Patients with severe injuries who refuse blood transfusion present complex medical, legal, and moral problems. Objections to blood transfusions may arise for personal, medical, or religious reasons. For example, Jehovah’s Witnesses object to blood transfusion primarily on religious grounds.
Methods available for minimizing blood loss:
Preoperatively Discussion with the patient regarding which (if any) blood products they are prepared to accept. Full investigation of anemia. Consider pre-op erythropoietin or iron if needed. In obstetric cases, discuss the increased risk of hysterectomy (for PPH) and the use of an ultrasound scan to determine the placental site.
Intraoperatively Positioning (avoiding venous congestion) Staged procedures Use of local or regional anesthesia means the patient can stay awake and retract their prohibition if they feel the need. Hypotensive anesthesia – of proven use but important to weigh risks against benefits Hemodilution techniques–both hypervolaemic and normovolaemic Tourniquets Meticulous surgical technique/experienced surgeon Vasoconstrictor use Use of drugs that affect coagulation, e.g. tranexamic acid, aprotinin and desmopressin Cell-saver use will need to be discussed with the individual patient Balloon occlusion/ligation of arteries that supply the bleeding area
Postoperatively Minimal blood draws for laboratory testing ICU Erythropoietin GI bleeding prophylaxis Methods to decrease oxygen consumption: IPPV/barbiturates/neuromuscular blockers/hypothermia hyperbaric oxygen therapy Perfluorocarbons Progesterone to decrease menstrual bleeding.
Doctors have no right to impose treatments on patients who do not want them. Provided that patients are adequately informed about the potential advantages and disadvantages of a proposed treatment and are judged competent to make healthcare decisions, we must accept and respect their views even if it may result in a fatal outcome.
It is unlawful to administer blood to a patient who has refused it by the provision of an Advanced Directive or by its exclusion in a consent form. To do so may lead to criminal proceedings.
A child’s right to life is paramount and must be considered before the religious beliefs of his or her parents. In a life-threatening emergency, all life-saving treatment should be given to a child who is unable to give competent consent, irrespective of the patients’ wishes. If the parents refuse to give permission for a blood transfusion, it may be necessary to apply for a legal ‘specific issue order.’ This is a serious step that should be taken by two consultants and should only be made when it is felt this measure is entirely necessary to save the child in an elective or semi-elective situation. Except in an emergency, a doctor can decline to treat a patient if they feel pressured to act against their own beliefs. In this case, the patient’s management should be passed to a colleague.
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