Refusal of blood policy

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					    Policy for the treatment of patients who have
 indicated that they do not wish to receive blood or
                  blood components.
                                          2.0




Equality impact
The Trust strives to ensure equality of opportunity for all both as a major employer
and as a provider of health care. This Policy has therefore been equality impact
assessed by the Specialist Practitioner of Transfusion to ensure fairness and
consistency for all those covered by it regardless of their individual differences.




                   Version:              2.0
                   Authorised by:        Hospital Transfusion Committee
                   Date authorised:      1st March 2011
                   Next review date:     1st March 2013
                   Document author:      Mark Storah
Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.




VERSION CONTROL SCHEDULE
policy for the treatment of patients who have indicated that they do not wish to
receive blood or blood components.

Version : 2.0

   Version Number                   Issue Date    Revisions from previous issue
   0.1                              July 2007     New Policy
   1.0                              February 2008
   1.1                              December 2008 Minor ammendments prior to FOI
                                                  publication.
   2.0                              March 2011    Two yearly review




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Tameside Hospital NHS Foundation Trust                             policy for the treatment of patients who have indicated that
                                                                      they do not wish to receive blood or blood components.



INDEX/ TABLE OF CONTENTS
INTRODUCTION ........................................................................................................ 4
OBJECTIVES ............................................................................................................. 4
SCOPE ....................................................................................................................... 4
POLICY DEVELOPMENT AND CONSULTATION..................................................... 4
IMPLEMENTATION.................................................................................................... 4
REVIEW ..................................................................................................................... 4
DEFINITIONS............................................................................................................. 5
DUTIES ...................................................................................................................... 5
  CHIEF EXECUTIVE................................................................................................ 5
  DIRECTORS........................................................................................................... 5
  HOSPITAL TRANSFUSION COMMITTEE ............................................................. 5
  DIVISIONAL RESPONSIBILITIES .......................................................................... 5
  MATRON/WARD MANAGER/DEPARTMENTAL MANAGER RESPONSIBILITIES5
  MEDICAL STAFF RESPONSIBILITIES .................................................................. 5
  ALL STAFF ............................................................................................................. 6
  RISK MANAGEMENT ............................................................................................. 6
POLICY STATEMENT................................................................................................ 6
EQUALITY AND DIVERSITY ..................................................................................... 6
IMPLEMENTATION PLAN ......................................................................................... 6
MONITORING ............................................................................................................ 7
THE LAW RELATING TO CONSENT/REFUSAL OF TREATMENT INCLUDING
BLOOD AND BLOOD COMPONENTS ...................................................................... 7
CLINICAL INDICATION TO TRANSFUSE ................................................................. 8
DETERMINE REASON FOR REFUSAL .................................................................... 9
  THE FOLLOWING DOCUMENTATION/CONSENT FORMS MUST BE
  COMPLETED:......................................................................................................... 9
ALTERNATIVES TO BLOOD AND BLOOD COMPONENTS..................................... 9
MANAGEMENT OF PATIENTS REFUSing BLOOD AND BLOOD COMPONENTS 10
TREATMENT OF CHILDREN .................................................................................. 10
LIFE – THREATENING EMERGENCY IN A CHILD................................................. 11
WOMEN IN PREGNANCY ....................................................................................... 11
ELECTIVE SURGERY ............................................................................................. 12
TRAUMA/EMERGENCY ADMISSION ..................................................................... 12
REFUSAL OF BLOOD AND BLOOD COMPONENTS – FLOW CHART ................. 14
ADVANCE DECISION DOCUMENT (PAGE 1) ........................................................ 15
ADVANCE DECISION DOCUMENT (PAGE 2) ........................................................ 16
CONSENT FORM 5 .....................................................................................................
CONSENT BY AN ADULT WHO INDICATES THAT THEY DO NOT WISH TO BE
ADMINISTERED ANY BLOOD COMPONENTS ...................................................... 17
NHSLA EQUALITY IMPACT ASSESSMENT ........................................................... 18
REFERENCES ......................................................................................................... 19




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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.




INTRODUCTION
The Trust’s Policy for the treatment of patients who refuse blood and blood
components is an operational policy and a procedure manual for all individuals
dealing with the practical elements dealing with patients who for whatever reason will
not accept blood or blood components as part of their treatment. The aim of these
guidelines is to provide information about the management of patients who refuse
blood (for religious or other reason), and to facilitate acknowledgement and respect
for their wishes in accordance with the Human Rights Act 1998, and the ethical
principle of patient autonomy.
It is a document that must be read by all Trust employees who are involved in any
aspect of this process.

OBJECTIVES
• To ensure that all staff involved in the handling of patient’s who refuse the use of
blood and blood components are fully conversant with the standards and procedure.
• To facilitate safe practice within all clinical areas and ensure the safety of the
patient.
• To act as a reference source for guidance and information.
• The policy is dynamic and at appropriate intervals new guidelines will be added to
the policy.

SCOPE
This policy relates to all professional, administrative and support staff employed by
Tameside Acute and to all locum, agency, temporary/bank and voluntary staff. The
scope of this policy is Trust wide.

POLICY DEVELOPMENT AND CONSULTATION
This policy was written with full discussion and imput from the Hospital Transfusion
Committee and staff members of the Blood Transfusion Laboratory.
The policy was widely distributed to stakeholders including all matrons, clinicians
and a patient representive from the Hospital Liaison Committee for Jehovah’s
Witnesses for consultation and comments before the policy was finalised.

IMPLEMENTATION
The Hospital Transfusion Committee will launch the policy following approval. The
policy will be uploaded onto the Intranet site and all wards and departments will be
notified of the policy’s launch.
The policy will backed up by the ongoing in house training program

REVIEW
This policy will be formally reviewed in 2 years, or earlier depending on the results of
monitoring. The policy may also be reviewed after change in legislation or updated
guidance.



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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


DEFINITIONS
Blood Product – Any therapeutic substance prepared from human blood
Blood Component – Platelets, Red Cells, Fresh Frozen Plasma, Cryoprecipitate and
White Cells.
DDAVP – (1 – deamino – 8 – D – arginine vasopressin). Raises circulating Factor 8
and von Willibrand Factor.

DUTIES
CHIEF EXECUTIVE
The Chief Executive has overall responsibility for ensuring that the Trust meets its
statutory and non-statutory obligations in respect of maintaining appropriate
standards contained in this policy. The Chief Executive devolves the responsibility for
monitoring and compliance to the Hospital Transfusion Committee

DIRECTORS
Directors are responsible for ensuring that the requirements of the Trust’s Policy for
the Treatment of Patients who have indicated that they do not wish to receive blood
or blood components are effectively managed within their Directorate and that their
staff are aware of, and implement, those requirements.

HOSPITAL TRANSFUSION COMMITTEE
The Hospital Transfusion Committee is responsible for ensuring that Trust staff
upholds the principles and guidelines within this policy and that appropriate polices
and procedures are developed, maintained, and communicated throughout the
organisation and that those policies and procedures are developed and implemented
in co-ordination with other relevant organisations and stakeholders.

DIVISIONAL RESPONSIBILITIES
Any incident arising should be investigated at a local level and any actions taken to
prevent reoccurrence and minimise risk. Documentation should be copied to the Risk
Management advisor to allow completion and closure of the incident. Any lessons to
be learnt should be shared at the Risk Management Divisional forum and where
appropriate the Trust Risk Management Committee Meeting. Any ongoing risks
should be registered on the Local/Divisional Risk register.

MATRON/WARD MANAGER/DEPARTMENTAL MANAGER RESPONSIBILITIES
It is the Ward Manager or Departmental Managers responsibility to ensure that staff
are made aware of the Trust processes for the correct administration of blood and
blood components. These procedures should be included in the induction of all staff
who may be involved in the care of the patient. Any incidents involving the use of
blood and blood components should be investigated and reported to the Matron or
Senior Manager via the Risk Management incident reporting route.

MEDICAL STAFF RESPONSIBILITIES
All medical staff should ensure that they are familiar with the Trusts procedures for
treating patient’s who refuse blood and blood components. These policies and
procedures include the Consent policy. Senior medical staff responsible for the

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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.

supervision and training of doctors in training should ensure that junior medical staff
are competent to undertake procedures within this policy. Any incidents should be
reported by all medical staff via the risk management incident reporting route.

ALL STAFF
It is the responsibility of every registered nurse, support worker or other member of
staff given responsibility of caring for a patient who has refused blood and blood
components that they follow the procedures laid down in this policy.
All staff should report any patient incidents involving the use of blood or blood
components via the Risk Management route. The Ward/Departmental Manager
should be informed of the incident.

RISK MANAGEMENT
The Risk Management Department will record on the Safeguard database system all
incidents reported through the incident reporting route. This data will be included in
the monthly reports to the Heads of Departments. Any specific trends identified will
be discussed at the Risk Management Committee meeting. The Risk Management
Committee reports to the Corporate Governance Committee which is a sub
committee of the Trust Board.

POLICY STATEMENT
• To ensure that all staff involved in the treatment of patients declining blood and
  blood components are fully conversant with the standards and procedures at all
  times.
• To facilitate safe practice within all clinical areas and ensure the safety of the
  patient.
• To act as a reference source for guidance and information.
• The policy is dynamic and at appropriate intervals new guidelines will be added to
  the policy.

EQUALITY AND DIVERSITY
The Tameside Hospital NHS Foundation Trust is committed to ensuring that, as far
as is reasonably practicable, the way we provide services to the public and the way
we treat our staff reflects their individual needs and does not discriminate against
individuals or groups on any grounds.

IMPLEMENTATION PLAN
• The policy will be advertised and held on the Intranet to achieve as wide an
  audience as possible.
• The policy will be available in Blood Bank.
• Relevant parts of the policy will be presented at regular training sessions for
  nursing, support and medical staff.
• The policy will be promoted by the Consultant Haematologists, Haematology
  Specialists Nurse, Specialist Transfusion Practitioner and Biomedical Scientists
  when discussing and advising on transfusion requests.


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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


MONITORING
The Hospital Transfusion Committee along with the Clinical Audit Department will
regularly monitor compliance to this policy.
Any deficiencies will result in an action plan being developed and presented to the
Hospital Transfusion Committee.

CONTACT DETAILS
• Consultant Haematologist – 0161 331 6501/07900175281
• Blood Transfusion Laboratory – 0161 331 6391
• Departmental Manager – 0161 331 6318
• Senior BMS, Blood Transfusion – 0161 331 6391
• Specialist Practitioner of Transfusion – 0161 922 5484, Page 621298
• Member of the Hospital Liaison Committee for Jehovah’s Witnesses – 01457 852
  117/07801981333
• 24 hour Hospital Liasion Committee contact number - 07850408158

THE LAW RELATING TO CONSENT/REFUSAL OF TREATMENT
INCLUDING BLOOD AND BLOOD COMPONENTS
•    If you have a patient who is 18 or over and who you deem to have mental
     capacity, that patient can consent to or refuse any treatment. If the patient
     refuses treatment, you must ensure they have received an explanation in terms
     that they can understand and the subsequent consequences. They must also
     understand the risks and benefits or any alternative options to the treatment
     advised.

•    If you have a patient of 18 and over who you think lacks mental capacity, you
     must treat that patient in accordance with his / her best interests. Close relatives
     and friends may be able to give you information about the patient’s known views
     on transfusion-related issues. Please refer to Mental Capacity Act Policy.
     (http://tis/documents/MentalCapacityActPolicy.pdf) For further advice please
     contact the Risk Management team

•    If your patient is under 18 then anyone with parental responsibility can consent on
     behalf of the patient. If the parents are married on or after the 1st December 2003
     the father’s name appears on the child’s Birth Certificate then both the mother
     and the father will normally have parental responsibility. Before December 2003
     only the mother of unmarried parents automatically had parental responsibility
     and although it was a simple procedure for the father to obtain it, provided the
     mother was agreeable, few fathers did so. Unless there is something that should
     arouse your suspicions, you can rely on what the parents tell you as to the family
     circumstances when deciding who has parental responsibility. Where there are
     unresolved differences of opinion between parents and child nearing adulthood
     who has mental capacity, these should be referred to the High Court.

•    If your patient is 16 or 17, then you can also obtain consent from the patient
     provided you are satisfied that the patient has mental capacity. If the patient is

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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.

     under 16 but you are satisfied that he or she is of sufficient age and
     understanding to appreciate the nature and implications of treatment, once again
     you can also obtain consent from the patient. If you are obtaining consent from a
     patient who is under 18, you should also normally make sure that someone with
     parental responsibility agrees to the treatment unless it is an emergency or there
     is an issue of confidentiality between the patient and the individuals with parental
     responsibility.

•    Wherever it is appropriate, consent to, or refusal of treatment must be
     appropriately documented in the patient’s health records. If necessary the patient
     can be asked to check and countersign the entry. This documentation should
     normally include a brief note of the risks and benefits of and any alternative
     options to the treatment that have been explained to the patient. Where there is
     an appropriate Consent Form, this should always be fully completed.

•    Advance Directive Document and Living Wills relating to refusal of blood and
     blood components have been tested and upheld in law, and Jehovah’s Witness
     patients will generally carry such a document, as well as lodging copies with their
     GP and family. (See page 14 for an example of this type of form). If an applicable
     Advance Directive exists, then this should be acted upon.

•    When a patient refuses blood and/or blood components, having had the possible
     consequences explained to them and understood and the Consultant in charge of
     the patient genuinely believes the procedure cannot be safely performed under
     the conditions the patient stipulates, then the Consultant has no obligation to
     proceed with the treatment. The patient must then be referred to an appropriate
     colleague or back to the General Practitioner so he/she can obtain further advice.
     In the event of the patient being a Jehovah’s Witness contact with the Hospital
     Liaison Committee can be made. They hold a list of clinicians willing in prinicple
     to accept the patient.

•    Remember to make sure that the patients realise that they can change their mind
     at any time. In an emergency situation where there is uncertainty about a
     patient’s wishes, any urgently required treatment should be given in accordance
     with normal good professional practice. If you are not sure what to do and if time
     allows you should consult the Duty Trust Manager and / or obtain advice from the
     Trust’s legal team.

CLINICAL INDICATION TO TRANSFUSE
In any procedure where blood transfusion is possible / indicated the following
procedure must be adopted:
• The risks and benefits of blood transfusion must be explained to the patient. The
    National Blood Service leaflet ‘Will I need a blood transfusion?’ should be given
    to the patient.
• The implication of refusing a transfusion must be clearly explained in a non-
    confrontational manner.


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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


•     It must be made clear to the patient that in certain circumstances refusing to
      accept a transfusion could be fatal.
It is essential in the management of any patients refusing a blood transfusion to
determine this at the earliest possible stage in their treatment (see flow chart).

DETERMINE REASON FOR REFUSAL
Patients can refuse a blood transfusion for many reasons. Every effort must be made
to determine why they refuse, in a non-confrontational manner.
e.g.:
• Religious belief
• Safety Aspects
• Development of Antibodies
• Previous transfusion reactions to blood/blood components
• Bad experience last time, cannula not sited correctly etc.
Having determined a reason for refusal, it is essential that efforts be made by the
Trust to resolve the problem. For example, if the patient is worried about transfusion-
transmitted infection, is there somebody else in the hospital able to talk to the patient
and reassure them (Consultant, Transfusion Specialist etc.)?

Documentation in the patient’s health records is essential. All actions /
discussions with patients and family members must be documented clearly,
must be signed and dated clearly by the person managing the patient and must
be signed and dated by another member of staff who has witnessed the events.

THE FOLLOWING DOCUMENTATION/CONSENT FORMS MUST BE
COMPLETED:
•    For surgical patients the Trust’s Consent Form 1 ‘Patient Agreement to
     Investigation or Treatment’ must be completed. The gold copy must be attached
     to the patient’s health records and the white copy given to the patient.
•    For all patients, documentation must be made in their health records by the
     person managing the patient, another member of staff who has witnessed the
     events and the patient themselves.
•    For any patient who refuses a blood transfusion for any reason, Consent Form 1
     ‘Patient Agreement to Investigation or Treatment’ and Consent Form 5 (page
     18) must be completed, detailing what products the patient is willing / unwilling to
     accept. The gold copy must be attached to the patient’s health records and the
     white copy given to the patient.

ALTERNATIVES TO BLOOD AND BLOOD COMPONENTS
Where possible and/or if the situation allows, an alternative strategy should be
discussed with the patient/guardian. See below for a list of alternative strategies that
could be used depending on the patient’s clinical condition and which may be
acceptable to the patient;
• Acute Normovolaemic Haemodilution (autologous)
• Post operative cell salvage (autologous)

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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


•    Intra-operative cell salvage (autologous)
•    Pre-deposit autologous transfusion (NOT acceptable to Jehovah’s Witnesses)
•    Iron tablets (prescribed at pre-op clinics)
•    Intravenous iron (prescribed at pre-op clinics)
•    Novo-seven (clotting agent)
•    Recombinant Clotting Factors
•    Erythropoietin (EPO)
•    Tranexamic acid
•    DDAVP
•    Aprotinin
•    Topical Haemostatic agents
•    Tissue sealants / adhesives

MANAGEMENT OF PATIENTS REFUSING BLOOD AND BLOOD
COMPONENTS
Having established the reason for not receiving a blood transfusion and which (if any)
alternative strategies are acceptable to the patient; clearly document this in the
patient’s health records.
The patient, person involved in the care of the patient and another member of
staff who has witnessed the refusal must sign, print their name and date in the
patient’s health records.
Ensure all teams (A+E/Surgical, Doctors/Consultants/Nurses/Carers etc) dealing with
the patient are absolutely clear on what treatment the patient will or will not accept.
• In life threatening situations all staff in the Trust must be professional in their
    attitude and care that they extend to the patient irrespective of whether they
    agree or not.
• The patient’s health records must be clearly documented.
• The patient, person involved in the care of the patient and another member of
    staff who has witnessed the refusal must sign, print their name and date the entry
    into the health records.
• The appropriate consent form must be completed.
• Jehovah’s Witness patients usually carry an ‘Advanced Decision Document’.
    Copy and attach to the patients health records. This document is renewed
    periodically.

Please Note: The patient has the right to change their mind at anytime during
treatment.

TREATMENT OF CHILDREN
See page 7 for the general position regarding consent to and refusal of treatment for
patients who are under 18.
It is advisable to involve senior Trust management and the Trust legal team at an
early stage where the possible refusal of treatment for a child is concerned.


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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.

Consent form 2 should be used for parental consent for a child or young person.

Remember that your duty of care is to the child and not to anyone with parental
responsibility. If you consider it essential for treatment to proceed against the wishes
of those with parental responsibility and if time allows, you should consult a senior
colleague and/or a Trust Manager who can obtain advice from the Trust’s legal team.

In an imminently life threatening emergency you should provide any treatment
that is judged to be urgently required in accordance with normal good practice
regardless of the views of those with parental responsibility as your duty is to
the patient.

Remember that as a matter of law you only need one valid consent whether
from an individual with parental responsibility or from the patient but as a
matter of good professional practice you should involve those with parental
responsibility in the decision wherever appropriate and you may not wish to proceed
with treatment which the patient objects to even if a person with parental
responsibility agrees.

LIFE – THREATENING EMERGENCY IN A CHILD
In an imminently life-threatening situation, where the delay of blood might be fatal, a
decision to proceed with treatment against the parent(s) or guardian(s) wishes is a
clinical decision by the medical staff / team managing the patient. The Consultant
must be informed at the earliest moment possible. Wherever possible another
Consultant should be consulted and a joint decision made. If time allows an
application must be made to the High Courts for a Specific Issue Order. However in
an imminently life threatening situation the Trust has a duty of care towards that
child.
• All actions must be documented in the patient’s health records clearly.
• Only justifiable blood / blood components must be used to save the patient’s life.
• The patient’s health records must be signed and dated by both Consultants
     involved in the case.
• The Consultants names must be printed clearly in the patient’s health records.
Important note: Legally, only one parent/guardian needs to consent.

WOMEN IN PREGNANCY
Objections to blood and blood components should be determined at the booking
clinic for antenatal patients. The Consultant Obstetrician and the team managing the
patient must be informed immediately and the health records clearly annotated.
‘Guidelines for management of women who decline blood transfusions is accessible
in the Obstetric and Gynaecology Guidelines on the Intranet.
Please note: The patient has the right to change her mind at any time during
treatment.



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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


ELECTIVE SURGERY
Objections to blood and blood components should be determined at the earliest
possible moment in the management of any patient going for elective surgery, where
there is the possibility that a transfusion of blood or blood components may be
necessary (i.e. Pre-Op clinics). This policy should be followed, please note these
additional points:
• The Consultant responsible for the patient must be informed about the patient’s
    wishes.
• Management of the patient must be discussed with the Consultant, the team
    looking after the patient and the patient / patient’s relatives.
• The patient must be made aware of the potential consequences in the event of a
    major blood loss.
• The agreed threshold for intervention could be lower than in other patients,
    however this is a clinical decision determined by the Consultant managing the
    patient and the patient.
• It is essential that all parties involved in patient care are aware of the patient’s
    decision about blood transfusion.
• Documentation of event/procedures etc. is essential. The patient, person
    involved in the care of the patient and a member of staff who has witnessed the
    refusal must sign, print their name and date the entry into the patient’s health
    records.
• The appropriate consent forms (Consent Form 1 and 5) must be completed.

If the patient’s haemoglobin concentration is low and there is insufficient time for an
alternative treatment to be effective (e.g. iron tablets), the procedure should be
deferred until the consultant has been informed and has discussed the situation with
the patient.
If a patient refuses blood and blood components, having the possible consequences
explained in a manner that they can understand and if the Consultant in charge of the
patient genuinely believes the procedure cannot be safely performed under the
conditions the patient stipulates, the Consultant has no obligation to proceed with the
treatment. The following must be undertaken:
• Explain the problems clearly to the patient in a professional manner.
• Refer patient back to their General Practitioner. The patient may wish to consider
     with the General Practitioner being referred to another Consultant/Trust.
• Document the events clearly in the patient’ health records. Ensure they are
     signed and dated.

TRAUMA/EMERGENCY ADMISSION
If treatment is to be withheld on the basis of an Advance Medical Directive / Release
(Living Will) you must be satisfied that: -
• It is signed by the patient. It is a recent document that expresses the patient’s
      current views.
• That the document covers clearly and precisely the circumstances in which the
      patient now finds himself or herself.
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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


•   A casual reading of the document is not sufficient.
•   If you are uncertain then you should consult a senior colleague and/or Trust
    Manager who can obtain advice from the Trust’s solicitors.
When it is established that the patient has refused a transfusion of blood or blood
components, which (if any) alternative strategies they will accept, the main principle
of management is to avoid delay. Rapid decision-making may be necessary,
particularly for surgical intervention.

If the patient is a Jehovah’s Witness, they should carry an Advanced Decision
document. It is important that a copy of this document is attached to the patient’s
notes as a permanent record.

•    Ensure the Consultant Surgeons and Anaesthetists are aware of the situation.
•    The Consultant Haematologist should be informed, although the options for
     treatment may be severely limited.
•    It is essential to keep the patient informed in a professional manner. It is
     important to maintain their trust.
•    The agreed threshold for intervention should be lower than in other patients.
•    Intravenous crystalloids and colloids should be used for fluid replacement. Some
     religious or other beliefs may preclude the use of certain animal derived colloids
     (although Jehovah’s Witnesses have no religious objection to them).
      Avoid the use of Dextran if possible, as it may affect haemostasis.
•    If the patient survives the acute episode and is transferred to Intensive Care,
     management should include erythropoietin, parenteral iron therapy and adequate
     protein for haemoglobin synthesis.

No other person is legally able to consent to treatment or refuse treatment on
the patient’s behalf. It is therefore, important when a patient refuses a blood
and blood components to ensure another person is not pressuring them.




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     Tameside Hospital NHS Foundation Trust                           policy for the treatment of patients who have indicated that
                                                                         they do not wish to receive blood or blood components.


     REFUSAL OF BLOOD AND BLOOD COMPONENTS – FLOW CHART
                                      Clinical indication / plan to
                                                transfuse



                                                                                                          Patient agrees to
                                              Discuss with patient
                                                                                                         transfusion - END



                                      Patient refuses Blood and
                                         Blood Components




 Determine reason for                              Assess patient’s                             Discuss alternatives to
       refusal:                                     competence:                                   blood transfusion:
                                                                                                 • Cell salvage
 •    Religion                                 •   Over 18                                          (Intra/post)
 •    Safety aspects                           •   Minor but Gillik                              • Haemodilution
 •    Antibodies                                   competent                                     • Oral Iron
 •    Previous reaction                        •   Minor-clinical decision                       • Intravenous iron
 •    Bad experience                               ‘duty of care’ to child                       • Erythropoietin, etc.




                                                                                                 Implement patient’s
Discuss/resolve problem                                                                               wishes
                                                                                                  document details



     If the patient refuses any treatment                                                  If patient a minor:
     • Explain consequences to patient
     • Inform all care teams                                              •     Clinical decision to transfuse
     • Document clearly in notes                                          •     Keep relatives informed
     • Patient, member of staff and
          witness (staff member) must sign,                               Trust has a ‘Duty of Care’ to the child
          print name and date entry in the
          patient’s health records.                                       •     The member of staff and witness (staff
                                                                                member) must sign, print name and date
                                                                                entry in the patient’s health records.

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Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


ADVANCE DECISION DOCUMENT (PAGE 1)




 Version 2.0 1st March 2011                                                                                    Page 15 of 19
                                         Check the Intranet for the latest version
Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


ADVANCE DECISION DOCUMENT (PAGE 2)




 Version 2.0 1st March 2011                                                                                    Page 16 of 19
                                         Check the Intranet for the latest version
Tameside Hospital NHS Foundation Trust                                            policy for the treatment of patients who have indicated that
                                                                                     they do not wish to receive blood or blood components.




                                                         CONSENT FORM 5

     CONSENT BY AN ADULT WHO INDICATES THAT THEY DO NOT WISH TO BE
                 ADMINISTERED ANY BLOOD COMPONENTS

I,                                                                      District Number,                                                              ,
Date of Birth,                                              , of
have given my consent for a procedure/investigation/operation on the appropriate
department of health consent form, the nature and purpose of which have been explained to
me by Dr/Mr.................................. and to the administration of general, local or other
anaesthetic.
I also give my consent to the performance upon me of any other operative procedure which
in the opinion of the surgeon it may be necessary to perform upon me, without having
obtained my express consent, during or by reason of the said operation/procedure or
anything connected with it; except that, although it has been explained to me that in the
course of or by reason of the said operation/procedure it may be necessary to give me a
blood transfusion (red cells, white cells, plasma or platelets) so as to render the
operation/procedure successful, or to prevent injury to my health, or even to preserve my
life, I hereby expressly withhold my consent to and forbid the administration to me of
a blood transfusion in any circumstances or for any reason whatsoever and I
accordingly absolve the surgeon, the hospital and every member of the medical staff
concerned from all responsibility, and from any liability to me, or to my estate, or to my
dependants, for any damage or injury which may be caused to me, or to my estate or to my
dependants, in any way arising out of or connected with this my refusal to consent to any
such blood transfusion.
I hereby expressly withhold consent for the following components to be used:
    □ Packed Red Cells
    □ Platelets
    □ Fresh Frozen Plasma
    □ White Cells
    □ Intra – operative Cell Salvage
    □ Post – operative Cell Salvage
    □ Recombinant Clotting Factors
Date.................................... Signed.............................................................................
                                                                                 (Patient)

Witness to Patient’s Signature...................................................................................
                                                                                                  (Health Professional)
                                                            ................................................................................
                                                                                     (Witness present at interview)
                                   Photocopy accepted by patient: yes / no (please circle)

 Version 2.0 1st March 2011                                                                                                                    Page 17 of 19
                                                     Check the Intranet for the latest version
     Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                        they do not wish to receive blood or blood components.


                            NHSLA EQUALITY IMPACT ASSESSMENT

                                                                         Yes/No                      Comments

1.      Does the policy/guidance affect one group
        less or more favourably than another on the
        basis of:

        • Race                                                              No

        • Ethnic origins (including gypsies and travellers)                 No

        • Nationality                                                       No

        • Gender                                                            No

        • Culture                                                           No

        • Religion or belief                                               Yes            Jehovah’s Witness patients
                                                                                          believe in not being treated with
                                                                                          any blood component. This
                                                                                          policy is to assist in the
                                                                                          treatment of ALL patient who
                                                                                          refuse blood components.

        • Sexual orientation including lesbian, gay and                     No
          bisexual people

        • Age                                                               No

        • Disability - learning disabilities, physical                      No
          disability, sensory impairment and mental
          health problems
2.      Is there any evidence that some groups are                         Yes            Jehovah’s Witness patients
        affected differently?                                                             believe in not being treated with
                                                                                          any blood component. This
                                                                                          policy is to assist in the
                                                                                          treatment of ALL patient who
                                                                                          refuse blood components.
3.      If you have identified potential discrimination,                   Yes            The justifiable exception is due
        are any exceptions valid, legal and/or                                            to the religious believes of the
        justifiable?                                                                      Jehovah’s Witnesses. This
                                                                                          policy will aid in the care of all
                                                                                          patients refusing blood
                                                                                          components
4.      Is the impact of the policy/guidance likely to                      No
        be negative?
5.      If so can the impact be avoided?                                   N/A
6.      What alternatives are there to achieving the                       N/A
        policy/guidance without the impact?
7.      Can we reduce the impact by taking different                       N/A
        action?



      Version 2.0 1st March 2011                                                                                    Page 18 of 19
                                              Check the Intranet for the latest version
Tameside Hospital NHS Foundation Trust                          policy for the treatment of patients who have indicated that
                                                                   they do not wish to receive blood or blood components.


REFERENCES
Management of Anaesthesia for Jehovah’s Witnesses 2nd Edition November 2005 –
The Association of Anaesthetists of Great Britain and Ireland

Clinical Strategies for Managing Haemorrhage and Anaemia without Blood
Transfusion
Jan 2003 – Hospital Information Services (Britain) for Jehovah’s Witnesses

Clinical Strategies for Avoiding and Controlling Haemorrhage and Anaemia without
Blood Transfusion in Obstetrics and Gynaecology
Jan 2004 – Hospital Information Services (Britain) for Jehovah’s Witnesses

Code of Practice for the Surgical Management of Jehovah’s Witnesses
2002 – The Royal College of Surgeons of England

Guideline for the Treatment of Patients who have indicated that they do not wish to
receive blood or blood components.
2005 – Salford Royal NHS Trust




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