THE COOPER HEALTH SYSTEM by mikesanye

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									             Caring For Patients Who
            Refuse Blood Transfusion:
             Challenge or Dilemma?
     Kathleen Yhlen RN MSN
     Clinical Educator
     Coordinator Bloodless Care Program
     Cooper University Hospital


February 24, 2012
 Why do people object to
 receiving blood transfusions?

                       Personal concern
                       Religious beliefs




February 24, 2012
Religious Beliefs
      Jehovah’s Witnesses
      Leviticus 17:13, 14, “You shall not partake of
       the blood of any flesh, for the life of all flesh
       is its blood. Anyone who partakes of it shall
       be cut off.”
      Excommunication and eternal damnation


February 24, 2012
Caring for Jehovah’s Witnesses
      A problem?
      A challenge?
      Is their belief right or wrong?

      Self-determination and Autonomy, including
       the right to die
      Upheld in court
February 24, 2012
CARING FOR THE JEHOVAH’S
WITNESS PATIENT
            WHY?
            Cultural Competence
                   Professional Practice Acts
                   JCAHO
                   CMS Code of Ethics
                   Mission and Vision Statements

February 24, 2012
CARING FOR THE JEHOVAH’S
WITNESS PATIENT
Culturally Competent Care
              Practitioners sense of awareness
                   Own attitudes
                   Biases
                   prejudices




February 24, 2012
     WHAT IS BLOODLESS CARE ?

                    A strategy of providing patient
                              care by conserving
                              blood and minimizing
                              or eliminating the use
                              of blood transfusions


February 24, 2012
                    BLOOD CONSERVATION
                        STATEGIES
      Interview patient
              ask about religious beliefs
              objection to transfusions
              advance directive
      Comprehensive physical assessment



February 24, 2012
                    BLOOD CONSERVATION
                        STATEGIES
      Anticipate and Plan
              communicate with health care team
              consider these pts. high risk
               blood directive
              consult hematologist
              don’t “wait and see”



February 24, 2012
                    BLOOD CONSERVATION
                        STATEGIES
1.        Conservation/Minimize blood loss

               perform essential lab studies only
               use pediatric/micro tubes
               return flush from arterial lines




February 24, 2012
                    BLOOD CONSERVATION
                        STATEGIES
Medical Management
              Sign blood directive
              Limit phlebotomy
              Use pediatric or micro tubes
              Correct anemia (iron, folic acid, B12,)
              Epoetin Alpha (Procrit)
               this contains human albumin!!!

February 24, 2012
Strategies
      Patient identification
              Computer/chart/wristband/labels
              Pharmacy
      Blood Directives/Consent forms
      Advanced Directives
      Nurse Coordinator
      Physician support
      Pastoral Care
February 24, 2012
                    The Patient’s Role
      Seek treatment early
      Prepare an Advanced Directive
      Prepare end-of-life decisions including
       assigning next of kin to children
      Talk to family, friends and doctor
      Find a doctor who will comply with your
       wishes
      Discuss and sign Blood Directive/Consent
February 24, 2012
                    The Patient’s Role
      All competent patients have the right
      to refuse treatment/care
      Understand diagnosis, options, alternatives
      Decision must be voluntary, and informed




February 24, 2012
BLOOD DIRECTIVE/CONSENT
      Refusal of all and/or some blood and blood
       products
      Doctor will discuss the risk and benefits of
       blood transfusion and alternatives
      Major blood fractions
      Minor blood fractions


February 24, 2012
                        Blood Directive
      Refuses major blood         May accept minor
       products                     blood fractions
              whole blood             albumin
              red cells               clotting factors
              White cells             immune globulins
              platelets               cryoprecipitate
              plasma                   antihemophilic factor
                                       other _____?________


February 24, 2012
Challenges
      Do not be judgmental
      Encourage and facilitate advanced planning
      Be alert for opportunities for sensitive
       conversation
      Hospitalization not ideal time to fill out
       advanced directive
      Consult Bloodless Coordinator
      Use Blood Directive or consent form
February 24, 2012
Physician Rights
      Have to be willing to let patient die
      Refuse to provide care
      Alternate physician agrees to take the
       case/transfer




February 24, 2012
EPIC Order Set
      “Bloodless Care”
      Please have Patient Sign Blood Directive
       (Form #C692400)- Web links: Blood
       Directive English, Blood Directive Spanish
      Limit Phlebotomy
      Draw all labs with lowest volume tubes


February 24, 2012
Case Studies
      Mercy Hospital versus Jackson
      J.W. presented at 26 weeks in preterm labor
      Vaginal delivery contraindicated
      C-section with 50% chance of needing a
       transfusion
      Refused transfusion any circumstance
      Court ruled competent to refuse
February 24, 2012
Case Studies
      Wons versus Public Health Trust of Dade County
      38 year-old female mother of two children 12 and 14
       years old
      Dysfunctional uterine bleeding
      Symptomatic anemia required transfusion
      Protection of innocent 3rd party?



February 24, 2012
Case Studies
      Shorter versus Drury
      J.W refused transfusion prior to procedure
      Wrongful death suit filed
      Patient hemorrhaged during a D&C when uterus was
       perforated
      No transfusion was administered



February 24, 2012
                    QUESTIONS




February 24, 2012
                    THANK YOU!

             Kathleen Yhlen, RN, MSN, NE-BC
             Nurse Coordinator Bloodless Care Program
             Cooper University Hospital
             office 342-2476 pager (856)962- 3763



February 24, 2012

								
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