Refusal of blood guideline (G092)

Any patient may refuse the transfusion of blood products. Reasons for refusal of blood products include:

• religious beliefs e.g. Jehovah’s Witnesses or Rastafarians
• specific personal reasons.

It is important that time is taken to discuss with the patient:

• the potential implications of their decisions i.e. that they may die or suffer serious harm from a potentially treatable condition
• the local availability of blood conservation techniques and techniques available for pre operative haemoglobin optimisation.

Looking after any patient who refuses a potentially lifesaving therapy can be stressful for all concerned but it is of paramount importance that healthcare professionals own beliefs should not prejudice the care that is provided. Guidance can be found in General Medical Council (GMC) guidance: Good Medical Practice :

"52. You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role."

"54. You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploits their vulnerability or are likely to cause them distress."

"59. You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange. You should challenge colleagues if their behaviour does not comply with this guidance, and follow the guidance in paragraph 25c (see section Domain 2: Safety and quality) if the behaviour amounts to abuse or denial of a patient’s or colleague’s rights."

The most common group of people who may refuse blood products in Ayrshire and Arran are Jehovah’s Witnesses. Information about Jehovah’s Witnesses can be found at the official website www.jw.org or details of members of the local Hospital Liaison Committee can be found later in this guide.

It should be remembered that any individual may refuse transfusion of any blood product and that no assumptions should be made as to what an individual finds acceptable prior to discussion with them.

3.1 Preoperative meeting^2,4,5,6

Surgical procedures should be carefully planned by a team sensitive to the patient not wishing to accept blood products.

If significant blood loss is possible or the patient suffers from medical conditions adversely affected by anaemia, the Consultant Anaesthetist involved in the case should be contacted at the earliest opportunity. The patient may wish to be accompanied by a relative, or if a Jehovah’s Witness a member of their church.

It is good practice to have an independent witness present.

If a surgeon or anaesthetist feels unable to proceed with surgery for a patient who refuses blood products they should arrange to transfer responsibility to a colleague who is prepared to do so early in the patients care1 taking care not to impose any delay to the patients’ care. Guidance with regard personal beliefs and medical practice can be found on the GMC website 

The meeting between the patient and the doctors should cover the following points:

1. The risks associated with surgery with particular reference to potential blood loss.
2. Techniques that can be used to avoid blood transfusion.
3. Discussion about which treatments are acceptable.
   • In the case of a Jehovah’s Witnesses many will have an “Advance Decision to Refuse Specified Medical Treatment” document. A copy should be placed in the patient’s case record in the ‘Clinical Alerts and Hazards’ section.
   • This section of the notes should be routinely checked prior to infusion or treatment of any kind. (Advance Directive forms should be available from the local Hospital Liaison Committee for Jehovah’s Witnesses or their local congregation.)
   • For patients who refuse blood products; or for situations where the clinician may wish to further clarify which products or procedures are acceptable to the individual Jehovah’s Witness patient, the Refusal of Blood Products form (Appendix A) found at the end of this guidance should be used.
4. Decision by clinicians to proceed with surgery. The discussion should be clearly documented in the patient’s notes and signed by the doctor, patient and witness.
5. Consent
   • Written consent for operation will be documented using the hospital “Consent for Operation” form.
   • The doctor must be satisfied that the patient is not being subjected to pressure from others.
   • G082 Consent Policy for Health Professionals contains advice and further guidance.
   • In order to avoid ambiguity a Refusal of Blood Products (Appendix A) form should be filled out.

3.2 Preoperative preparation

Preoperative planning should commence at the earliest opportunity and conducted by the surgical and anaesthetic team who will be undertaking the procedure.

Phlebotomy

Check full blood count (FBC), coagulation screen, serum Ferritin, Folate and B12. The smallest volume of blood possible should be drawn from the patient. If the patient is iron deficient, prescribe oral iron and consider the use of intra venous iron therapy.

Higher blood loss surgery⁹ erythropoetin (EPO)¹⁶

The use of EPO pre-operatively must be discussed with a Consultant Haematologist prior to use. Dr William Gordon is the first point of contact for the use of EPO in the pre operative patient in NHS Ayrshire & Arran.

After baseline haemoglobin (Hb) levels have been established, the use of recombinant erythropoietin (EPO) several weeks prior to surgery can be considered to increase oxygen-carrying capacity of patient’s blood.

Eligibility

• patient must be at risk of significant blood loss
• for males Hb <13g/dL, females <12g/dL.

Contraindications

• EPO should not be used for patients with a baseline Hb >13g/dL owing to increased risk of postoperative thrombotic events (eg deep vein thrombosis or pulmonary embolism).
• EPO must not be used/must be stopped if a patient’s Hb >15g/dL.
• EPO is in general contraindicated in patients who are suffering from uncontrolled hypertension, arterial diseases, recent myocardial infarction (MI) or cerebrovascular accident (CVA) (within the past month), unstable angina or have a history of thrombosis.

Cautions

• Caution is advised in using EPO in patients who are: pregnant or lactating, older patients (>70yrs) or are suffering from chronic liver failure, hypertension, raised platelets, epilepsy or malignancy.

Haematinics

• EPO is ineffective in patients with iron, B12 or folate deficiency. Patients with a ferritin level <100 ng/ml should have IV iron administered provided that there are no contra-indications.
• Ferritin levels are likely to fall in patients receiving EPO and, as such, levels should be monitored prior to, during and following treatment and replacement used where deficiency occurs.

Timing of EPO

• The first dose should be given three weeks before surgery and the last dose on the day of surgery. If a sufficient response is seen after the second or third dose then subsequent doses should be omitted.

Antiplatelets/anticoagulation

Indications for oral anticoagulation, antiplatelets and non steroidal anti inflammatory drugs in use during the perioperative period should be considered and their use suspended if able.

Patients taking warfarin should be managed as per the NHS Ayrshire & Arran guideline ‘Perioperative management of the patient on oral anticoagulants’.

3.3 Intraoperative management^{4,6,8,9,10,11,12}

Surgical techniques

• A senior surgeon should operate and a consultant surgeon been involved in the decision to operate.
• Meticulous attention should be paid to haemostasis.
• Consideration should be taken as to whether a 2 staged procedure is more appropriate to reduce blood loss where this may be applicable e.g. bilateral mastectomy.

Anaesthetic management

• use cell salvage when indicated
• use tranexamic acid
• consider controlled hypotension to reduce intra-operative bleeding
• consider acute normovolaemic haemodilution.

3.4 Post-operative management^4,6

Significant blood loss and serious post operative anaemia may necessitate that the patient remains sedated and ventilated in ICU.

Erythropoietin may be indicated in this scenario and discussions should take place with a Consultant Haematologist at an early stage in the treatment of a severely anaemic patient who refuses blood products.

Phlebotomy should be minimised and paediatric sample bottles used.

In an extreme situation hyperbaric oxygen should be considered.

A patient's decision as to whether they are prepared to accept blood products or not is one of consent. As such, reference should be made to the NHS Ayrshire and Arran document G082 ‘Consent Policy for Health Professionals’

The following situations are ones that most clincians are concerned about. If there is any concern with regards consent then discussion should take place between the clinician in charge of the case and the Medical Director and/or their deputy.

4.1 Change of mind

Any patient may change their mind when confronted with the need for blood transfusion as a life-saving measure. Any change in the patient’s views at this point should be regarded as a modification of consent and should be witnessed and recorded in the patient’s notes contemporaneously. The discussion between the patient and treating clinician should be witnessed by another competent individual/ health care professional who should also sign the record of the change of consent.

If the patient has received sedation or has become confused or delirious, their competency to vary the consent which they have previously given will depend on the facts of the case.

Generally speaking, a patient has capacity to consent to treatment if they are capable of receiving advice from a doctor, of understanding that advice, of balancing their issues in their mind and making their wishes known.

4.2 Emergency or trauma situations⁶

In the management of trauma or emergency situations, the Jehovah’s Witness status of the patient may be unknown. Nevertheless, the majority of Jehovah’s Witnesses carry on their person a signed and witnessed ‘Advanced Decision’ document absolutely refusing blood and releasing clinicians from any liability arising from this refusal. The following situations may arise:

• A conscious and competent patient identifies himself as a Jehovah’s Witnesses and states that he is unwilling to accept the transfusion of allogeneic blood. The patient may or may not have on his person an ‘Advance Decision’ document. This document will clearly indicate their refusal to accept blood. It may also indicate what blood derivatives they will accept and what autologous procedures are acceptable to them. If the ‘Advance Decision’ document is not to hand, the treating clinician will need to ascertain such details by interviewing the patient. Details should be fully documented and included in the patient’s notes. It is not the responsibility of clinicians to question these decisions, but they should discuss the medical consequences of non-transfusion in the management of his/her specific condition.
• The patient is unconscious or incompetent. Accompanying relatives or associates state that he is one of Jehovah’s Witnesses and would not accept the transfusion of allogeneic blood. Such relatives or associates should be invited to produce evidence in the form of a valid ‘Advance Decision’ document. If they can produce such a document, the patient should be treated in accord with the decisions indicated therein. If documentary evidence cannot be produced, the clinical judgement of the treating team should take precedence.

Even though clinicians may have treated Jehovah’s Witness patients on previous occasions it is important not to presume to know what therapies they will or will not accept.

4.3 Children under the age of 16⁶

In Scotland, young persons aged sixteen or over have the exclusive right to determine their own medical treatment. The parent has no right to consent or interfere.

As with any other form of treatment children younger than sixteen may be competent to make their own decisions if they demonstrate a clear understanding of the proposed treatment and the issues involved. If the clinician is convinced that a child’s refusal to accept blood transfusion is a genuinely held personal belief, and not just a reflection of their parents' belief, then a clinician should give very serious consideration to the child’s views. This principle is unlikely to apply to a child below the age of twelve.

If parents refuse the administration of blood products to a child who is not deemed to be competent the clinician should proceed as per guidance set out in section 7.9 of G082 ‘Consent Policy for Health Professionals’.

5.1 Antenatal management

If at the booking clinic a woman is found to be a Jehovah’s Witness or wishes to refuse blood transfusion for other reasons they should be transferred to the RED pathway.

The refusal of blood products requires to be highlighted in:

• Badgernet
• Case notes
• Scottish Woman Hand Held Maternity Record (SWHHMR) notes.

An appointment should be made with her own Obstetric Consultant, preferably < 24 weeks gestation to discuss:

• The risk of haemorrhage, including management options and the increased risk of hysterectomy.(The death rate from haemorrhage in women refusing blood products for delivery has been estimated at 44 -100 times greater than would be expected^14,15)
• The woman’s wishes and attitudes to blood transfusion, ensuring that any blood and primary blood components that the woman would not accept and treatments that she will accept are clearly documented.
• Careful consideration should be made to the location of delivery given the lack of onsite interventional radiology and out of hours cell salvage service.

Anaesthetic High Risk Clinic referral should be made to the clinical mailbox Clinical_Obstetric_Anaesthetic_Clinic@aapct.scot.nhs.uk. Clinic availability can be checked via the Anaesthetic Secretary (ext. 27172). The appointment should occur between 28 and 32 weeks gestation. If delivery is imminent or more urgent advice is required the Duty Anaesthetist should be made aware and they will advise the best way to proceed (Page 2824/5)

The woman should provide a completed “Advance Decision to Refuse Specified Medical Treatment” form or similar and the form must be filed in her case notes. A copy should also be placed in patient’s hand held records.

A “Refusal of Blood Products” form (Appendix A) form should also be completed complete and filed in the case notes.

Haemoglobin and serum ferritin should be checked monthly.

Regular oral iron should be commenced to maximise iron stores and early consideration of intravenous iron made further guidance can be found in the protocol
“Administration of Intravenous Venofer® (iron sucrose) in Pregnancy ADTC 273 / 2”.

The woman and her partner should be offered the opportunity to read and discuss the treatment guidelines in this protocol.

5.2 Elective delivery

Induction of labour

Induction should occur on Monday, Tuesday or Wednesdays in order that delivery can occur during weekdays.

Caesarean delivery

Early discussions should take place with the Consultant Anaesthetist on for labour suite on the planned day of delivery as soon as the planned delivery day is decided to ensure that Cell Salvage is available.

5.3 Intrapartum/delivery

Staff involvement

The Consultant Obstetrician and Duty Anaesthetist should be informed when a woman refusing blood transfusion is admitted in labour.

A Consultant Obstetrician should be present at any operative delivery (vaginal or caesarean section) if possible.

Student midwives and junior doctors should not conduct deliveries.

Location of delivery

The labour should be managed routinely in the Consultant Led Obstetric Unit by the most senior medical and midwifery staff available.

Third stage of labour

Should be actively managed and routine prophylactic oxytocin given.

5.4 Postnatal management

The woman should not be left alone for at least an hour after delivery.

A postnatal Early Warning Score chart should be commenced. Check the woman’s pulse, blood pressure, uterine contraction and the lochia every 15 minutes for two hours following delivery.

5.5 Management of obstetric haemorrhage in the parturient who refuses blood products

The MAIN PRINCIPLE of management is to AVOID DELAY

• If significant bleeding occurs at any time during pregnancy Consultant Obstetric, Anaesthetic and Haematology involvement is mandatory and should be initiated as soon as possible.
• A 2222 call should be made and both a “Major Haemorrhage” and “Obstetric Emergency” declared.
• A second Obstetric or Gynaecology Consultant should be contacted if laparotomy required. This surgeon must be suitably skilled to aid major surgery.
• The threshold for intervention should be lower than in other patients.
• Complications such as clotting abnormalities should be detected as quickly as possible and the quantity of blood loss accurately recorded.
• Provided that it is acceptable to the patient Cell Salvage should be initiated early if available. Its use should not delay resuscitation.
• Identify and correct cause of haemorrhage.
• Catheterise and monitor hourly urine output.
• The woman and her family should be kept fully informed about what is happening by an informed member of staff.

5.6 Surgical management of obstetric haemorrhage

In a Major Haemorrhage situation early consideration of the following surgical interventions should be made:

• intrauterine balloon
• B-Lynch suture
• internal iliac artery ligation
• hysterectomy: The woman’s life may be saved by timely hysterectomy though even this does not guarantee success.
  • uterine arteries should be clamped as soon as possible.
  • subtotal hysterectomy can be just as effective as total hysterectomy, as well as quicker and safer.
  • the timing of hysterectomy is a decision for the Consultant on site. A second Consultant’s presence is advised only if this does not cause undue delay in definitive treatment.

5.7 Ongoing care of the parturient

Following major haemorrhage persons with haemoglobin levels <30 g/L have all been successfully treated although patients with this degree of anaemia will require transfer to the Intensive Care Unit (ICU).

Staff from the ICU are available to assist in life threatening haemorrhage and are alerted during the activation of the Major Haemorrhage Protocol. The ICU can be contacted directly (ext. 27741) or via the ICU Anaesthetist (page 3504).

5.8 Epidural blood patch

Careful explanation should be given and written consent taken prior to the performing of an epidural blood patch as some patients such as Jehovah’s Witness’s may not consent to epidural blood patching.

It is increasingly possible to treat haematological malignancies without primary blood component support. This will require a multidisciplinary team and the design of a specific care plan. Further guidance is beyond the scope of this document and each patient should be discussed with the consultant haematologist looking after each case.

If, in spite of all care, the patient dies it should be remembered that relatives will require support.

Staff Care services staff in NHS Ayrshire & Arran, both on an individual basis and to healthcare teams. Critical Incident Stress Management can be arranged after difficult or stressful experiences. are available to provide support to all.

Peer support is provided by a network of staff trained in psychological first aid to provide support for colleagues.

Medical Peer Support provides confidential and compassionate support for non training grade doctors in hospital, at particular times of stress or when things go wrong.

Advice may be a sought from a number of sources including defence unions who usually offer telephone advice.

NHS Ayrshire and Arran Legal Office Ext 27076.

Hospital Liaison Committee (HLC) Network for Jehovah’s Witnesses

This Guideline was previously impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional Equality & Diversity issues were identified.

An Equality and Diversity Impact Assessment was completed May 2016.

1. Good Medical Practice; 2013; GMC, UK
2. Jehovah’s Witnesses; McIlveney, F.K & Pace, N.A; Anaesthesia and Intensive Care Medicine 2004; Issue5, Volume 2; Pages 57-59.
3. Epidural blood patch in a Jehovah’s Witness; Anesthesia and Analgesia 1987; Bearb M.E. & Pennant 1987; Issue 66, Volume 1052
4. Management of Anaesthesia for Jehovah’s Witnesses; Association of Anaesthetists of Great Britain and Ireland; Second edition; November 2005
5. Haematological Care of the Jehovah’s Witness Patient; Marsh, J.C.W & Bevan, J.H; British Journal of Haematology 2002; Issue 119; Pages 25-37
6. Code of Practice for the surgical management of Jehovah’s Witnesse;. Royal College of Surgeons of England; 2002
7. Handbook of Transfusion Medicine; Editor, Dr Derek Norfolk, HMSO, Editor; 2007; 5th edition
8. Cell Salvage in Jehovah’s Witness patients’; UK Cell Salvage Action Group; July 2008. Available at: http://transfusionguidelines.org.uk/docs/pdfs/bbt-03_icsag-fs06_0807.pdf
9. How to Approach Major Surgery Where Patients Refuse Blood Transfusion (Including Jehovah’s Witnesses); Gohel M.S., Bulbulia R.A., Slim F.J., Poskitt K.R., Whyman A.R.; Coll Surg Eng 2005; Issue 87, Pages 3-14
10. Editorial: Management of blood loss in Jehovah’s Witnesses; Busuttil D. & Copplestone A.; British Medical Journal 1995; 311, pages 1115-1116
11. Effects of Tranexamic Acid on Death, Vascular Occlusive Events, and Blood Transfusion in Trauma Patients with Significant Haemorrhage; Shakur H., Roberts R., Bautista R., Caballero J., Coats T., Dewan Y., El-Sayed H., et al.; a randomised, placebo-controlled trial. The Lancet 376; 2010; Issue 9734, pages 23–32
12. Developing a Blood Conservation Care Plan for Jehovah’s Witnesses with Malignant Disease’ presented at the BSH Annual Scientific Meeting, April 2007. Available at : http://www.transfusionguidelines.org.uk/docs/pdfs/bbt-03_malignant-diseases-v21.pdf
13. Chapter 4: Annex A. Guidance for the management and treatment of obstetric haemorrhage in women who decline blood transfusion; CEMACH 2000 – 2002; Published 2004
14. Are women who are Jehovah's Witnesses at risk of maternal death? Singla AK, Lapinski RH, Berkowitz RL, Saphier CJ. Am J Obstet Gynecol. 2001 Oct;185(4):893-5.
15. Confidential Enquiry into Maternal Deaths, 1991-1993. Annexe to Chapter 3.
16. “Caring for Patients who Refuse Blood” Royal College of Surgeons of England, 2016 https://www.rcseng.ac.uk/library-and-publications/collegepublications/docs/caring-for-patients-who-refuse-blood/

Refusal of blood products form