, she would never get, because he sent it to himself. Mr. Ehrlich told me out in the hall that the order of August 30 was entered because it was uncontested. There’s a reason why it was uncontested; because Ms. Brun was not properly served.”Brun finally got a break in October 2017 when attorney Lisa Orlando became Wahab’s new Guardian ad Litem.In two reports Orlando submitted to Hallmark in 2018, she wrote “I visited [Wahab] at Lourdes Senior Community first on November 16, 2017 and then again more recently, on February 28, 2018, at which time I again served her a copy of the petition, notice of hearing and the order appointing a Guardian ad Litem. I don’t believe that Virginia was able to understand the information being presented, however she did clearly say that she did not want to go to court. I then asked her if she wanted Mimi to be her guardian and she said ‘of course!’”“In the opinion of this GAL, it is Virginia Wahab a 94-year-old woman, who is paying the price of these ongoing legal disputes and suffering harm by not being able to see her daughter for more than 17 months,” Orlando added. “To isolate and prohibit an aging Mother from seeing her daughter is heartbreaking to this GAL. Mimi Brun has priority under the statute and is Virginia’s choice to be her Guardian.”An affidavit signed by Wahab’s sister Sr. Helen Essa reads “Mimi is a devoted daughter and attended to every detail of her mother’s care not ever putting her own needs first. I know how desperate my sister is to go home with Mimi and have Mimi care for her. I pray, as we all do, that my sister will not die in a nursing home.”In concluding her report, Orlando cited Michigan statutes.“Under MCL 700.5313(3)(b), [Brun] has priority over a professional guardian,” she wrote. “’If suitable and willing to serve as guardian, the court shall appoint, an adult child of the legally incapacitated individual.’” Under MCL 700.5313(2)(b), [Brun] is Virginia’s choice to serve as her guardian. I discovered no clear and convincing evidence why the Petition should not be granted.”Yet, Munger still remains as the sole guardian for Wahab who is still at Lourdes. Despite her best hopes, Brun has yet to see her and bring her homeThe question remains as to why the Oakland County Probate Court effectively became a debt collector for a nursing facility and why the now 95-year-old Wahab is still held there despite her own Guardian ad Litem opinion that Brun replace Munger as guardian and family members’ pleas to Hallmark that Wahab be allowed to go home with her daughter.On May 25, 2018 Hallmark vacated the order to pay $25,000.00. Hallmark also found Brun not guilty of contempt of court.Brun does not believe the petitions she filed in October to have Munger removed as guardian will even be heard until July.“I have been offering to pay Lourdes the money to let my mother go but Munger refuses to accept my working with the facility,” she said. “I promised Mom that her last chapter would be her best. But I think my mom will die before Munger ever lets her go.”Strehle, who has been Brun’s attorney since October, 2017, told me that he felt the entire case against Brun was “bizarre.”“The transcript of June 29, 2016 does not comply with the statute or the court rules,” he said. “There’s not a single bit of evidence to support even the creation of a guardianship; not one iota of evidence.”He added that for a nursing home to present a petition for guardianship based on a past-due bill is something “I’ve never seen in all my years of doing probate. Ever.”In the [June 29, 2016] transcript, the guardian ad litem [Brown] is the one that’s asking the questions,” he added. “Not Munger. Not an attorney for Lourdes. That’s even more bizarre. Usually, the person asking the questions is the petitioner not the guardian at litem. The court grated it because of an overdue bill. That’s not a basis for getting even a limited guardianship.”Strehle also addressed the March 1, 2017 subsequent bench warrant and injunction issued against Brun.“In my view, the bench warrant against Mimi was entered improperly because of the $25,000 provision which the court recently vacated,” he said in an interview with me. “In her petition Lyneis was seeking a restraining order against Mimi. A restraining order lapses on its own in 14 days. That’s not what she got. The court granted her a broad injunction. Lyneis had a huge burden of proof to get the restraining order. After that, she was supposed to notify us of a hearing within 14 days. She didn’t do that. It was based on no evidence whatsoever.”“After all this time, I still have not seen any evidence to support [Munger’s] guardianship,” he concluded. “I have emails from Lourdes saying ‘we don’t want [Wahab] here.’”“Twice on the record now in open court Ehrlich has said he wants to get the house to pay fees,” [referring to both his and Munger’s legal fees]. “I don’t see how that’s a basis for keeping this poor woman in this location, isolated, with no visitation. I’ve never seen it before in 31 years of doing this.”I reached out to both Lourdes CEO Sr. Maureen Comer and Lyneis. In a series of email responses, Lyneis requested my “credentials” in the form of a “CV”. When I refused to provide her with a resume, Lyneis declined to confirm or deny any of the emails or statements on court transcripts made by her or Lourdes staff members. She also refused to answer a long list of questions pertaining to everything from Wahab’s initial medical diagnosis to why a petition for guardianship was filed over a past-due bill.I also reached out to Hallmark via email and telephone and was told by a staff member in her office that, since she had not responded to my email, it was an indication that she had no comment.An Oakland County Probate Court Administrator later replied, “In the interest of fairness to those involved, it is this court’s policy not to comment on pending litigation.”Wahab’s first GAL, Brown, however, did respond. “As I stated in my report, Ms. Wahab consented to the guardianship,” he wrote. “I also felt, after interviewing Ms. Wahab, that she needed a guardian to be appointed. The information regarding the medicals was given to me by the nursing home regarding Ms. Wahab’s medical condition and are consistent with my report and testimony.”This is not a story drawn from a dystopian fantasy. It is happening today all over America, where Probate Courts employ an exponentially growing network of professional, for-profit guardians.I talked at length to six other families—in Michigan, Arizona, New York and Illinois respectively about their experiences with predatory guardians; some are court appointed professionals, others are family members granted leave by Probate Courts to cut their siblings out of a ward’s life.The tapestry of each story was as complicated as it was heartbreaking. Each narrator pulled on the memory of each thread of that tapestry and found tears, despair, rage and frustration behind it.In October, 2017 WXYZ television in Lansing, Michigan launched an investigation into the Oakland County Probate Court and its court appointed guardians Barbara Andruccioli and Thomas Brennan Frasier whom a family member accused of neglecting and financially exploiting her parents Lorrie and Sandy Kapp.Andruccioli and Brennan have yet to respond to these allegations.The Oakland County Probate Court judge in the case, Daniel A. O’Brien, issued an ex parte order denying WXYZ the ability to show the Kapp’s faces.Andruccioli was subsequently fired as a public administrator and has become part of a still ongoing criminal investigation by both the Oakland County Prosecutor’s Office and the Sherriff’s office yet she still remains conservator and guardian for cases at the Oakland County Probate Court.According to court documents from the Michigan Court of Appeals, in 2011, Hallmark appointed Munger as guardian to Angela M. Robinson who had been declared legally incapacitated. In 2012, her parents Remo and Marie Marzella petitioned Hallmark to remove Munger as guardian and transfer her to their care. They claimed Munger “had not investigated Angela’s best interests or made proper decisions regarding her future care.”Following an evidentiary hearing, Hallmark denied the petition.“I am not going to remove Mr. Munger at this point,” she said. “I don’t find that Mr. Munger did anything wrong.”In a subsequent 2014 lawsuit, the Marzellas accused Munger of committing legal malpractice. Among the complaint’s allegations, Munger “failed to investigate and ascertain Angela’s best interests with respect to her living arrangements, advocated for Angela to live in an institution instead of with her family” and “failed to foster Angela’s family relationships and family involvement in her care and life.”“Angela and her special needs trust were subsequently shorted and she and her family suffered economic and non-economic damages,” the complaint added.Munger claimed that, because Hallmark had already ruled he “did nothing wrong” during the petition for his removal, the Marzellas were barred by “collateral estoppel” (preventing an issue from being relitigated.)In 2016, the Michigan Court of Appeals found that “no discovery was even conducted before [the evidentiary] hearing. Simply stated, the probate court’s decision not to remove Munger as Angela’s guardian was not tantamount to a finding that Munger did not commit legal malpractice or breach fiduciary duties owed to Angela.”It concluded that the Marzellas “never had a full and fair opportunity to litigate the issues underlying their claims.”The same court dealt with the 2007 case of Brenda Cupp—who suffered head injuries after a car accident. According to court documents, her sister Dana Browning had been appointed as guardian. After Cupp’s attorney contested the case, Munger was appointed co-guardian and co-conservator of Cupp’s special needs trust.Five weeks later, Munger petitioned the probate court for Browning’s removal as co-conservator “on the basis that she acted erratically during Cupp’s independent medical examination [IME] and Munger heard second-hand that Browning intended that the money in Cupp’s estate would not be used to pay legal fees.”The petition was granted.In 2010, the Michigan Court of Appeals ruled “the IME incident was not sufficient good cause to remove Browning from her co-conservatorship position a mere five weeks after her appointment” and that “the probate court abused its discretion in finding that good cause existed to remove Browning as co-conservator.”In 2002, Joseph Ehrlich, was sanctioned over $113,000 by a Michigan Court for “pursuing frivolous litigation” in a case disputing the estate of John J. Fannon, Jr.Ehrlich appealed in 2005 and, in denying that appeal, the court stated that “The record reflects that, when they joined the case, Ehrlich and his firm continued to file pleadings and documents that lacked factual and legal support. The record clearly reflects that Ehrlich failed to make reasonable inquiry into the factual and legal merit of the claims he asserted on behalf of plaintiff when he knew or should have known that they lacked such support.”On his website, Munger claims to be an Oakland County Public Administrator although an email from State Public Administrator Michael Moody reads “Mr. Munger’s appointment as an Oakland County Public Administrator was terminated on October 6, 2017.” Munger is also not among the Oakland County Probate Court’s list of Public Administrators.Between June 29, 2016 and September 19, 2017 Munger’s statement of fees and services billed for his guardianship of Wahab totaled $12,282.I reached out to Munger by email and telephone and was told by his office secretary that he had no comment.I reached out to Ehrlich via email and telephone. His office secretary responded that Ehrlich had never received the email. When I asked to speak to him in person, she concluded the conversation.There are also a number of cases involving Holocaust survivors.Al Katz barely escaped numerous Nazi camps, including Dachau, only to become the ward of guardians in Florida at the age of 89, as court documents show.“My father came to the United States in 1946,” his daughter, Dr. Beverly Newman, told me.“His mommy, daddy, little brother, older sister, her husband and their one-month-old baby had all been murdered. He was a walking skeleton with no money, no job and didn’t know the English language. He felt very alone.”Nevertheless, Newman remembered that her father never lost a wonderful sense of humor while he lived by the motto “Never forget, never forgive and never be bitter.”It was at a Purim ball in Indianapolis that Katz met Sophia Passo.“He was stricken with love,” Newman laughed. “He asked her over and over again to marry him. She just would not do it.”Katz started to work in bakery and then a packing house where he was injured twice. It was when Sophia was visiting him in the hospital that she relented.He and Sophia were married in 1947. Katz began a successful insurance career. The couple had two children, Newman and her younger brother, and were inseparable for over thirty years until Sophia passed away in 1977.The devastation Katz felt remained with him the rest of his life.After retirement, Newman said that her father became a snowbird, spending winters in Florida.In 2009, concerned for his health, one of Katz’s doctors contacted a public guardian.That individual was M. Ashley Butler who worked in the Office of Public Guardian for three Florida counties since 2006 together with a partner, Jo Eisch, under the business name Aging Safely, Inc.Newman maintained that the first she heard about it was when she was told by Katz’s Indianapolis attorney that “there are people poking around about putting your father into guardianship. That was August of 2009.Newman added that hospital records she obtained from the time include numerous orders made by the guardians not to inform her of any medical decisions or procedures.“On Rosh Hashanah, September 18, [Butler and Eisch] filed papers to put my dad into Emergency Temporary Guardianship,” Newman said, adding that neither guardian had ever met her father. “They didn’t even know him. I have the transcripts of the hearing. The judge knew that I had not been contacted and went ahead and approved it anyway. Things then moved very quickly.”A 2011 Florida Supreme Court complaint filed by Newman and her husband noted that Bradenton attorney Ernie Lisch was appointed by the court to act as Al’s counsel.“Despite many irregularities at the hearing, Lisch took no steps to advocate for or protect the rights of his client,” the complaint reads. Lisch contested these allegations, and the Florida Appellate Court ruled in his favor.Newman discovered that Katz had been placed in Casa Mora Nursing Home in Bradenton.In 2015, the Bradenton Herald reported that the facility was one of three on a Florida watch list “due to prior problems or deficiencies.”The Herald noted, among those deficiencies, “A 58-year-old Casa Mora resident and the resident’s representative had requested in a resuscitate order that the resident receive CPR if she was ever found unresponsive. This procedure was not followed when she fell unresponsive. She was pronounced deceased after not receiving CPR.”According to the article, these deficiencies have since been corrected.Casa Mora is no longer on the state’s watch list.Newman and her husband Larry immediately drove from their home in Indianapolis down to Florida.She asserted that, shortly before they arrived on September 20, Butler utilized the Florida Baker Act—which allows for involuntary commitment—in order to place Katz in Manatee Memorial Hospital.“They said that he had taken his walker and bumped it into someone at the nursing home,” Newman said. “But my Dad was barely able to use a walker. He was in very poor physical condition and not a danger to anyone else. They never told him anything. Not what was going on, nothing. We arrived while daddy was in the Manatee Hospital emergency room. It was horrifying. My dad just wanted to go home. A psychiatrist chosen by Butler and Eisch made a No-Contact order. The hospital kept my daddy in an underground unit, like a dungeon. There were armed guards and these huge electronic doors. A nurse told us he was pacing the halls like a caged animal. It was traumatizing.”She added that Katz was there for three weeks.Newman remembered Katz calling Butler and Eisch “Nazis” to their faces.Meanwhile, like the family members in Michigan, Newman launched a fight to have Butler’s guardianship removed and her father returned to her care, as court documents show.Opposed by Lisch, the case was heard on October 26, 28, and 30, 2009 in Florida’s Twelfth Judicial Circuit Court.“In the intervening three weeks, Katz was repeatedly hospitalized and near death,” the 2011 complaint noted.“Guardianship in Florida is a very lucrative industry,” Newman said. “People who go into guardianship lose every cent they ever had. Their families are wrecked.”She stated that the guardians even took control over her father’s Holocaust Survivor Compensation checks as part of their oversight of her father’s assets.I attempted to track down Butler. The telephone numbers for Aging Safely have been disconnected. Email addresses for Butler have been shut down. The last I-990 tax return filed by the organization in 2014 listed bet assets of $1,767.00.As of publication, Eisch had not returned phone calls or email requests for comment.In Newman’s case, Florida Circuit Court Judge Paul E. Logan (now retired) restricted visits to her father to only three hours-per-day. “He said I could never tell my daddy that I was fighting in court to get him home or that he was under guardianship,” Newman asserted. “If I did, I would lose visitation completely. Daddy was crying and saying, ‘Take me home!’ ‘Why do you have to leave me?’ ‘Why can’t I go home with you?’ and I was prohibited by court order from telling him the truth.”On November 23, 2009 Newman won her petition for guardianship of her father but not his property.“I didn’t care,” she said. “I just wanted to get daddy out of the nursing home and hospitals and give him a real life. It was such a relief that I couldn’t stop crying.”However, by then, Katz was extremely ill and in the hospital.“I spent Thanksgiving that year with my daddy and in the hospital,” Newman said. “In some ways, that as the best and worst Thanksgiving of my life. At least I could shower him with love and attention.”By the time Newman and her husband got Katz home, it was Hannukah.“He was finally smiling,” she said. “By New Year’s Eve, he was able to eat and talk. We took him to a restaurant that he liked. We got him all dressed up. He wanted us to take pictures of us celebrating New Year’s Eve. It was a happy time.”Their time was all too short. Katz passed away on July 11, 2010.“He had no catheters or feeding tubes in him,” Newman said. “He was just as normal as you could be at 90-years-old.”In January that same year, Lisch filed a petition for $24,354.15 in attorney’s fees and expenses.“For doing essentially nothing,” Newman asserted.She opposed it and took the case all the way to Florida’s and then the United States Supreme Court, the latter of which declined to hear the case. Ultimately, Lisch prevailed in his original petition.Even nine-years after her father’s death, Newman said she is still subjected to verbal abuse and numerous accusations from those with a vested interest in a system against which she has actively taken a stand. Meanwhile, she continues to fight in Indianapolis to settle her father’s estate and to remove liens on Katz’s properties.In 2006, in the case of Marshall v. Marshall, the USSC determined that issues dealing with Probate Courts are “reserved to state probate courts” and “also precludes federal courts from disposing of property that is in the custody of a state probate court.”In memory of her father, the Newmans founded the Al Katz Center for Holocaust Survivors and Jewish Learning in Bradenton.“We serve many hundreds of persons every year through advocacy and programming open to the entire community,” the Center’s website reads, “and we are life-sustaining and life-saving to elders in peril and trauma.”On the opposite side of the country, the probate and guardianship system created another activist and family advocate out of an individual who found herself opposing those who have successfully exploited it.The Bradenton police department wouldn’t help Newman. Brun said that the police in her case were similarly unable to act, unless it was to prevent her from entering Lourdes to see her mother.[T}here is an organization that advocates for those working in the profession.The National Guardianship Association (NGA) was formed during a national conference in Chicago in 1988—one year after the AP’s article was released.In the 30 years that followed, the NGA’s membership increased to over 1,000.Sally Hurme is an attorney and member of the NGAs Board of Directors. She said that, while she is not and has never been a guardian, she has been involved in developing guardianship policy for decades.“NGA does not have any mechanism by which to do anything other than to keep developing standards of practice and educating individuals who want to provide excellence in guardianship,” she said.According to the NGA’s website, those standards of practice have increased from the original seven to their present number of 25. In 1997, the NGA voted to create an entirely separate entity, the Center for Guardianship Certification (CGC) on whose board Hurme has also served.It states its vision as one in which “every professional guardian will obtain and maintain CGC certification.”“The CGC is the only national certifying body for guardians,” Hurme said. “Any guardian; professional, family, public or volunteer is welcome and encouraged to become certified.”Among the five pillars Hurme listed as necessary to obtain certification is an examination.To become a Nationally Certified Guardian (NCG), the $375 exam is scored on core competencies including professional practices, knowledge of person under guardianship, application of surrogate decision making, medical decision making and personal and financial management.The competencies listed in the $525 examination to be certified as a National Master Guardian (NMG) are basically the same with the addition of “professional practices of a master guardian” and knowledge of the guardianship planning process.Hurme stated that, at present, there are approximately 1,500 certified guardians.“There is an agreement to a disciplinary process which receives grievances, determines whether there is probable cause to go forward with a professional review board,” she stated.Ironically, according to Hurme, the professional review board is one in which “due process” is afforded to a certified guardian while a determination is made as to whether or not they have violated standards of practice.“The professional review board has a range of sanctions from a letter of concern, to suspension, dismissal to decertification,” Hurme said. “The one problem with the CGC process is that we can only hear grievances if the individual is certified. If we receive a complaint about a guardian that is not certified, our hands are tied. There’s nothing the CHC can do.”The CGC’s list of disciplined guardians posted on its website numbers 12 and includes April Parks alongside guardians from Oregon, Texas, Utah, Nevada, New Hampshire, New Mexico, Ohio, Oregon and Michigan.The CGC lists 12 States that ask for mandatory CGC certification for its guardians or have their own State-specific licensing requirements. In the case of California, it’s a combination of the two. Michigan is not among them. Since 2016, Florida has employed The Office of Public and Professional Guardians (OPPG) to regulate “more than 550 professional guardians statewide, which includes investigating and, if deemed appropriate, the discipline of guardians in violation of the law.“NGA and many of the other organizations such as those that are members of the National Guardianship Network are continually striving to make guardianship work better for those individuals who will need it,” Hurme said.As an example of those efforts, Hurme noted the Uniform Guardianship, Conservatorship, and Other Protective Arrangements Act (UGCOPAA). The over 150-page document was drafted, over the course of two years, by a committee consisting of multiple stakeholders including representatives from the American Bar Association (ABA) and was approved and recommended for enactment in all US States at a July, 2017 meeting of the National Conference of Commissioners of Uniform State Laws.Hurme stated that members of the NGA, herself included acted as technical advisors to the commission “in making sure that the new model; law addresses many of the issues that are floating around in guardianship; perhaps that there are too many guardianships and that there needs to be more emphasis in limiting the authority of the guardian, better recognition of the due process rights of the individual and a more person-centered focus of the individual in the hearing process that limits the authority of the guardian.”American Association of Retired Persons (AARP) Senior Legislative Representative Diana Noel was part of the drafting committee.“I felt as if it was a very thorough process that was very public,” she said. “There were a lot of people in the room. One of the things that is very important; that the drafting committee really wanted to come across, which is why the name is so long, is to recognize that guardianship was a system that was really not including the individual that it was about. One of the things the act did was to update terminology. Instead of using the term ‘ward’, it’s ‘individual’ so that the focus is on the individual and so that they have a say in their care.”A Uniform Law Commission document encouraging States to adopt the UGCPOAA, declares that, under the act, “Each guardianship and conservatorship will have an individualized plan that considers the person’s preferences and values. Courts will monitor guardians and conservators to ensure compliance and approve updates to the plan in response to changing circumstances.”It adds that “Without a court order, a guardian under UGCOPAA may not restrict a person under guardianship from receiving visits or communications from family and friends for more than seven days, or from anyone for more than sixty day” and that the act “prohibits courts from issuing guardianship or conservatorship orders when a less-restrictive alternative is available.”These provisions and others in the UGCOPAA could have protected Brun and her mother had the act been adopted in Michigan.It hasn’t.As of the time of publication only Maine has adopted it. The New Mexico State Legislature introduced it this year and opened it up for public comment.Hurme pledged that the NGA would direct its advocacy efforts to assisting States in understanding the importance of what she called “a forward-thinking law.”“This isn’t a partisan issue,” [Noel] asserted. “This isn’t a caregiving and an aging issue. I don’t want you to think that, because States haven’t adopted it, that means that they are not looking at it. They may be looking at it. These things take time. They look at their current laws, they see what’s working and what’s not working and how things like the Uniform Act could help fix what’s not working or enhance what is.”“As long as I’ve been here, I’ve been working on this issue,” she said. “States have been working on and updating their statutes because they are pretty outdated. They’ve been around for a very long time. It’s a very complicated system. What we’re doing and what states are doing is making sure that policy and practice meet and complement each other.”The Elder Abuse and Prevention Act passed by the senate and signed into law by President Trump in 2017, charged the Department of Justice with establishing “best practices for data collection on elder abuse” and “in coordination with the Elder Justice Coordinating Council, [to] provide information, training, and technical assistance to help states and local governments investigate, prosecute, prevent, and mitigate the impact of elder abuse, exploitation, and neglect.”“We have a real long history in combatting abuse and exploitation and ensuring that State laws address and prevent abuse by a guardian or a neighbor or whoever,” Noel said. “We’ve really been engaged in working not just with State legislators but State courts.”Wondering about the laws in a State like Michigan and how far they extended in the protection of wards and their families from predatory guardians and the probate courts which employ them, I reached out to probate attorneys across the State.Nathan R. Piwowarski is a highly respected lawyer and share-holder at the firm of McCurdy Wotila & Porteous, PC in Cadillac. He has been practicing trust, estate and elder law for ten years.Ronald Dixon has practiced law since 1975 and served as a hearing panelist for Michigan’s Attorney Discipline Committee for approximately 25 years.Neither Dixon nor Piwowarski were asked to comment on or given the details about any case pending or decided in Michigan Probate Courts.“The problem is that when a person needs a guardian or conservator, frequently the family members are not worked with by the court or by the guardian appointed,” Dixon said. “The families are concerned, always, about the living conditions for the ward.”He added that a conflict between a conservator and the family can be easily avoided with a durable power of attorney that specifically names a family member and an alternative as guardian and conservator “and none other.”However, if judges arbitrarily strike down a durable power of attorney in favor of a court-appointed guardian, Dixon noted that “they should not do that. They should follow the family wishes. If that happens, it should be immediately appealed.”He added that a judge needs to demonstrate sufficient grounds as to why a power of attorney listing a family member can be discarded.“The record should be complete,” he said. “Showing the reasons why this person is not qualified or cannot maintain their position.”Piwowarski noted that the issue “can get a little bit complicated” depending on whether the power of attorney is generic and related to financial transactions or whether it concerns healthcare and placement issues (a patient advocate designation.)“In the case of the latter, unless the court specifically invalidates that document and removes the patient advocate, it remains in place,” he said. “The law presumes that the patient advocate would continue serving. That document should stay around unless there was some problem with it like there were not an adequate number of witnesses when it was signed. There are also situations where there is a valid document, but the patient advocate is not doing their job or honoring the person’s preferences.”In terms of the Constitutional rights a participant in Michigan’s Probate Courts can expect, Piwowarski cited Michigan Compiled Law (MCL) 700.5304 (4) through (6) which addresses the rights of the individual who is allegedly incapacitated.“They include the right to a jury trial [or] a closed hearing, if they request it, the right to be present at a hearing, the right to obtain an independent medical examination,” Piwowarski said. “There are other procedural rights and protections that are supposed to be afforded the individual who is the subject of a guardianship petition. For example, they’re entitled to personal notice in advance of the hearing. The minimum personal notice requirement is seven days. They are supposed to be given a visit by the Guardian ad Litem who is then supposed to report back to the court, in a timely manner, about whether that individual desires to contest any aspect of the petition or exercise any procedural rights such as the right to request something less intrusive than a full guardianship.”According to Piwowarski, different rights are afforded to those who have an interest in the subject’s welfare.“There are certain rights that they just don’t have,” he said. “They can’t demand a jury trial. But if there is a durable power of attorney, all of those individuals are entitled to notice and entitled to participate in the proceeding.”“In terms of who should be serving as a guardian, the nominated patient advocate is right near the top of the list,” he added. “So, the court should be looking to the patient advocate before almost anyone else. The way the statute should work and the way that it’s written is that the court can only intervene in a person’s affairs if that person is legally incapacitated and if there’s an actual need for the court to intervene. The court should evaluate, on the record, why a patient advocate is inadequate. There are express provisions in the Estates and Protected Individuals Code that tell the petitioner and the judge that they have to identify why the court has to actually intervene alternatives short of guardianship can’t be used.”The question of how much power a professional guardian in Michigan has Piwowarski noted both a statutory and political dynamic.“In terms of the statue, a guardian has the right to set appropriate access and limit access for a protected individual,” he acknowledged. “That said, the guardian is specifically required by statute to do everything they can to have as full of a life and as high of a level of function as possible. In terms of financial transactions, the court can issue protective orders to remediate situations where a vulnerable person made a property transfer when they didn’t understand it or were under inappropriate influence. A conservator is not able to do something like that without a court order and there should be pretty significant showing before a court would reverse a transaction like that.”“In my experience the court is typically appreciative of the willingness of a public fiduciary [guardian] to serve,” Piwowarski added. “There is such a need right now for a variety of reasons; families are smaller and more spread out. The public fiduciaries typically are overworked so I can certainly see a situation where a court adopts an overly deferential attitude because of the role that they serve in keeping the local legal system functioning.”“Oakland County is the wealthiest county in Michigan bar none,” Dixon said. “Frequently estates are incredibly large. Public administrators can err on the side of greediness for him or herself. Frequently, because the judge trusts them to carry out their tasks properly and in good order and rely on them for accurate information.”On a national level, the sheer power that has been extended by Probate Courts over wards and family members raises the question as to what the point is of making any kind of will when it can be rendered meaningless.******Gretchen Rachel Hammond is an award-winning journalist and a full-time writer for Tablet MagazineGuardians from Hell - Tablet Magazine

Re your query: Do Jehovah's Witnesses know that 4.5 million lives are saved each year by blood transfusion? Would God want the equivalent of half the JW population to die each year because he views life as sacred?I appreciate your query but please note the following comments by well know surgens:Please note the following comments from well known Surgens on the matter of ‘Blood Transfusions’TRANSFUSION ALTERNATIVE HEALTH CAREMeeting Patient Needs and RightsNarrator: Each year in this new millennium, pressures on health-care systems mount. The growing number of patients, particularly the elderly, challenges health-care providers’ ability to meet patient needs with available resources. At the same time, legal and ethical voices increasingly advocate that patients be permitted a greater role in choosing their treatment. These developments especially affect one major sector of health care.Prof. Neil Blumberg: There’s a growing concern on the part of physicians that our approach to blood transfusion needs to be reevaluated.Prof. Roland Hetzer: Today at least 80 percent of the patients would strongly favor not to have blood transfusions.Narrator: News headlines show this, both physicians and patients are faced with transfusion complications, supply shortages, and concerns about blood product safety. As just one example, the world health organization calculates that around the globe unsafe transfusion and injection practices cause some 5,000,000 Hepatitis-C virus infections each year. Increased efforts by national health-care systems to achieve a safer blood supply have caused the cost of blood to spiral upward.Dr. Guy Turner: Two years ago it cost us about 63 euros per unit of transfused blood. It now costs us 142.Narrator: Treating transfusion-related side effects has incurred additional costs.Dr. Aryeh Shander: These costs, which are indirect and delayed, are enormous and clearly would raise the cost of the unit of blood substantially.Narrator: The same holds true for compensation totaling billions of euros or dollars that have been paid to recipients of tainted blood and to their surviving families. As society faces these issues—transfusion risks and costs—is there a better approach? Might transfusion-alternative health care meet patient needs and rights? Professors Earnshaw and Hetzer and countless other clinicians have responded to the requests of patients and of parents of minors. Consider three examples of complex surgeries performed without transfusion. Open-heart surgery is consistently a major challenge. In Berlin, Professor Roland Hetzer explains why he had to operate on the tiny heart of a ten-month-old baby girl.Prof. Roland Hetzer: This child has a congenital heart defect, which is relatively rare. It means there is a direct communication between the left ventricle and the right atrium, which creates a continuous abnormal flow between the left heart and the right heart.Narrator: The defect was corrected with a heart arrest time of only 26 minutes, and the blood flow normalized. No transfusion was given—in fact, there was virtually no blood loss. Another example: Liver surgery usually involves considerable donor transfusion. In Jena, Germany, at the University Clinic, Professor Johannes Scheele here removes the cancerous portion of the liver from an elderly man.Prof. Johannes Scheele: How much was the blood loss today? ...250 CCs.Narrator: No donor blood was given, and 18 hours later, the patient is chatting with the doctor in the ICU. Now an example of orthopedic surgery: In London, Royal College fellow Peter Earnshaw successfully performs a total knee replacement on an elderly woman, typically a high-blood-loss operation. All three successful operations were accomplished by surgical teams committed to respecting the patient’s or parent’s preference that donor blood not be given. Were these experimental operations by three pioneering surgeons? There are more than 100,000 physicians and surgeons in 150 countries who routinely treat patients without donor transfusion. Some experts feel…Dr. Linda Stehling: Every anesthesiologist and surgeon should be interested in blood-conservation strategies because it’s good patient care.Narrator: When physicians who turn to transfusion-alternative health care are asked why, they often cite as a major reason—respect for their patient’s decision. Professor Blumberg, director of a transfusion medicine unit and blood bank:Prof. Neil Blumberg: Well, I think there are a growing number of patients who are interested in being treated with either no transfusion or the minimum amount of transfusion possible, and there are some folks who strictly don’t want to be transfused under any circumstances.Narrator: Another area motivating physicians and surgeons to change their approach is the growing evidence of inconsistent practices leading to unnecessary transfusions. Everyone concerned with improving health care or protecting the individual patient should consider some revealing studies on blood use. First, the Sanguis Study. As part of a concerted action by the European Commission Medical Research Program, transfusion rates in 43 major teaching hospitals across Europe were analyzed. The ramifications of the Sanguis Study are staggering—for the same type of operation, there were enormous variations in the number of units transfused, depending on the hospital! In 1998 in Brussels, Professor Baele published a follow-up study.Prof. Philippe Baele: All types of hospitals were included in the Belgium Biomed Transfusion Study for Surgery. And we found exactly the same range of variability.Prof. Lawrence T. Goodnough: So we are left with the conclusion that variability implies that a lot of these blood transfusion components are being given unnecessarily.Narrator: A comparison of the two studies revealed another significant fact.Prof. Philippe Baele: There were two centers which participated both in the Sanguis Study and in the Biomed Study.Narrator: Based on their findings in the Sanguis Study:Prof. Philippe Baele: They had somehow managed to reduce their blood consumption for major surgery. The mortality was the same before and after the changes. The hospital stay was shorter. The new procedures they adopted weren’t very difficult to adopt, although they took time and took a considerable educational effort, but they didn’t result in increased costs.Narrator: Soon after, in Canada, Dr. Hebert did a large-scale study of critically ill patients in intensive care. Professor Spahn evaluates the results.Prof. Donat R. Spahn: I talk about the Hebert paper, where they showed in more than 800 patients that less transfusion results in an improved outcome.Narrator: The obvious conclusion is that unnecessary transfusion translates into unnecessary labor and unnecessary cost. Besides patient demand and overtransfusion, many physicians cite as motivation to implement transfusion-alternative health care the desire to avoid medical risks.Prof. Lawrence T. Goodnough: There’s the risk of bacterial contamination in a stored unit of blood.Narrator: Bacterial contamination, whether occurring at donation or subsequently from improper storage, can cause infections having fatal consequences. In another arena, despite improved testing viral infections continue to pose a serious threat. Experts are concerned about what the future holds.Dr. Howard L. Zauder: Will existing viruses mutate and produce disease? There’s no reason to believe that they won’t.Prof. Peter H. Earnshaw: The problem with contamination of transfusions, it always seems to be one step ahead of us.Prof. Donat R. Spahn: In addition, blood transfusions induce a immunosuppressive state with the recipient, and that results in increased postoperative infections as well as earlier and more often recurrence of tumors.Prof. Neil Blumberg: We’ve estimated that, approximately, in the United States, we can expect that 10,000 to 50,000 patients a year may be dying from transfusion-immunomodulation related causes.Narrator: Likely the most surprising and least recognized medical risk is human error—giving blood of an incompatible type can cause a reaction ranging from mild to fatal. Professor Spence, a director of surgical education, acknowledges:Prof. Richard K. Spence: We can mix the blood up and cause catastrophe. Patients have died and do die from getting the wrong blood.Narrator: In fact, reports indicate that human error causes up to one half of all transfusion-triggered deaths! In the light of such realities—patient decision, unnecessary transfusions, medical risks, as well as shrinking blood inventories and soaring blood costs—Professor van der Linden summarizes what many experts have concluded:Prof. Philippe van der Linden: In view of the potential for a better patient-care and a reduced health-care cost, blood conservation is not an option, it’s a must.Narrator: The good news is that safe, practical, and cost-effective therapies already exist.Dr. Aryeh Shander: The best medical care can be delivered without the use of allogeneic blood.Prof. Peter H. Earnshaw: There are some very simple, very cheap things you can do, which would help the majority of people, and this could be done in the smallest of hospitals.Prof. Johannes Scheele: Blood conservation is a very simple method, which make things rather smooth, less expensive, and with a better outlook for the patient.Narrator: The transfusion-alternative techniques used by these surgical teams can be grouped within one of three basic principles, or pillars. The first is “tolerance of anemia.” Racing through the arteries, red cells carry life-sustaining oxygen to all parts of the body. The anemic patient has a low number of red cells in relation to his blood volume. If a person suffers extensive blood loss during surgery or as the result of an accident, the body can tolerate anemia to a considerable degree. Professor Moore, an acknowledged pioneer in trauma surgery:Prof. Ernest E. Moore: Studies have shown, physiologically, that the human being can tolerate much lower hemoglobin levels than previously assumed safe.Dr. Aryeh Shander: The medical community is starting to realize that tolerance of a significant anemia is doable for patients.Narrator: However, anemia is tolerable only when the body has sufficient circulatory volume to continue to function.Prof. Richard K. Spence: We also know that with that anemia, we can compensate with volume, because volume is the critical component here to maintaining blood pressure.Narrator: With low-cost blood volume expanders being available, current medical opinion increasingly abandons the arbitrary rule, proposed back in 1942, that a hemoglobin level of 10 was the transfusion trigger, or the lowest acceptable figure before administering a transfusion. Thus, Professor Earnshaw notes his first step in implementing a transfusion-alternative program:Prof. Peter H. Earnshaw: I halved our transfusion rate by simply saying, ‘could we lower our triggers from 10 to 8?’ And just taking a little more control over the decision. That was very easy. That cost nothing.Narrator: Simply implementing the first pillar would cut out millions of transfusions and save billions of euros or dollars annually! The second important principle in transfusion-alternative strategies involves stimulating red-cell production in the patient’s body. This is important for an anemic patient before surgery, and it can speed recovery after extensive blood loss. Studies directed by Professor of Obstetrics Albert Huch have shown:Prof. Albert Huch speaking German: Sufficient iron supplementation can already normalize the blood count to a large extent and at relatively little expense.Narrator: In selected cases, the genetically engineered drug erythropoietin, commonly called epo, can be used. Professor Mercuriali, a director of transfusion services, explains:Prof. Francesco Mercuriali: Stimulated by the administration of erythropoietin, there is an acceleration of production of new red blood cells.Narrator: The third principle, or pillar, is to minimize blood loss.Prof. Johannes Scheele: The most important technique to control bleeding is to avoid bleeding.Narrator: Meticulous surgery is practical and cost-effective. A variety of tools can be used to assist. For example, electrocautery devices enable surgeons to cut rapidly and to seal blood vessels immediately. There are also modern drugs that can reduce bleeding. Some are applied directly to the bleeding area. Here a fibrin glue pad is used to stop blood from oozing out of a dissected liver. Professor Baron notes about the cost-effectiveness of such agents:Prof. Jean-François Baron: The decrease in the intraoperative bleeding and the decrease in the use of blood products compensates for the cost of the drug.Narrator: Another effective technique to minimize loss in instances of heavy bleeding is to salvage the patient’s own blood. Recovery of as much as 50 percent of the blood otherwise lost has become a reality. This technique also meets the ethical needs of many who absolutely refuse donor transfusions. For instance, some of Jehovah’s Witnesses have allowed cell salvage to be used. There are even such machines designed for small children.Prof. Donat R. Spahn: Cell salvage is a very important technique because when you use cell salvage, the blood lost by the surgeon is not lost for the patient.Narrator: Many other beneficial strategies are available. All assist in avoiding the risks and societal costs of millions of transfusions. To illustrate the impact of properly combined techniques, consider the task faced by the medical team of four-year-old Luana in Modena, Italy. She was born with a serious heart defect. Her team, headed by Professor Marcelletti, chief of cardiovascular surgery, had to perform a series of complex operations. As requested by Luana’s parents, the first operation was successfully done without donor blood. Once again, for the second procedure, there were both skilled personnel and the appropriate equipment, including a cell-salvage machine. The meticulous surgery, utilizing electrocautery, took two hours, and Luana lost only 100 milliliters of blood! Her parents were delighted, and the medical team was pleased with the outcome.Prof. Carlo F. Marcelletti: We have performed the operation without the use of a blood transfusion, as we try to perform with all of our children.Dr. Nicoletta Salviato: I think all these little babies deserve not to be transfused and not to take the risk of a blood transfusion.Narrator: Further proof of the effectiveness of heart surgery without transfusion is provided by Dr. Rosengart:Dr. Todd K. Rosengart: When we looked at a series of 50 Jehovah’s Witnesses patients and 100 patients in the general population, we found a shorter length of stay and a lower cost using our blood-conservation strategy.Narrator: While many clinicians would hold that some situations absolutely require blood, what is the view of those experienced in the use of transfusion alternatives in life-threatening emergencies? First, an anesthesiologist’s perspective:Dr. Aryeh Shander: The cessation of bleeding, whether surgically or by other means, must be the first principle. It’s important to act quickly, and to keep in mind that modalities are still available even in a trauma situation.Narrator: Next, a surgeon’s perspective:Prof. Johannes Scheele: In any trauma patient with a significant blood loss, I would always prepare the cell-saver system.Narrator: In one of the busiest trauma centers in the United States, Professor Cohn, chief of Trauma and Surgical Critical Care, notes about patients declining donor blood:Prof. Stephen M. Cohn: We see more than 3,000 patients a year here that are Jehovah’s Witnesses, and we do about 250 to 275 major operations on them each year. And what we have seen in our population is no increased length of stay, no increased mortality. In fact, it appears to be somewhat decreased.Narrator: On the basis of such experience, many physicians conclude that, overall, transfusion-alternative health care is cost-effective:Prof. Richard K. Spence: One of the beauties of transfusion alternatives is that the most effective alternatives are generally the cheapest.Prof. Stephen G. Pollard: There’s no doubt that blood is a costly product. We’ve been able to reduce our blood-transfusion bill for the liver-transplant program here by 70 percent since we started adopting new techniques. And that equates to hundreds of thousands of pounds in a year, and it’s far more than the cost of the drugs and the other therapies we use and the mechanical methods we use for reducing blood loss.Prof. Philippe Baele: It takes more dedication than technical means. Similar results can be achieved without the use of costly machinery.Narrator: And transfusion-alternative health care has a benefit beyond saving money and meeting patients’ physical needs. There is an ethical benefit. This care honors the patient’s freedom of choice to accept or reject a certain treatment.Prof. Neil Blumberg: One of the primary principles of good medical care is being concerned about what the patient wants.Narrator: Professor Harding, who teaches ethics to medical and law students:Prof. Timothy W. Harding: Today one would link that ethical duty not to do harm, to seek the best possible outcome for one’s patient, with another duty, which is to respect the autonomy of the patient, to respect the patient’s own views and decisions.Narrator: At Glasgow University, Professor of Law and Ethics in Medicine Sheila McLean summarizes:Prof. Sheila A. M. McLean: Doctors have virtually an absolute obligation, both legally and ethically, to respect the patient’s choice.Narrator: Concerning the advancing legal view generally designated “patient rights,” Professor Guillod, founder of the Health Law Institute at Neuchatel University:Prof. Olivier Guillod: I believe the basic element of patients’ rights is the right of self-determination, that is, the right of any patient to decide what shall be done with his or her own body.Prof. Sheila A. M. McLean: Patients have a right to be told that there are alternatives and, more than that there are alternatives, what are the respective risks and benefits expected to be associated with those.Narrator: Concerning the evolution of patient rights, Professor Weissauer explains:Prof. Walther Weissauer speaking German: Earlier, the doctor determined how to proceed and thereby shouldered the entire responsibility. In the course of time, the relationship has changed more and more into a partnership, doctor and patient meeting each other with full equal rights.Narrator: Recognizing patient rights accords with the UN’s universal declaration of human rights. In fact, these legal issues have become so important that in 1997 the Council of Europe formulated the Convention on Human Rights and Biomedicine. Article 5 proclaims: “An intervention…may only be carried out after the person concerned has given free and informed consent to it.”Prof. Olivier Guillod: The doctrine of informed choice says that it is up to the patient to accept or to refuse any kind of medical act, for instance, a blood transfusion.Narrator: Addressing a sensitive issue, Article 6 states: “The opinion of the minor shall be taken into consideration as an increasingly determining factor in proportion to his or her age and degree of maturity.”Prof. Timothy W. Harding: There’s no doubt that minors, in a legal sense, can and very often are able as adolescents to take decisions about their own treatment and their own health.Narrator: How does freedom of choice for patients and parents work out in practical terms?Prof. Olivier Guillod: Well, if the physician cannot think of finding a way of accommodating a patient’s desire about alternatives to blood transfusion, he should try to refer the patient to one of his colleagues or to another institution or health-care facility where this alternative is really practiced.Narrator: But what about emergencies where the victim may not be able to speak, to convey personal conviction?Prof. Timothy W. Harding: It’s now recognized that people have the right to indicate treatment choices in advance. And this takes the form of a written document where the patient shows that they have considered certain situations and they have taken a clear position about a treatment choice.Prof. Walther Weissauer speaking German: In an emergency, one would always also search for an advance directive or a durable power of attorney, for instance, in the wallet of the patient.Narrator: Respecting patient rights also has health-care benefits.Prof. Sheila A. M. McLean: There is empirical evidence that patients who feel engaged in their treatment are likely to get better quicker.Narrator: Consider, for example, a case at St. Richard’s Hospital in Chichester in southern England.Dr. Vipul Patel: Mrs. Whittington had arthritis of her hip, which was so advanced that she required a total hip replacement. She is a Jehovah’s Witness and therefore declined to have a blood transfusion.Mrs. Whittington: Well, I do believe that God’s word is against taking blood, and we should appreciate that God’s word is the truth. Mr. Patel was quite happy to do it without blood.Dr. Guy Turner: It is the doctor’s responsibility to listen to patients’ demands, listen to what they have to say, and give them an informed choice of alternatives.Narrator: In frank dialogue between physician and patient, the question of whether she would accept cell salvage arose:Mrs. Whittington: When I knew more about the machine and it was explained to me, I said I would accept having the machine.Jo Light: The relationship between the patients and the medical staff is excellent here. We have a very open culture and a good learning environment.Narrator: What was the outcome of this cooperative approach?Dr. Vipul Patel: The strategies that we used intraoperatively during Mrs. Whittington’s operation were meticulous hemostasis, salvage of blood using a cell-saver system, as well as using a cemented hip replacement. She tells me that she is delighted with the operation in terms of the pain relief.Narrator: As earth’s population continues to grow and age, their medical needs will be a greater challenge to health-care structures, many of which are already struggling. In this regard, transfusion-alternative health care offers a promising direction.Prof. Philippe van der Linden: A well-adopted blood-conservation program means a decrease in the total cost for the patient but also a decreased cost for society.Narrator: While all medical interventions involve risks, transfusion-alternative health care uniquely meets both patient needs and rights.Dr. Vipul Patel: I can foresee that in the future, patients will almost expect that any surgery which is necessary is carried out without blood transfusion.Prof. Olivier Guillod: Patient empowerment is important, not only to better respect autonomy but to promote good medical treatment.Prof. Roland Hetzer: The various steps to reduce the need of blood transfusion, nowadays, are very well established, well tested, and they are certainly safe.Dr. Aryeh Shander: This is universal, can be practiced in any institution, in any part of the world.Prof. Philippe van der Linden: Blood conservation is safe, effective, and progressive medicine.Dr. Aryeh Shander: This is the best way of treating patients and clearly should be a standard of care._____________________________________________________________________________________More examples of peoples thoughts about Blood Transfusions:NO BLOOD - Medicine Meets - the ChallengeNarrator: Dorothy McPhee has a life-threatening medical problem. An artery that could burst at any time.—"The normal way of doing this operation is, generally through the abdomen, a long vertical incision . . . "Leslie is a young girl with a serious spinal deformity.—"The patient is a Jehovah's Witness, and in a procedure of this magnitude, it's unavoidable that some blood loss will occur.Both patients need surgery, yet, both patients have religious beliefs that preclude their accepting a blood transfusion. Medical science is now providing doctors with alternative strategies to treat successfully patients who, for various reasons avoid blood transfusions. These new strategies may soon benefit all patients.NO BLOODMedicine Meets the ChallengeAt the dawn of the 21st century, society is becoming increasingly diverse. People everywhere are being exposed to different languages, customs, cultures, and religious beliefs. Adapting to these differences is a challenge to all strata of human society. It is a singular challenge for the medical community.Prof. Timothy W. Harding: "We're living in a pluralistic society, and the doctor has one set of values. But, he or she will meet patients who have their own values and their own position about certain issues."Eileen Yost, R.N: "There's a lot of different cultures out there, and they have entities specific to their own cultures, that we as health-care workers need to understand."Prof. Oliver Guillod: "I think the duty of physicians is not simply to preserve life, but the first and foremost duty of physicians is to respect the patient."Narrator: In the past the medical profession found it difficult, at times, to respect the health care need of one religious group, in particular—Jehovah's Witnesses. This was because of their avoidance of blood transfusions.Alexis: "That was the easiest decision, because there was. . . under no circumstances would I accept blood. . . "Jessica: "One thing I heard; he said: 'blood transfusion,' and immediately I said: 'No! No!' . . . "Wayne: "I just couldn't live with myself if I turned my back on my beliefs, and my God, and . . . I wasn't going to accept a blood transfusion."Narrator: Their abstaining from blood transfusions was often misunderstood by the public.Prof. Roland Hetzer: "There was certainly a time, years back, when Jehovah's Witnesses were looked at by physicians, and especially surgeons, in a negative way."Jamie Pollard, R.N.: "I think that before I ever met a Jehovah's Witness, I had a certain mind-set, that they were maybe a religious fanatic-type person."Prof. Charles H. Baron: "Part of it, I'm sure, is prejudice, about a religious sect, which the physician, or the judge, or the lawyer, . . . about which they may know next to nothing."Gene Smalley—JW spokesman: "Á lot of people nowadays have heard of dangers, or diseases, that might be contracted from blood and blood transfusions. But frankly, for Jehovah's Witnesses, central to their avoiding blood transfusions, is because the Bible highlights the preciousness of blood."Eugene Rosam—JW spokesman: "It's a very clear statement, by the way. It isn't something that takes a lot of theological study to determine, or work out. It says very plainly in the Christian scriptures:"Abstain . . . from Blood."—Acts 15:20.Prof. Charles H. Baron: "From the point of view of someone who is not a believer, it seems an irrational act."Prof. Edward Keyserlingk: "For some people, it seems to be anti-medicine. It seems to be, somehow, putting the patient in jeopardy."Diane Mitchell C.C.M.: "I think that some of us, myself included, was under the impression that maybe Jehovah's Witnesses didn't want the best medical treatment, that they were sort of against medical care."Alec: "There's no question, it mattered to me whether she lived or died. I brought her to the hospital in the first place, to help her recover."Cynthia: "I didn't want her to die, and I don't think anybody wants that to happen."Dr. Mark E. Boyd: "It's not some sort of suicide pact that they want to enter into with you. They want to live, they want to have good health care, and I think that you can work with them."Diane Mitchell, C.C.M.: "I realized that they wanted the best medical health care, but they just wanted it without blood."Prof. Edward Keyserlingk: "I think the effort has to be made to remove the perception that Jehovah's Witnesses are somehow in a category by themselves."Dr. Aryeh Shander: "Clearly, you can point to many religions, they all have one issue or another, with which you may or may not agree, but that's not the issue."Dr. Peter Carmel: "If this is a religious precept, this is not illogical stubbornness. This is a religious belief. And just as I respect the religious beliefs of many other religions, I think I have to respect that."THE RIGHT TO CHOOSE TREATMENTDavid C. Day, Q.C.: "All patients, as a general rule, have the right to receive treatment or to refuse to receive that treatment, after they've had full, open, and candid discussion with the treating physician.Prof. Oliver Guillod: "I believe that the basic element of patient's rights is the right of self-determination. That is, the right of any patient to decide what shall be done to his or her own body."Narrator: Patients' rights not withstanding, some have claimed that declining, what they say, is 'life-saving medical treatment,' is irrational.Prof. Timothy W. Harding: "It's wrong to equate a refusal of treatment with suicide, which is a conscious choice to end one's life."Prof. Edward Keyserlingk: "There is always a legitimate question about a patient's competence. But just the mere refusal of blood, in itself, is not any kind of such indication."Dr. Stephen M. Cohn: "I don't believe that refusal of treatment is irresponsible or irrational. I think that just because one person chooses to not to take this pill, or that fluid, this kind of solution, is their own personal choice."Dr. Nicholas Namais: "We have patients who say that they don't want to be on a mechanical ventilator, they don't want a breathing tube."Dr. Mark E. Boyd: "It's an everyday even, for a patient who has a malignancy or cancer, to refuse some treatment of other. They don't want to have chemotherapy, they don't want to have radical surgery, so the idea that patient's refuse treatment, is something that I work with, not take it . . . I don't take it as a personal insult."Narrator: These facts are often obscured by news stories claiming that someone died because he refused a blood transfusion.Dr. Aryeh Shander: "To say that one has died because of refusal of blood, I think is a very general misleading statement."Dr. Mark E. Boyd: "That's an oversimplification of the . . . of the tragic event."Dr. Peter Carmel: "It's rarely, if ever, the case that a patient refused a blood transfusion and therefore died."Dr. Aryeh Shander: "People die because of either a medical disease, or a consequence of trauma, or surgery where there has been complications."Dr. Hooshang Bolooki: "I can tell you I have done over 200 Jehovah's Witness patients. I have never lost a patient because I could not give the patient blood."Narrator: Why then does blood transfusion remain the standard treatment for serious blood loss?Dr. Peter Carmel: "I think that physicians have been brought up with the idea that blood is the 'gift of life,' and that inherently, blood is good for you."Dr. Avroy Fanaroff: "The refusal to accept a blood transfusion bothers and concerns many physicians because they're worried that without the transfusion, the well-being of the patient is jeopardized."Narrator: To appreciate fully why physicians feel this way, one needs to understand a little about blood and why transfusions are given.THE FLUID OF LIFE—BLOODBlood circulates through the body by means of an amazingly intricate system of conduits called veins and arteries. Arteries carry oxygenated blood away from the heart, eventually branching into tiny vessels called capillaries. These deliver the oxygen-rich red blood cells to every part of the body. Nutrients and oxygen are exchanged for carbon dioxide and other wastes at the cellular level. Veins then transport the oxygen-depleted blood back to the heart which pumps it to the lungs. There the carbon dioxide is exchanged for oxygen and the cycle begins anew. This cycle is absolutely essential to life.Dr. Nicholas Namais: "If there's no blood to bring the oxygen to the cells, the cell dies—the body dies!Narrator: When someone suffers severe blood loss, Doctors have two urgent priorities.Dr, Edwin A. Deitch: "The most critical immediate need is to stop the bleeding."Dr. Nicholas Namais: "Everything takes 'backseat' to stopping the bleeding."Dr. Stephen M. Cohn: "And number 2, is to restore the volume within your system."Narrator: "What can happen when a patient looses too much blood volumeDr, Edwin A. Deitch: "Then you don't deliver blood to the brain or the other organs and a person can die."Dr. Nicholas Namais: "And what you need to do is restore volume, restore profusion, and restore oxygenation."Dr, Edwin A. Deitch: "A way of correcting that decrease in blood volume is by giving other fluids intravenously. This can be done using any one of a number of fluid types, and doesn't necessarily require blood."CHANGING ATTITUDESNarrator: Increasing numbers of patients are opting to avoid blood transfusions for personal reasons.Prof. Lawrence T. Goodnough: "If you've ever had a conversation with a patient the night before surgery, and you were to ask them if they had a preference, would they prefer to avoid a blood transfusion, the answer is always, 'Yes.'"Prof. Roland Hetzer: "I would say that today, at least 80 percent of the patients, would strongly favor not to have blood transfusions."Prof. Francesco Mercuriali: "Blood transfusion, traditionally considered a normal adjunct to surgery, presently is considered something that has to be avoided."Dr. Willem de Groot: "There are real risks as far as transfusions are concerned."Dr. Gerard A. Kaiser: "There are concerns about blood bore pathogens, and certainly the concern about AIDS."Dr. Richard K. Spence: "It's a biological product. It can have diseases, etc. We screen for most of them, but there are some there we just don't know about."Prof. Neil Blumberg: "We've certainly seen some horrendous new diseases in the form of HIV come along that probably didn't exist in the past. Whether the next disease will come along in ten weeks, ten years, or a hundred years, nobody can say."Dr. Concha Lewand: "We have Hepatitis C, Hepatitis B, transmitted, and the social costs of that are very high."Dr. Todd K. Rosengart: "There are transfusion reactions that occur, they are very rare, but they can potentially dangerous or even life-threatening."Dr. Richard K. Spence: "We could mix the blood up and cause a catastrophe. Patients have died and do die from getting the wrong blood."Prof. Donat R. Spahn: "It is interesting to realize now, that during the late 90s or early 2000s that the blood transfusion, to a certain extent, does not do what we always used blood transfusions for."Prof. Neil Blumberg: "We've become persuaded, over the years, that many of the bad things that happen to patients after surgery, are in fact, not bad luck, are not a lack of surgical skills, but are in fact, the complications of transfusions."ALTERNATIVE STRATEGIESNarrator: These concerns have spurred a wide range of alternative strategies, treatments that are acceptable to many of Jehovah's Witnesses, an others who also choose to avoid blood transfusions. Alternative strategies can be grouped around four organizing principles.[Minimize Blood Loss;Conserve Red Blood Cells;Stimulate Blood Production;Recover Lost Blood]Prof. Donat R. Spahn: "That involves an aesthetic factor, it involves the use of certain substances, and certainly involves also the surgical technique."MINIMIZE BLOOD LOSSProf. Johannes Scheele: "The most important technique to control bleeding is to avoid bleeding. . . . so that with less bleeding during surgery, the result of that is better, and the outcome is more likely to be smoother."Dr. Richard K. Spence: "Careful surgery means preventing blood loss. Age is no factor. We have operated on newborns, we have operated on people in their 90s."Dr. Mark E. Boyd: "The surgeon who operates without losing large amounts of blood, is almost invariably a good and careful surgeon. One who loses large amounts of blood is most often, the reverse."Narrator: A variety of instruments are now available to help surgeons minimize bleeding.Dr. Nicholas Namais: "There are strategies for inter-operatively using electrocautery instead of scalpels."Prof. Johannes Scheele: "If there is some bleeding persisting, there are coagulation techniques. The best of which is, at the moment, Argon-Beam Coagulator."Narrator: There are non-invasive tools that enable the surgeon to see inside the body, minimizing surgical incisions.Dr. Richard K. Spence: "You can use drugs, topical application of different products that will help prevent blood loss."Prof. Roland Hetzer: "We have now, several methods available, like the 'fibrin glue' . . .Narrator: Fibrin glue made from blood fractions stimulates coagulation upon contact.Prof. Johannes Scheele: "The fibrin tissue adhesive is certainly very, very useful because it does not harm the tissue."Dr. Nicholas Namais: "In a Jehovah's Witness, where the blood loss is so, so, so critical, I think you have to be very, extremely meticulous not to lose even a drop of blood."CONSERVE RED BLOOD CELLSDr. Peter Carmel: "There are new technologies of hemodilution and reinfusion, that make the operation easier, and which are acceptable to people who have a religious precept against blood transfusion."Dr. Linda Shehling: "The principles of hemodilution, in terms of reduction of blood loss, are really quite simple."Dr. Concha Lewand: "Basically, we do the closed circuit on the patient. We draw off blood from the patient—keep it in contact with the patient—and substitute it with fluids."Prof. Donat R. Spahn: "That results in a diluted blood, and therefore, the patient looses only diluted blood, rather than native, or concentrated blood."Dr. Linda Shehling: "When the patient bleeds interoperatively, the red cell lose is less."Dr. Herbert Dardik: "It would be like taking a quart of milk and turning it. . . or adding water so that you have 3 gallons of it now, but the original quart is still in there. But if you were to spill it into something, it would be a lot of water—and a fraction of the milk—then at the end, you get rid of the water, and then you're back where you started."Dr. Aryeh Shander: "And we use that routinely in this institution, especially for those patients who have anticipated significant blood loss."Dr. Concha Lewand: "I think that's nowadays, besides—I think that for Jehovah's Witnesses it’s a pretty good standard of care for large volume loss surgery."RECOVER LOST BLOODDr. Richard K. Spence: "If we do loose blood, this is the kind of case where we'll use a cell saver. We will suction up any blood that's lost—we wash it, we clean it, we process it, we filter it—and then we'll give it back to you."Prof. Donat R. Spahn: "Cell salvage is a very important technique, because when you use cell salvage, the blood lost by the surgeon is not lost for the patient."Prof. Johannes Scheele: "In any trauma patient with a significant blood loss, I would, always, prepare the cell saver system."STIMULATE BLOOD PRODUCTIONNarrator: "A key element in stimulating the body's ability to replenish its own blood supply is a hormone called erythropoetin.Dr. Blair Siefert: "Erythropoetin is a natural substance. It is formed in the kidneys, other organs as well, but primarily the kidney, to help our bone marrows to form the red blood cells that are going to carry our oxygen."Narrator: Blood cell production takes place primarily in the sternum, the ribs, the vertebra, and the pelvis. Recombinant Erythropoetin boosts the body's natural production of red blood cells.Dr. Nicholas Namais: "So if I know the patient is going to be in the hospital a long time, I may start them on some recombinant erythropoetin so they can start building up their own blood storage."Prof. Francesco Mercuriali: "This can be a very cost effective strategy, to reuse the utilization of allergenic blood transfusion."Dr. Richard K. Spence: "One of the most exciting things about this whole field, is that the majority of things that we talk about is within the reach of physicians and hospitals around the world."Dr. Peter Carmel: "There are now available, techniques in almost every sub-specialty of surgery and medicine that allow bloodless treatment."Major Spry—JW spokesman: "Alternatives, like any other therapy, are not necessarily, free from risk. So a patient, a Witness patient in particular, may want to become informed about the benefits and the risks that are associated with any particular treatment."Dr, Edwin A. Deitch: "They should be a prudent consumer."Narrator: How effective are these alternative strategies in helping doctors treat patients who do not want blood transfusions?CASE HISTORIESLeslie Lacks had just begun elementary school when it became apparent that she had a degenerating spinal deformity. Doctors diagnosed Leslie's condition as a severe form of Scoliosis.Dr. Tarek Mardam-Bey: "Scoliosis is a curvature of the spine, so we have to correct it as much as the spine's flexibility allows us."Narrator: After a brace failed to correct her condition, doctors recommended an extensive surgical procedure.Dr. Tarek Mardam-Bey: "We used essentially a series of hooks and metal rods made out of stainless steel, that are implanted in the patient's back, and are used essentially to distract the spine and achieve alignment."Narrator: The Lacks wanted the surgery performed without a blood transfusion. So they found a surgical team that had experience using bloodless techniques. Before the surgery, Leslie's doctors boosted her blood through the use of iron and recombinant erythropoetin.Dr. Tarek Mardam-Bey: "So it was essential that we do the surgery without excessive blood loss. The way that we were able to achieve this is using two techniques basically. One of them is called the cell saver. The other technique we used is called hemodilution. It is safer in that, it's the patient's own blood and its has remained in continuous circulation with the patient, so there's no chance for contamination or blood transmitted diseases.Narrator: The surgery was a success, and no blood transfusion was administered! Within days, Leslie was up and walking.Bobbie Lacks: "She's so happy. She can completely stand, now she says, 'Mommy, I'm almost as tall as you now!'Narrator: Although Leslie will have to wear a brace for a while—doctors are confident she will lead a normal life.Leslie Lacks: "I'd like to skate, and skateboard, maybe learn how to snowboard, . . .stuff like that!"Narrator: Sometimes alternative strategies involve new surgical techniques to reduce blood loss in patients that don't want a transfusion. 75 year-old Dorothy McPhee suffered an abdominal aortic aneurysm, a life threatening condition, that traditionally requires extensive surgery.Dr. Herbert Dardik: "The normal way of doing this operation is, generally through the abdomen, a long vertical incision from the lower chest down to the pubic area, having to work around and behind the entire intestinal tract. Hospitalization ranging—at best, days, 4 or 5 days, to averaging a week or even more—presuming that there are no operative complications."Narrator: Since Dorothy is one of Jehovah's Witnesses, her physicians used a surgical technique that minimizes bleeding.Dr. Herbert Dardik: "What we did today is called endovascular aortic surgery. Essentially that's; Endo—meaning we are working within the artery. Through that artery we place our catheters, our wires, all the instruments that we steal right up to where the aneurysm is. And then we can visualize the aneurysm by doing coroscopy, x-ray technology.Narrator: Dorothy's doctors inserted a wire mesh called a stint, and were thus able to repair her aorta without a large surgical incision that would have caused a lot of bleeding.Dr. Herbert Dardik: "A small incision through the groin, all the manipulation through that—a virtually pain-free, complication-free, in post-operative, of course—home, generally in 24-hours—so, everybody's a winner!Dorothy McPhee: "I feel fine! I never would have believed it, but I do!"Narrator: Two days after her surgery, Dorothy was sent home. She recovered nicely!A NEW STANDARDA growing number of health care providers are willing to meet the challenge of treating patients who avoid blood transfusions.Prof. Roland Hetzer: "With the development of all those techniques, there's nothing really specific about Jehovah's Witnesses anymore. We know that they don't want blood transfusions and we have the technology to follow their wish."Dr. Stephen M. Cohn: "The belief that you don't want a blood transfusion should not in any way . . . that should be a tiny part of the whole medical care environment. That should be acknowledged—put over to the side, fine—now to the other 99 percent of your care!"Major Spry—JW spokesman: "I guess it could be likened to a patient who is allergic to penicillin. You wouldn't expect the physician to say, 'Well, I'm sorry, I can't treat you because I can't administer penicillin.' No, he simply says, 'We'll give you a medical alternative. We'll give you another antibiotic.' Then he gets on with treating the patient."Narrator: This enlightened approach to patient care has exciting implications for the public at large.Dr. Stephen M. Cohn: "The fact that we couldn't use blood in Jehovah's Witnesses, we learned how we didn't have to use blood in many other situations. So, it has actually propelled us in the right direction."Dr. Richard K. Spence: "Transfusion alternatives clearly, are good medical practice. Sound practice—safe practice, for a patient."Dr. Linda Shehling: "Indeed it is a standard that should be available to all patients."Dr. Peter Carmel: "What we're talking about here is going to be a mute point, because bloodless medicine and surgery will become in the next 5 to 10 years, so widespread that, it won't be novel anymore."Eugene Rosam—JW spokesman: "Jehovah's Witnesses have had the unique privilege, because of their religious position on the matter, of helping doctors learn better ways to treat patients without subjecting them to the risks of blood transfusions."Prof. Charles H. Baron: "What I have seen in my own experience is that they have turned the medical profession around, where the gold standard, is to treat people without blood."Narrator: Already some 100,000 physicians worldwide, are making bloodless medicine and surgery available to anyone who does not want a blood transfusion. Many experts agree that in the new future medicine and surgery without the use of blood transfusions will become the standard of care for all patients."There are now available, techniques in almost every sub-specialty of surgery and medicine that allow bloodless treatment, so that we are getting away from blood transfusions in general.""As a heart surgeon, I guess it's unusual for a guy not to like blood, he should like blood, but I don't—I'm very proud when my patient comes out of the operation room, and has not received any transfusion.""I can see within the next few years, us getting to a point of where we do not have to even think about getting blood."