Women Who Refuse Blood Products, Gynaecology (319)

In the management of an unconscious adult (e.g. ruptured ectopic pregnancy) the status may be unknown. Most practicing Jehovah’s Witnesses will carry a clear Advance Directive/Release card with them at all times. This is a legal document and, if in clear and unambiguous terms, should be respected. Contact could also be made with the patient’s GP who may hold a copy of such an Advance Directive.

Every effort should be made to avoid the use of blood and blood products in the perioperative period under these circumstances, however if a patient is unable to give an opinion, and no applicable advance directive exists, then the clinical judgement of the doctor should take precedence over the opinion of relatives or associates and this may include the administration of blood products. GMC guidance on patients who refuse treatment affirms this stating that: ‘In an emergency, you can provide treatment that is immediately necessary to save life or prevent deterioration in health without consent’ (Personal Beliefs and Medical Practice, paragraph 27 [GMC, 2013]). 

Any blood or blood products administered without prior patient consent should be clearly documented in the casenotes and it is the clinician’s duty to inform the patient about its use and the reasoning for this as soon as possible.

Pre-Operative Management:

• Consideration should be given to non-surgical management of condition where possible e.g. Uterine Artery Embolisation versus Myomectomy; medical management of menorrhagia etc.
• It is acceptable for a surgeon to refuse to perform an elective procedure on the basis that they feel the risk to the patient from refusal of blood products outweighs the benefits of the procedure provided they refer the patient to another doctor if she wishes, and clearly document the reasoning to avoid accusations of religious discrimination (Personal Beliefs and Medical Practice, GMC 2013).
• Establish with each Jehovah’s Witness patient which derivatives of the primary blood components are acceptable if any, and also whether procedures involving the patient’s own blood such as cell salvage or haemodialysis are acceptable. Patients should be asked explicitly about situations in which loss of life or limb are likely to confirm that their refusal extends to include these circumstances.
• Document a clear record in the medical records and care plan regarding what the woman will accept.
• Complete the Refusal of Blood Transfusion Form and file in the casenotes (to be scanned onto Clinical Portal). Complete the Advanced Directive if this is available.
• Arrange pre-operative Anaesthetic review.
• Assess the patient for personal or family history of unexpected bleeding or clotting issues following medical or dental procedures.
• Avoid any medication that can increase blood loss, including NSAIDs, aspirin and vitamin K antagonists.
• Establish a plan for emergency management of haemorrhage and damage control strategies for reducing risk to life and limb of the patient. Inform all relevant team members and any external departments that may be required if emergency occurs.
• Baseline haemoglobin and serum ferritin should be checked well in advance of theatre date to allow early consideration to giving haematinics or parenteral iron if indicated.
• Early discussion of an individual case with a Haematologist may be beneficial. Consider use of recombinant erythropoietin (EPO) several weeks pre-op.
• Liaise regarding the availability of cell salvage for the procedure.

Intra-Operative Management

• Inform Consultant Gynaecologist and Anaesthetist if a patient declining blood transfusion is admitted as an emergency.
• Each surgical procedure should be managed routinely, by the most senior medical staff available. Junior medical staff should not conduct these procedures unless in an emergency situation where waiting on the arrival of more senior staff would be detrimental.
• A Consultant Gynaecologist should be present at any surgical intervention if possible.
• Consider operative approaches or techniques that can minimise the loss of blood and/or interventional radiology.
• Where appropriate and acceptable to the patient consider the use of intraoperative autologous procedures such as cell salvage (which should be available for all elective procedures if required) and acute normovolaemic haemodilution. Consider early use of coagulation stimulants such as tranexamic acid, recombinant clotting factors (e.g. VIIa, VIII, IX) and desmopressin where appropriate.
• Meticulous attention to haemostasis throughout the procedure and topical absorbable haemostatic agents may be appropriate.

Post-Operative Care:

• A post-operative NEWS chart should be commenced and prompt review by medical staff for any score above 3.
• After discharge, women should be advised to promptly report any increased bleeding.
• Haematinics should be continued unless blood loss deemed to be minimal. Iron supplementation should be augmented with Folic Acid and Ascorbic Acid supplementation.
• Thromboprophylaxis risk assessment and therapy should follow standard process.

Management of Haemorrhage:

This should be as for all patients with haemorrhage but with early consideration to the additional aspects below: 

• Involvement of senior medical staff including the Haematologist
• Use of IV Tranexamic Acid.
• If available and acceptable to the patient, cell salvage may be life-saving if there is substantial blood loss.
• If standard treatment is not controlling the bleeding, she should be advised (if not under general anaesthetic) that blood transfusion is strongly recommended.
• If the woman dies, debriefing and support should be provided to family and staff involved.

A competent adult is legally and ethically entitled to accept or refuse any specific treatment or procedure even though this decision may endanger her life. To administer blood in the face of refusal by a competent adult is unlawful, ethically unacceptable and may lead to criminal +/- civil proceedings.

For patients under the age of 16, blood products can be administered in a lifethreatening haemorrhage to prevent lasting disability without patient or parental consent. Two consultants should agree and document the clinical urgency for blood administration. Legal permission for treatment in the face of parental refusal should be sought at the earliest available opportunity.

Any patient is entitled to change her mind about a previously agreed treatment plan.

The doctor must be satisfied that the woman is not being subjected to pressure from others. It is reasonable to ask any accompanying persons to leave the room so that the doctor (with a witness) can ask her if she is making her decision of her own free will. If she maintains her refusal to accept blood or blood products, her wishes must be respected. No other person is legally able to consent to treatment for that adult or refuse treatment on that person’s behalf.

The Hospital Liaison Committee can be contacted as a resource for more information 24/7 regarding the non-blood management of Jehovah’s Witnesses.