The main group of patients who refuse a blood transfusion are Jehovah’s Witnesses. However, there are other religious groups who may hold similar views. Apart from religious beliefs there may be individuals who refuse blood because they fear blood borne infection or are not able to put the various transfusion risks into perspective.

The Jehovah’s Witness movement was founded 120 years ago in the USA. Their belief is based on their interpretation of various passages in the Bible (Genesis, Leviticus & Acts); they believe it describes the prohibition of the consumption of blood. The prohibition of blood transfusion is a deeply held core value & is a sign of respect for life. However, there are no absolute rules & some individual Witnesses may accept plasma protein fraction or products such as albumin, indeed some individuals might accept blood products or components in exceptional circumstances.

All patients who may need blood transfusion should be asked about their willingness to accept it. This includes:

• All booked admissions for surgery where blood loss is possible

• All antenatal bookings

• Any patients having any intervention that could lead to the need for blood or blood products.

Competent adult patients have the right to refuse treatment & can make ‘Advance Decisions’ to specify treatment(s) they would refuse, & the circumstances that this refusal will apply to, in the event that they lack capacity in the future. Advance Decisions must be written if life-sustaining treatment is being/will be refused & must be signed, witnessed, & include a clear statement that the decision applies even if life is put at risk as a result of refusal of treatment.

Most Jehovah’s Witnesses will carry an Advance Directive in the format specified in the Mental Capacity Act, 2005 to communicate their refusal of whole blood, packed red cells, white cells, platelets & plasma & their individual choice regarding acceptance or refusal of ‘fractions’ of plasma or cellular components. This document is entitled Advance Decision to Refuse Specified Medical Treatment (available on Epic to print if required).

For further guidance on advance decisions see the Trust Safeguarding Lead or policy. A copy of the Advance Decision/Directive should ALWAYS be filed in the patients notes & all decisions & plans clearly documented.

Some Jehovah’s Witness patients may wish to wear their own ‘No Blood’ wristband. The NPSA (National Patient Safety Agency) Safer Practice Notice No.24 (3 July 2007) states: ‘Patients who wish to wear their own wristbands in hospital should be permitted to do so but advised of the dangers of confusion for staff.’

The table below is a guide; patients should make their choices & include this in their advance directive.

Table J1: acceptability of blood products & components

A checklist has been created to ensure preferences are documented (Available on Epic once refusal order is completed –Refer to Epic step by step Blood Refusal).

(See Epic F1 Button, or links in refusal order for flowcharts)

• Competent non-emergency adult patient refusing red blood cells or/& other blood products (including Jehovah Witnesses);

• Incompetent non-emergency adult patient refusing red blood cells or/& other blood products (including Jehovah Witnesses);

• Competent emergency adult patient refusing red blood cells or/& other blood products (including Jehovah Witnesses);

• Incompetent emergency adult patient refusing red blood cells or/& other blood products (including Jehovah Witnesses);

Elective admissions require careful advance planning in which the patient actively confirms their status at an early stage. Follow the non-emergency patient care pathways & complete the patient checklist with the patient &/or guardian (available on Epic as part of refusal note).

Assess the patient to determine whether they have the necessary mental capacity to make this decision. If there is any doubt as to the patient’s capacity, then it is essential to follow the Trust policy for establishing competence & safeguarding the patient.

• Ensure that the patient is not under duress. It may be necessary to speak to the patient in private if the Consultant feels that someone else is trying to exert pressure on the patient to refuse a blood transfusion &/or blood products.

• Explain in simple but full terms the operation or procedure & the risks for the patient of not having a blood transfusion &/or blood products. The clinician should ensure that they are not placing the patient under duress but instead is giving them enough information to make an informed choice whether to consent to this treatment.

• If pre-operative anaemia is diagnosed the treatment options & timescales should be discussed with the haematologist, the patient & the surgeon. Section 10 gives a summary of possible Erythropoietin/iron treatment.

• The aim of the meeting is to formulate a plan for surgery that complies with their wishes & beliefs. No attempt should be made to frighten or place the patient under duress. They should be asked if they wish to consult the JW Liaison Committee & this should be documented.

Once the patient understands & fully appreciates the significance of their refusal to have a blood transfusion &/or blood products then this must be clearly documented on the patients EPR record using the refusal note and checklist.

Clinicians should decide whether they are willing to accept limitations in patient management.

• If the clinician is willing to proceed then the Consultant in charge of that patient’s care must have a structured discussion between the surgeon, anaesthetist, haematologist & patient prior to the proposed surgery. The patient may request the presence of a member of the local Hospital Liaison Committee.

• If the clinician is not willing to proceed then the patient should be referred to a co-operative doctor or Trust before his/her condition deteriorates (Royal College of Surgeons 2016). Contact the local Hospital Liaison Committee of Jehovah’s Witnesses for cooperative Consultants at other facilities, to confer with regarding alternative care. The local Jehovah’s witness liaison member can be contacted via switchboard and if that fails there is 24-hour helpline available: +44 20 8371 3415

When a patient is admitted as an emergency, either unconscious or unable to communicate, unless obvious (such as advance directive carried in wallet) they will be treated in their best interests. See the care pathways on Epic (F1 button & links in Refusal note). If at a later stage it becomes obvious the patient refuses blood products the situation will be reviewed.

8.1 Adults: A competent adult has an absolute right to refuse any aspect of medical treatment. If the patient is treated against their will the Tort of Battery is committed. A written, signed declaration of refusal of blood products is legally binding & cannot be revoked by the court or a relative even if massive blood loss occurs whilst the patient is anaesthetised.

8.2 Patients with a mental health disorder

Patients with a mental health disorder are still capable of making competent decisions. They should be able to demonstrate they understand in broad terms & simple language what the medical treatment is & for what purpose. They should be able to understand the principal benefits, risks & alternatives. They should be able to understand the implications of refusing treatment, make a free choice without pressure, retain the information & make an effective decision. In cases of uncertainty contact the Legal Services Department.

8.3 Obstetric Patients

Removing administration of blood from the treatment of post-partum haemorrhage without modifying practice has the potential of placing patients in grave danger.

Antenatal Preparation: The woman should be seen by the Consultant Obstetrician. Follow the non-emergency patient care pathways & complete the checklist with the patient (available on Epic as part of refusal note).

Outcome of this discussion must be clearly documented in the medical notes. Refer to Haematology if appropriate or needed.

Intra-partum & Postnatal Management: Avoid all possible haemorrhage – active management of the third stage is strongly recommended. Ensure any perineal damage is promptly repaired.

Caesarean Section: If elective plan using the refusal checklist on Epic.

The pre-operative clinical assessment

• Clinical History

• Drug history (NSAIDs, Aspirin, Clopidogrel, Warfarin, Dabigatran, Rivaroxaban)

• When taking samples for testing use paediatric bottles to minimise the amount of blood used for diagnostic purposes

• Treat anaemia if found

• Accept a lower Hb concentration.

• General measures that may be considered to reduce blood loss during surgery include meticulous surgical haemostasis, enlarged surgical teams, staging of complex procedures, patient position to reduce venous congestion, use of tourniquet, skin infiltration with vasoconstrictors, topical haemostatics (Surgical, Oxycel, Gelfoam, Tuisseel, etc) & regional anaesthesia.

Please refer to the FHFT formulary for full guidance on the administration of Erythropoietin and Iron.

Consider use of recombinant erythropoietin (EPO) for patients who meet the criteria for blood transfusion but declines it because of religious beliefs or other reasons. EPO must only be considered if the patient has a Hb <13g/dL (Hb ≤12g/dL for female patients) and are at risk of significant blood loss during their procedure.

Due to the increased risk of Thrombotic and cardiovascular complications associated with erythropoietin, the risks & benefits should be weighed in these patients who are already at risk of these complications.

EPO is ineffective in patients with iron, B12 or folate deficiency. Patients with a ferritin level <100 ng/ml should be given IV iron.

Refusal of Consent for Blood Transfusion

Under the Mental Capacity Act 2005, Advance Decisions cannot be made by children less than 18 years of age. Full discussion should take place between the clinician (e.g., surgeon, anaesthetist), parents and child if the child is considered to be ‘Gillick competent’, i.e., the child has sufficient maturity and understanding to consider the treatment and weigh up the risks and benefits of that treatment. Further advice should be obtained from the Legal Services Department should there be conflict between parents, child and the treating clinicians.

Section 8 of the Children Act 1989 ‘specific issue order’ was designed specifically with this in mind. This order permits the court to exercise its power over (in this case) the specific issue of blood transfusion; whilst leaving the rest of the rights and responsibilities conferred by parental responsibility firmly with the parents. With such an order, transfusion is permissible. In desperate circumstances, such an order, or its oral equivalent, can be obtained over the telephone from a High Court judge in a matter of 30 minutes. This can be done through the site manager, who will direct you to the appropriate person to make this call, depending on the time of day. If there is insufficient time (i.e., less than 30 minutes) to make this application, where the child will die without transfusion, and all feasible clinical alternatives and adjuncts to transfusion have been exhausted, then blood must be given to save the child's life, despite the refusal of patient and parents. English courts have never allowed litigation to commence against a clinician who saves a life in good faith.

11.1 Children Over 16 Years Old

Children who are 16 or 17 years old are deemed to have the necessary capacity to consent to medical treatment. If a 16- or 17-year-old consents to receiving a blood transfusion or blood products and the parents are refusing the treatment every opportunity should be taken to discuss the issues bearing in mind the Courts' normal strong presumption in favour of preserving life. However, the guidance set out in 5.2.2 should be followed.

However, if a 16- or 17-year-old refuses treatment this can be overridden either by a holder of parental responsibility for that child or the court. If staff are faced with a situation where the child is refusing a blood transfusion, but the parents wish them to have a blood transfusion then, in an emergency situation, a blood transfusion should be given. However, if the situation is not an emergency, the staff should discuss the issue with senior staff who may then seek legal advice.

11.2 Children under the Age of 16 Years

Usually, the consent of a holder of parental responsibility is required to treat a child under the age of 16. However, if the child is Gillick competent, then they can consent to treatment themselves and this can be given regardless of the parents’ opposition.

If parents refuse to consent to a blood transfusion for their child and the child is either not Gillick competent or also refuses a blood transfusion, then staff should contact the Litigation/Legal Services Manager, as a Court order may be required (see the ‘Consent for examination and treatment policy’ for managing this including out of core hours guidance).

If the child requires a blood transfusion in an emergency situation, then clinicians should take steps to preserve the child’s life even if this means giving a blood transfusion against their wishes. As always staff should ensure that the patient’s notes clearly document the event and reasons for their actions.

Royal College of Surgeons of England Professional and Clinical Standards (2016) Caring for patients who refuse blood. Available at: https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/caring-for-patients-who-refuse-blood/ (Accessed: 18 September 2024).

The Society of Thoracic Surgeons, The American Society of Extracorporeal Technology, and Elsevier Inc. Patient Blood Management Guidelines (2021) Update to the Clinical Practice Guidelines on Patient Blood Management Available at: https://www.annalsthoracicsurgery.org/article/S0003-4975(21)00556-7/fulltext (Accessed: 18 September 2024).

Klein, A.A. et al. (2018). 'Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation 2018.' Anaesthesia, 73, pp. 1141-1150. Available at: https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_Cell_salvage_for_peri-operative_blood_conservation_2018.pdf?ver=2019-01-08-171406-510×tamp=1546967666882&#x26;ver=2019-01-08-171406-510×tamp=1546967666882 . (Accessed: 18 September 2024).

Association of Anaesthetists of Great Britain and Ireland (2016) 'The use of blood components and their alternatives 2016’, Anaesthesia 71, pp. 829-842. Available at: https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_blood_components_alternatives_2016_final.pdf?ver=2018-07-11-163753-007&#x26;ver=2018-07-11-163753-007. (Accessed 18 September 2024).

García-Erce, JA., Cuenca, J., Haman-Alcober, S., Martinez, AA., Herrera, A. and Munoz, M. (2009) 'Efficacy of preoperative recombinant human erythropoietin administration for reducing transfusion requirements in patients undergoing surgery for hip fracture repair. An observational cohort study', Vox Sang, 97(3), pp. 260-267.

García-Erce, JA., Cuenca, J., Martínez, F., Cardona, R., Pérez-Sarrano, L and Muñoz, M. (2006) 'Perioperative intravenous iron preserves iron stores & may hasten recovery from post-operative anaemia after knee replacement surgery', Transfus Med, 16(5), pp. 335-341.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version Control Sheet

Related Documents