People Who Abstain From Blood and Blood Products

“It is estimated that there are approximately 8 million Jehovah’s Witnesses worldwide, with 140,000 currently resident in the UK. Jehovah’s Witnesses have refused allogenic blood transfusion and primary components (red cells, white cells, platelets and plasma) on religious grounds.

In addition to Jehovah’s Witnesses, a growing number of patients are choosing to decline blood transfusions; many of whom do so for reasons other than religious faith. Fears about the safety of blood transfusion as well as the scarcity of donors and changing patient expectations are leading some patients to withhold consent for blood transfusion.” (Royal College of Surgeons of England, p3, 2018).

NHS Borders aims to respect the wishes of all patients, adults and children and their families, and to provide high quality health care acceptable to them. All patients have the right to be treated with respect and staff must be sensitive to their individual needs, acknowledging their values and beliefs.

1.1 Principles of Consent

Consent refers to a patient’s autonomous agreement for a health professional to provide care, and it must be confirmed in writing. For consent to be valid, it must be:

 Given by a person with the capacity to make the decision in question.

• Given voluntarily.
• Based on appropriate information (informed) and understood.

If one or more of these factors is missing, the patient is not considered to have given permission to proceed to treatment.

All patients in the UK with mental capacity have the absolute legal and ethical right to refuse treatment or any aspect of treatment. To administer blood against a patient’s wishes may be unlawful and could lead to criminal and/or civil proceedings.

It is the right of an adult patient to withhold consent to treatment, even when doing so would be potentially fatal (British Medical Association, 2019). It is also the case for pregnant women choosing to refuse treatment even if it might lead to harm for their unborn child (Royal College of Surgeons of England, 2018).

Doctors must listen to patients and respect their views about their health. The options for treatment should be discussed in relation to the patient’s own values and wishes. Working in partnership with patients requires learning their views and expectations regarding their treatment and working together to inform patients of their options for achieving the best outcome for them as individuals.

Patients must be made aware of their right to refuse or to give consent to treatment at any time and assumptions must not be made about the patients’ awareness of their right to make treatment decisions.

Patients should be asked explicitly whether any refusal of treatment extends to situations where loss of life or limb without these treatments is likely. The patient’s decision should be recorded and placed in their clinical record.

When supporting a patient to reach a decision about treatment, doctors must be satisfied that the patient gave or withheld consent to treatment themselves, without coercion or unwelcome influence from other persons. Although patients may value the aid of a friend, family member or other supporter to provide comfort through their decision-making process, it is important to ensure that any decision represents the patient’s own views and is not unduly influenced by the wishes of another person.

At the end of the consent discussion, the doctor should review with the patient the potential implications of any choices that could be contrary to their wellbeing. This should include any risks and benefits associated with such choices. This review should not, however, be intended to influence the patient to take a course of action that is not in keeping with their values and wishes (General Medical Council, 2019).

It is appropriate to anticipate that a Jehovah’s Witness patient will wish to discuss the issue of treatment with blood and blood products, however no assumptions beyond that should be made until the medical consequences of non-transfusion in the management of their specific condition have been discussed.

Doctors have the right to refuse to treat an individual in an elective situation if constraints are put on their practice that will adversely affect their ability to provide care.

However, they also have a responsibility to then refer the patient to a suitably qualified colleague.

In an emergency, doctors are obliged to provide the care. If, however, a patient has competently expressed a wish not to receive the care, and there is robust evidence of that wish (e.g. an Advance Directive), that wish must be respected.

2.1 Jehovah’s Witnesses

The majority of patients refusing transfusion of blood, blood components or products are Jehovah’s Witnesses. Their anticipated objection is treatment with allogenic blood and the primary blood components.

However there may be variation in preferences so each patient should be treated individually and clarification should be sought as to which treatments are acceptable or not.

(See Appendix A: ‘Consent Form for Specific Blood Components and Procedures for Jehovah’s Witness patients who refuse blood transfusion’)

2.1.1 Treatment Not Normally Acceptable to Jehovah’s Witnesses

It is anticipated that all Jehovah’s Witnesses will refuse the transfusion of the four primary blood components.

Red cells, White cells, Platelets, Plasma (including FFP). Pre-deposited autologous blood also falls under this heading.

2.1.2 Treatment Normally Acceptable to Jehovah’s Witnesses

It is anticipated that Jehovah’s Witnesses are likely to accept medical management to build up or conserve their own blood, to avoid or minimise blood loss and to replace lost circulatory volume.

This would include

• Sodium chloride (saline) solution,
• Hartmann’s (Ringer-Lactate) solution
• Modified gelatines, (e.g. Gelofusine, Haemacel).
  
  

Recombinant products such as erythropoietin (r-HuEPO) and clotting factors VIIa, VIII and IX are normally accepted.

2.1.3 Treatment That Jehovah’s Witnesses Consider to be a Matter of Choice

Blood products: Derivatives of primary blood components (albumin, coagulation factors, immunoglobulins, etc.).

Treatment and procedures involving their own (autologous) blood: This would include normovolaemic haemodilution, cell salvage (both intra- operative and post-operative), renal dialysis, plasmapheresis, blood radiolabelling cardiac bypass etc. There may be ways of performing these procedures that are acceptable to some and not to others (e.g. cell salvage).

They may have a guardian, continuing attorney or welfare attorney as outlined in the Adults with Incapacity (Scotland) Act 2000 who has powers relating to the proposed intervention.

There are various principles underpinning the 2000 Act including an obligation to take account of:

• Any guardian, continuing attorney or welfare attorney of the adult who has powers relating to the proposed intervention.
• The present and past wishes and feelings of the adult as far as they can be ascertained by any means of communication.
• The views of the nearest relative and the primary carer of the adult, as far as it is reasonable and practicable to do so.

If a blood transfusion is non-urgent, time should be taken to furnish documentary evidence of the patient's refusal of blood transfusion.

‘If (the practitioner) learnt that the patient was a Jehovah's Witness, but had no evidence of a refusal to accept blood transfusions, he would avoid or postpone any blood transfusion so long as possible." (1992 court of appeal 3 W.L.R.782 at 787G).

Most Jehovah’s Witnesses carry the document ‘Advance Decision to Refuse Specified Medical Treatment’ and copies are often lodged with GP, friends and fellow worshipers.

This document confirms the patient’s legal decision to withhold consent from receiving specified treatments provided it is appropriately completed, signed and witnessed.

3.1 Welfare of Power

Valid only if it is expressed in a written document which:

• Is subscribed by the granter (i.e. signed by the patient)
• Incorporates a statement, which clearly expresses the granter’s intention that the power be a welfare power; states that the granter has considered how a determination as to whether he is incapable in relation to decisions about the matter to which the welfare power of attorney relates may be made.
• Incorporates a certificate in the prescribed form by a practising solicitor or by a member of another prescribed class.

Persons aged sixteen or over have the exclusive right to determine their own medical treatment. The parent has no right to consent or interfere. In Scotland, a child is someone under the age of 16.

Please note: An advance directive has no legal standing in children under the age of 16.

A child is able to give or withhold consent to medical treatment provided the medical practitioner attending believes that he or she is capable of understanding the nature and possible consequences of the procedure or treatment (Age of Legal Capacity (Scotland) Act 1991 section 4).

There is no lower age limit for being competent to consent, but ability to do so will be dependent on a number of factors, including the complexity of the procedure and possible long-term consequences. Thus, a child may be competent to consent to certain medical treatments, but not to others.

If the child is deemed to, have capacity to consent then only the child can give or withhold consent and a parent cannot override the child’s decision.

The Children (Scotland) Act 1995 states that a person with parental rights and responsibilities reaching any major decision in relation to a child, including consent to treatment, shall have regard as far as practicable to the views of the child concerned, if the child wishes to express a view and taking account of the child’s age and maturity.

The Act specifically states that a child of 12 or over shall be presumed to be of sufficient maturity to form a view, although this does not exclude a younger child from having a view. Thus, even where a child lacks capacity to consent it will be important to ensure that his or her views are taken into account in accordance with this section.

If the child is legally competent to consent to treatment on his or her own behalf, and the clinician is persuaded 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 proceed as if following this guidance for an adult, ascertaining exactly what the child would, and will would, accept by way of treatment.

4.1 Children Undergoing Elective Surgery

Concerning an elective surgical procedure, the parents may feel able to consent to the surgery but unable to consent to the use of blood. This type of surgery is most likely to include minor ENT procedures.

In this situation, the parents may be willing to allow surgery to proceed on the understanding that the clinicians will endeavour to avoid allogeneic blood use. If during the procedure the use of blood is considered necessary the situation is analogous to an emergency and guidance would be as detailed below.

All cases of elective paediatric surgery in patients who are Jehovah’s Witnesses or whose parents are Jehovah’s witnesses must be discussed with the Anaesthetist.

Please note: In the situation of an elective surgical procedure, which will probably or definitely require the use of autologous blood, surgery is not normally carried out at the Borders General Hospital. Such cases will be referred up to Royal Hospital for Sick Children (Edinburgh).

Jehovah’s Witnesses are generally aware of the possibility of such an order, but it should rarely be necessary.

If it is considered, it is of the utmost importance to keep parents fully informed that a Court order is being sought to override the parents’ position. A Court will almost certainly ensure that the parents have the opportunity to be represented at any hearing.

5.1  Children – Emergency and Trauma

In a situation where the parents feel unable to give permission to transfuse blood, it may be felt that application for a Specific Issue Order would be too time consuming. If two Doctors of Consultant status make a clear, unambiguous decision, that a blood transfusion is essential, or is likely to become so to save a life or prevent serious harm, then they should act upon the basis of their own clinical judgement, and in the best interests of the patient.

The clinician’s duty of care is to the patient and the courts are likely to uphold the decision of the doctors who administered the transfusion in such circumstances and any such decision must be clearly recorded in the medical notes.

It is vital that the parents are kept fully informed and supported during this difficult time, and the Hospital Liaison Committee may be particularly helpful.

It is essential to involve a Consultant Paediatrician in the preparation and care of all children who refuse blood or whose carers cannot consent to the use of blood. The therapeutic principles below are largely applicable to children but it is essential that an individualised care plan is developed in each case.

Patients in whom elective moderate to major surgery is planned where blood loss is possible or expected will not be operated on within the Borders General Hospital. These patients should be referred to Royal Infirmary Edinburgh or Western General Hospital, Edinburgh depending on speciality. These tertiary centres have access to cell salvage, interventional radiology and other blood conservation therapies not available within NHS Borders.

Pre-operative principles and preparation can be adhered to however:

• Investigate and treat pre-operative anaemia and coagulopathy if possible.
• A multi-speciality team approach will be utilised at the hospital where surgery will be performed.

In minor surgical procedures, where minimal or no blood loss is anticipated, surgery may be performed at the Borders General Hospital in consultation with both the surgical and anaesthetic teams involved. If surgery is carried out:

• Maintain frequent, close observation for haemorrhage.
• Early recognition and prompt intervention to prevent/control abnormal bleeding is the cornerstone of effective care of patients who will not accept allogeneic blood. Avoid a “watch and wait” approach to a bleeding patient.
• Exercise clinical judgement and be prepared to modify routine practice when appropriate
• Consult promptly with senior specialists experienced in non-blood management if complications arise
• Contact Hospital Liaison committee (see section 10) for advice with Jehovah’s Witness patients if necessary
• Discuss with the patient/family the risks (short and long-term), benefits and alternatives to proposed interventions.

6.1  Pre-Operative Planning, Operative And Post-Operative Care

Whilst thorough assessment of a patient is always desirable, it is absolutely essential when dealing with one who is refusing allogenic blood. A comprehensive care plan should be drawn up taking into consideration the risk factors and then employing an optimal combination of available alternative strategies.

6.2  Medical History and Physical Examination

For moderate to major surgery, this may be carried out at the hospital performing the procedure.

For minor surgery, the anaesthetist in Pre- Assessment Clinic for should see all patients who refuse blood or blood products:

• Congenital/acquired bleeding disorders.
• Suspected by reviewing obstetric history, circumcision, frequent nosebleeds, easy bruising without trauma, tonsillectomy, dental extraction, menorrhagia, prolonged bleeding after minor skin lesion, surgery, pregnancy, etc.
• Personal history and family history
• End organ disease/injury - especially renal or hepatic
• Previous surgery - blood loss may be increased with repeat surgery
• Identify medications that may adversely affect haemostasis
• g. aspirin, NSAIDs, anticoagulants, platelet aggregation inhibitors, antibiotics, etc. Ensure non-prescription drugs are not inadvertently taken.
• Physical examination e.g. purpuric lesions, petechiae, ecchymosis, hepatomegaly, splenomegaly

6.3  Laboratory Assessment/Screening

• Establish baseline parameters
• Full blood count
• Serum ferritin
• Serum folate
• Serum vitamin B12
• PT, PTT, fibrinogen
• Liver function
• Renal function (urea & creatinine)
• Additional investigation as indicated by the history of the patient and the degree of haemostatic challenge
• Further coagulation tests if personal or family history of bleeding – contact Haematology department for advice

Please note: Minimise iatrogenic blood loss – consider using paediatric blood tubes. Review and minimise frequency of sampling. Take multiple tests per sample.

6.4  Blood Sparing Options

If the procedure and the patient’s condition is such that the clinician would normally request two or more units of cross-matched blood, the patient will be having their elective procedure elsewhere.

The hospital performing the procedure will discuss with the patient which of the blood sparing options and alternatives would be acceptable. This may include cell salvage, acute normovolaemic haemodilution, human recombinant blood products or blood products derived from plasma.

The existence of an advance directive should be ascertained and a copy filed in the Clinical Alerts Section of the medical notes. The ‘Alerts’ section on Trak should be completed or updated as a priority to support multi-disciplinary communication.

In addition, consent or refusal of specific therapies should be clearly documented on the ‘Consent Form for Specific Blood Components and Procedures for Jehovah’s Witness Patients who Refuse Blood Transfusion’ and ‘General Consent Form Excluding Blood Transfusion’ detailed in Appendix A and Appendix B respectively.

7.1 Treatment Plan

The treatment plan drawn up by the hospital performing the procedure should be distributed to all those involved and a copy filed in the medical notes. For those patients undergoing minor surgery at NHS Borders some of these areas will need clarification pre-operatively. This should include, but not be limited to:

• Named specialists involved
• Pre-operative plan for optimisation of blood count and coagulation. (Including modifying chronic medication: aspirin, warfarin etc.)
• Blood conservation strategies planned
• Blood products, strategies and treatments deemed acceptable to patient
• Blood products, strategies and treatments deemed unacceptable to patient
• Presence and location of any advance directives and those who hold copies.

7.2 From 6 Weeks Pre-Operatively

• Oral iron unless contra-indicated
• Consider stopping aspirin, NSAIDs and other anti-platelet agents, at least 7 days pre operatively
• Consider stopping warfarin and other anticoagulants if possible
• If the expected blood loss is high – consider recombinant Erythropoietin subcutaneously daily for 10 to 14 days pre operatively to elevate haemoglobin level
• Ensure acceptability with patients and discuss further with Haematologists
• Liaise with the hospital performing the surgery to clarify who is carrying out the pre-operative management and where this will be done. For geographical reasons it may be easier to carry out a significant proportion of pre-op preparation at the BGH

• Ensure senior surgeon, anaesthetist and theatre staff are aware of the patient’s admission and wishes concerning declining blood, blood components and blood products.
• If safe and practicable, consider transfer to a tertiary centre pre- operatively.
• Only if the risk of transfer is greater than the risk of surgery should the operation be carried out at NHS Borders.
• Review any existing investigations and repeat as appropriate (FBS, coagulation screen, LFTs and U & Es).
• Ensure completed copies of Advance Directive and Consent Form for Specific Blood Components and Procedures for Patients who Refuse Blood Transfusion (Appendix A) are filed in the ‘Medical Alerts’ section at front of contemporary medical notes.
• If the patient is unconscious/confused, but an Advance Directive is present, within the notes, this must be assumed the patient’s current wishes and blood/blood products should not be administered.
• Ideally the Consent Form for Specific Blood Components and Procedures for Patients who Refuse Blood Transfusion (Appendix A) will have been completed at a previous time and can be used to guide resuscitative measures.
• No transfusion should be carried out on any patient without checking the ‘Medical Alerts’ section of medical notes for advance directives.

Surgical procedure(s) specifically to avoid and prevent blood loss:

• Minimally invasive techniques (endoscopic/laparoscopic surgery)
• Enlarged surgical team to reduce time
• Surgical positioning to minimise bleeding
• Staged surgery for complex procedures

Anaesthesia technique may be modified to reduce blood loss and maintain patient communication if possible:

• Local and Regional anaesthesia
• Hypotensive anaesthesia
• Maintenance of normothermia
• Early and frequent assessment of coagulopathy and aggressive early treatment in keeping with patient’s acceptance of blood products

• Minimise blood sampling
• Consider use of pulse oximetry
• Paediatric sample tubes
• Plan multiple tests per sample
• Consider tranexamic acid
• Continue iron and erythropoietin therapy as indicated by haemoglobin level

Please see the separate ‘NHS Borders Obstetric Policy for women who refuse blood and blood products’.

Guidance on the law of consent: Please refer to “A Good Practice Guide on Consent for Health Professionals in NHS Scotland” HDL (2006)

Treatment of haematological malignancies

It is increasingly possible to treat haematological malignancies without primary blood component support. This will require a multidisciplinary team approach and the design of a specific care plan.

• Keep blood sampling to a minimum but ensure careful monitoring of the patient’s haematological status is carried out.
• Correction of anaemia should be commenced promptly with special consideration being given to the use of erythropoietin and intravenous iron.
• Consider the early use of novel therapies, which may have a reduced myelosuppressive effect.

For suggestions that are more detailed see, ‘Developing a Blood Conservation Care Plan for Jehovah’s Witnesses with Malignant Disease’ (Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee, 2014).

12.1 The Hospital Liaison Committee

Members of this group are trained to facilitate communication between medical staff and Witness patients and are available at any time, day or night, to assist with difficulties either at the request of the treating team or the patient.

Central UK Office (08.00 – 17.00)        020 8371 3415 

Emergency (24/7)                           020 8906 2211

hid.gb@jw.org

www.jw.org/en/medical-library

12.2 Patient Support Group

Provide spiritual comfort and practical assistance to Jehovah’s Witness patients and their families during periods of illness or hospitalisation.

Consent Form for Specific Blood Components and Procedures for Jehovah's Witnesses

General Consent Form excluding blood transfusion