Management of Patients Who Decline Blood Transfusions

Key Points

Adult patients with decision-making capacity have the legal right to decline blood transfusion. Respect for autonomy, coupled with meticulous documentation of acceptable products and interventions, is foundational to treatment.
Early identification of transfusion refusal enables anemia optimization, multidisciplinary planning, and use of pharmacological and physiological hemostatic optimization.
Postoperative management focusing on minimizing iatrogenic blood loss and maximizing physiological recovery is key to successful hospital discharge.

Introduction

There are multiple reasons for patients to decline blood transfusion, including religious (e.g., Jehovah’s Witnesses [JW]) and personal preferences regarding the risks of allogeneic blood transfusion.
Anesthesia management for patients who decline blood transfusions centers on balancing patient autonomy with comprehensive patient blood management (PBM) throughout the perioperative period.
PBM is defined as “a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving patients’ own blood, while promoting safety and empowerment.”1 Principles of PBM include optimizing hemostasis, managing anemia, implementing blood conservation modalities, and discussing patient-centered decision making, which are crucial perioperatively.¹

Ethical, Legal, and Consent Considerations

Patient-centered discussions and decision-making about declining transfusion will require more time and should be done, especially for elective surgeries, ahead of time in the anesthesiology preoperative clinic.
There are multiple JW hospital liaison committees worldwide that JW patients can contact for help with this decision.
Discussion about reasons for the possible need for allogeneic blood transfusions and their adverse outcomes should be discussed in detail with these patients and documented.
Physicians must discuss and clearly document patients’ preferences regarding alternatives to blood transfusion, including which blood products, fractions (fibrinogen, prothrombin complex concentrates, etc.), and procedures (such as cell salvage) are acceptable to them.^2,3
The entire team (surgeons, anesthesiologists, nurses, and scrub technicians) managing the patient will need to understand and agree to the plan, whether it is to decline all blood product transfusions or to have acceptable alternatives to blood transfusions. If a team member is uncomfortable with the plan, one should find an alternative team member willing to move forward with it. If no team can be found that agrees with the plan, patients will need to be referred to another hospital.
- Adults Who Decline Transfusions
Adult patients with capacity have the legal right to decline blood transfusion, and nonconsensual transfusion by a physician is considered a physical violation.³ For incapacitated adult patients without advance directives, physicians should proceed under presumed consent. However, if there is a clear advance directive refusing transfusion, it must be followed.⁴
- Minors Who Decline Transfusions
  - Special considerations apply to minors, where parental refusal may be overridden in the child’s best interest. These laws, however, vary by jurisdiction.⁴
  - For mature minors, legal documentation may need to be acquired if they decline blood transfusions for their surgeries. These would require added time and involve other departments, such as social work and psychologists.
  - Proven emancipated minors would be treated as if they are adults.^1,2
  - Please see the OpenAnesthesia summary “Pediatric Consent and Assent” for further details. Link

PBM

Core elements of PBM include respect for patient autonomy through informed choice and consent. Ensuring that patients are educated about their blood status, available treatment options, and associated risks and benefits allow for individualized decision-making that balances clinical effectiveness with medical, legal, ethical, economic, and patient considerations (Figure 1). Thoroughly reviewing transfusion consent forms is also critical to patients’ understanding of and approval for the range of available blood products and interventions (Figure 2).
Please refer to the OA summary on PBM for further details: Link

Figure 1. Conceptual overview of patient blood management emphasizing patient-centered care, informed choice, and ethical decision-making. Isbister JP et al. Patients’ choice, consent, and ethics in patient blood management. Anesth Analg. 2022;135(3):495-504. https://pubmed.ncbi.nlm.nih.gov/35977359/

Figure 2. Standardized Transfusion Consent Form and Classification of Blood Products and Blood-Related Interventions. Reprinted with permission of the American Society of Anesthesiologists.

Perioperative Management of Patients Who Decline Blood Transfusions

Perioperative management of patients who decline blood transfusions requires proactive planning and early identification of acceptable products and interventions, multidisciplinary coordination, and implementation of blood conservation strategies across all phases of care (Tables 1).

Table 1. Overview of perioperative interventions for patients who decline blood transfusions.^3-7

References

Shander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, Kor DJ, Faraoni D, Freedman J; Collaborators. A global definition of patient blood management. Anesth Analg. 2022;135(3):476-88. PubMed
Tan GM, Pasko B. Children of Jehovah’s Witness parents. In: Perioperative pediatric patient blood management and transfusion safety. Springer 2025:437-456. Link
Klein AA, Bailey CR, Charlton A, et al. Anaesthesia and peri-operative care for Jehovah’s Witnesses and patients who refuse blood. Anaesthesia. 2019;74(10):1379-89. PubMed
Coccolini F, Shander A, Ceresoli M, et al. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg. 2024;19:26. PubMed
Webert KE, Zeller MP. The untransfusable patient. Hematology Am Soc Hematol Educ Program. 2025;2025(1):191-8. PubMed
Crowe E, DeSimone R. Transfusion support and alternatives for Jehovah's Witness patients. Current Opinion in Hematology. 2019; 26 (6): 473-9. PubMed
Practical-Haemostasis.com. ISTH-SSC Bleeding Assessment Tool (ISTH BAT). A Practical Guide to Haemostasis. Practical-Haemostasis.com. Updated July 31, 2025. Accessed February 8, 2026. Link

Other References

Turnipseed J, Martini A. Perioperative Patient Blood Management. OpenAnesthesia. Published October 7, 2025. Accessed April 15, 2026. Link
Manohar C, Knuf K. Perioperative Anemia. OpenAnesthesia. Published July 27, 2023. Accessed April 15, 2026. Link
Anderson RM, Clay SJ. Pediatric Consent and Assent. OpenAnesthesia. Published February 20, 2025. Accessed April 15, 2026. Link
Rhymes D, Sheth M. Topical Hemostatic Agents. OpenAnesthesia. Published May 22, 2025. Accessed April 15, 2026. Link

Copyright Information

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.