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Background
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In some circumstances, a competent adult patient may refuse transfusion of blood or its major components. This refusal may be based on religious or personal beliefs.
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Some Jehovah's Witnesses do not accept transfusion of blood or its major components and are prepared to die rather than compromise this belief. They accept and expect the highest standards of modern medical care and full use of of appropriate modern medical technology.
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Note: It is strongly recommended that legal advice be obtained where the transfusion is thought desirable (e.g. to protect a fetus, or where relatives disagree with the patients decision).
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Life-threatening bleeding in an adult obstetric patient who refuses blood transfusion
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- Any documentary evidence such as a Refusal of Treatment Certificate (in the form of Schedule 1 to the Medical Treatment Act 1998) should be requested from relatives of the patient and examined. A copy should be placed in the medical record and its contents respected.
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- The doctor (who should be of consultant status) managing the patient should discuss with the patient or the relatives the implications of withholding blood.
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- The patient should be managed by a team including consultant obstetrician, anaesthetist and haematologist.
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- Rapid and definitive management of obstetric bleeding should be undertaken according to the cause of blood loss (oxytocics, embolisation, internal iliac artery ligation, hysterectomy).
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- General supportive measures, including fluid resuscitation, maintenance of blood pressure and renal output, should be undertaken.
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- Management may include transfer to an intensive care unit if the patient requires intubation and high dose oxygen support.
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- Anaesthetic techniques will be tailored to the specific situation and may include use of salvaged blood if acceptable to the patient.
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- Haematological protocols for the treatment of severe anaemia may be appropriate.
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Antepartum care of the low risk obstetric patient who refuses blood transfusion
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- Any documentary evidence such as a Refusal of Treatment Certificate (in the form of Schedule 1 to the Medical treatment Act 1998) should be requested from relatives of the patient and examined. A copy should be placed in the medical record and its contents respected.
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- Haematological parameters should be optimised during pregnancy by: treatment of any haematinic deficiency (iron, folate, B12); avoidance of antiplatelet drugs such as aspirin prior to delivery.
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- Active management of third stage should be discussed in advance.
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- Discussion should include which of the minor blood fractions are acceptable to the patient. Eg Rhesus immunoglobulin (anti-D).
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- Discussion should include what is acceptable in the event of unexpected bleeding, e.g. intraoperative blood salvage.
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Antepartum care of the high risk obstetric patient who refuses blood transfusion
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- Any documentary evidence such as a Refusal of Treatment Certificate (in the form of Schedule 1 to the Medical treatment Act 1998) should be requested from relatives of the patient and examined. A copy should be placed in the medical record and its contents respected.
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- The patient should be managed by a consultant obstetrician and should be seen by the consultant anaesthetist and haematologist at least two weeks prior to planned delivery.
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- The purpose of the pre-delivery consultation is to formulate a plan for delivery that complies with the patient's wishes and beliefs.
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- The proposed delivery and possible complications that may result in bleeding should be discussed by the obstetrician.
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- The anaesthetist will outline techniques used to avoid transfusion and will obtain and document consent for these.
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- The anaesthetist will ask what action the patient will sanction if they are unconscious or unable to communicate and dying of unexpected blood loss - this is documented.
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- The haematologist will ascertain which therapeutic agents are acceptable to the patient for support of blood volume.
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- The haematologist will consider enhancement of pre-operative haemoglobin with recombinant Epo if appropriate.
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Elective gynaecological surgery in the adult patient who refuses blood transfusion.
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- The patient must be seen by a consultant gynaecologist, anaesthetist and haematologist at least two weeks prior to elective surgery.
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- Any documentary evidence such as a Refusal of Treatment Certificate (in the form of Schedule 1 to the Medical treatment Act 1998) should be requested from relatives of the patient and examined. A copy should be placed in the medical record and its contents respected.
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- The purpose of the pre-operative consultations is formulating a plan for surgery that complies with the patients wishes and beliefs.
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- The proposed operation and possible complications that may result in bleeding should be discussed by the gynaecologist.
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- The anaesthetist will ask what actions the patient will sanction if they are unconscious or unable to communicate and dying of unexpected blood loss - this is documented.
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- The haematologist will ascertain which therapeutic agents are acceptable to the patient for support of blood volume.
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- The haematologist will consider enhancement of pre-operative haemoglobin with recombinant Epo if appropriate.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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Please remember to read our disclaimer.
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