Patient refuses blood products. How does your hospital ensure their wishes are followed?

AJJKRN · Jan 15, 2015

It is asked and charted in our admit navigator and would be charted on a blood consent refusing blood products. We can also put in bold font on the patients EMR chart area. Hope this is helpful

Editorial Team / Admin · Jan 15, 2015

We have a blood refusal form that patients sign if they decline to sign the blood consent form. We also have an area for "sticky notes" to other nurses, social work, and physicians in our EMR where this can be mentioned.

Working in open heart surgery, patients who decline blood products are a big deal- and it's well known ahead of time and we go over various uses and products. We've had some Jehovah Witnesses accept platelet gel use and/or albumin while others have refused. We make sure to document, document, document, and communicate with other members of the surgical team and post-op care team. Also, the missing blood bank band is a big tip off as patients are type and crossed the day before if elective or in-house and in either the ER or cath lab if emergent.

But in the end, it all comes down to documentation in an obvious place and communication.

blondy2061h, MSN, RN · Jan 16, 2015

I work blood and marrow transplant. They simply don't get BMT's if they're against blood products. The transplant itself is a blood product, and it would be extremely difficult to impossible to survive the BMT experience without RBC and platelet transfusion support.

Back when my facility had a smaller oncology population my unit was mixed heme/onc. We'd occasionally get newly diagnosed leukemics who were Jehovah's Witnesses. They'd come in with hemoglobins anywhere from 3-6 and next to no platelets. It was then they'd have to choose between their life and their religion. Not an enviable position. I always found it heart breaking.

Even worse than that, was the thankfully very rare pediatric oncology patient who's family was Jehovah's Witness. Things get messy when the child is getting a court ordered blood transfusion and the parents are sobbing in the corner trying not to look, half relieved that their child is getting life saving blood and they didn't have to make that decision, and half mad that we just condemned their child to hell.

Esme12, ASN, BSN, RN · Jan 16, 2015

Welcome to AN! The ;largest online nursing community!

Is this for school? What semester are you?

Meriwhen, ASN, BSN, MSN, RN · Jan 16, 2015

We have the patient's preferences regarding blood products indicated in the EMR. They're asked that question at their initial intake and for subsequent hospitalizations, we review the info and ask if there are any changes. Anyone may opt out for any reason--they don't have to justify their decision.

classicdame, MSN, EdD · Jan 16, 2015

I have had the local Jehovah's Witness group send reps to the hospital to teach staff what is the actual recommendation by the organization. I think you can contact their office online and get a local rep. They have DVD's and brochures explaining their position, which , the the way, does NOT exclude all blood products. They decline whole blood, which we do not give anyway. Some members do not fully understand the denomination's position or do not fully agree with it, so some will still refuse. We offer to conact the rep if they want to hear from that resource person. If a minor is involved and a life is threatened, then a judge may have to intervene, but this is rare since we have blood expanders that are not opposed by JW members.

nurseprnRN, BSN, RN · Jan 16, 2015

The nurse would have the moral obligation to say to such a patient, "Before I hang this albumin, I notice that you are a Jehovah's Witness (or have some other stated refusal to accept blood products), and I know that many people are flexible on the restriction. Did you know albumin is derived from blood, and is this one OK with you?"

It would be completely unethical to hang albumin (or other blood product) for such a patient without ascertaining this first. It might already be on the chart, but if it isn't, you can't sneak it in just because you or the physician might think it would be better.

Sounds like an inservice or policy posting is in order so everybody knows this. No, it is not the MD's responsibility to do this, even if you have a policy that the MD has to. Nursing is the last safety check before any drug or treatment is given, and this counts as safety.

MunoRN, RN · Jan 16, 2015

It's the nurse's responsibility to ensure that the patient is aware of everything they are getting, blood product or not, and willing to take it. Albumin isn't actually against JH doctrine, although it might be a personal decision that a JH makes. We also still ask the patient what they went when a living will is present, partly because a living will only takes effect when the patient cannot make their wishes known, but also because Jehovah's Witnesses will more often than not (at least in my experience) still want a blood transfusion, so long as we can keep it secret.

calivianya, BSN, RN · Jan 17, 2015

How exactly are they getting blood products without being aware? Are they unconscious and it's being forced on them unknowingly, or are the health care providers lying about what's in those bags/bottles? Is the fact that these patients are Jehovah's Witnesses being skipped over in report? There definitely needs to be somewhere obvious in the chart that a nurse has to look that will mark the patient as a Jehovah's Witness.

I'd say the best thing that can happen is your hospital has a mandatory inservice on respecting patient's wishes and not forcing things on them just because we think it should be done, and talking about the importance of checking in with the patient before hanging anything derived from human blood to make sure it's okay with them. I have some real respect for Jehovah's Witnesses - I don't think there's much of anything I believe in strongly enough that I'd be willing to die for it, and that's exactly what I've seen some of them do. It takes a lot of moral fortitude to stare death straight in the face and say you are willing to die if that's what it comes down to. It's awful to force them to violate that belief unknowingly.

delphine22 · Jan 17, 2015

How exactly are they getting blood products without being aware?

Most blood products require a consent. Albumin does not -- it's just hung and documented like any other IV med.

I worked in one facility that had a white band with the circle "no" sign and said "NO BLOOD" on it; we'd put it on the patient next to the ID and allergy bands. I liked that idea so much, that when my new facility didn't have this, I made them for any JW pts I had (after clarifying with them first -- some JW's will take blood! You should always ask and not assume). I'd either use a red band or turn it inside out, and just write NO BLOOD really big on it. That, and as someone else said, the lack of a type and screen band, should make it clear enough, especially if there's an emergency and the pt can't speak for themselves.

nimtzmary · Jan 17, 2015

No t for school. I'm a nursing supervisor at our hospital and took the complaint and decided to make it a personal project.