Policy for the treatment of patients who have indicated that they do not wish to receive blood or blood components.

Policy for the treatment of patients who have indicated that they do not wish to receive blood or blood components. 3.0 EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This Blood Transfusion Policy has therefore been equality impact assessed by the Director of Quality & Governance to ensure fairness and consistency for all those covered by it regardless of their individual differences, and the results are shown in Appendix 4 Version: 3.0 Authorised by: Hospital Transfusion Committee Date authorised: 7 th September 2016 Next review date: 6 th September 2018 Document author: Caroline Holt

VERSION CONTROL SCHEDULE they do not wish to receive blood or blood components. Version : 3.0 Version Number Issue Date Revisions from previous issue 0.1 July 2007 New Policy 1.0 February 2008 1.1 December 2008 Minor ammendments prior to FOI publication. 2.0 March 2011 Two yearly review 2.1 September 2013 Update of contacts Update to Treatment of Children 3.0 September 2016 Addition of alternatives to blood transfusion for patients having surgery Organisation name change Version 3.0 September 2016 Page 2 of 19

INDEX/ TABLE OF CONTENTS 1.INTRODUCTION... 4 2.OBJECTIVES... 4 3.SCOPE... 4 4.POLICY DEVELOPMENT AND CONSULTATION... 4 5.IMPLEMENTATION... 4 6.REVIEW... 5 7.DEFINITIONS... 5 8.DUTIES... 5 CHIEF EXECUTIVE... 5 DIRECTORS... 5 HOSPITAL TRANSFUSION COMMITTEE... 5 DIVISIONAL RESPONSIBILITIES... 5 MATRON/WARD MANAGER/DEPARTMENTAL MANAGER RESPONSIBILITIES 5 MEDICAL STAFF RESPONSIBILITIES... 5 ALL STAFF... 6 9.POLICY STATEMENT... 6 10.EQUALITY AND DIVERSITY... 6 11.IMPLEMENTATION PLAN... 6 12.MONITORING... 6 13. CONTACT DETAILS 7 14.THE LAW RELATING TO CONSENT/REFUSAL OF TREATMENT INCLUDING BLOOD AND BLOOD COMPONENTS... 7 15.CLINICAL INDICATION TO TRANSFUSE... 8 16.DETERMINE REASON FOR REFUSAL... 9 The following documentation/consent form(s) must be completed:... 9 17.ALTERNATIVES TO BLOOD AND BLOOD COMPONENTS... 9 18 ALTERNATIVES TO BLOOD TRANSFUSION FOR PATIENTS HAVING SURGERY..10 19.MANAGEMENT OF PATIENTS REFUSING BLOOD AND BLOOD COMPONENTS... 10 20.TREATMENT OF CHILDREN... 11 21.LIFE THREATENING EMERGENCY IN A CHILD... 12 22.WOMEN IN PREGNANCY... 12 23.ELECTIVE SURGERY... 13 24.TRAUMA/EMERGENCY ADMISSION... 13 25.REFERENCES... 14 APPENDIX 1... 15 REFUSAL OF BLOOD AND BLOOD COMPONENTS FLOW CHART... 15 Discuss with patient... 15 Patient refuses Blood and Blood Components... 15 Discuss/resolve problem... 15 ADVANCE DECISION DOCUMENT (PAGE 1)... 16 ADVANCE DECISION DOCUMENT (PAGE 2)... 17 CONSENT FORM 5... 18 EQUALITY IMPACT ASSESSMENT.19 Version 3.0 September 2016 Page 3 of 19

1.INTRODUCTION The Trust s Policy for the treatment of patients who refuse blood and blood components is an operational policy and a procedure manual for all individuals dealing with the practical elements of dealing with patients who for whatever reason will not accept blood or blood components as part of their treatment. The aim of these guidelines is to provide information about the management of patients who refuse blood (for religious or other reasons), and to facilitate acknowledgement and respect for their wishes in accordance with the Human Rights Act 1998, and the ethical principle of patient autonomy. It is a document that must be read by all Trust employees who are involved in any aspect of this process. 2.OBJECTIVES To ensure that all staff involved in the treatment of patient s who refuse the use of blood and blood components are fully conversant with the standards and procedure. To facilitate safe practice within all clinical areas and ensure the safety of the patient. To act as a reference source for guidance and information. The policy is dynamic and at appropriate intervals new guidelines will be added to the policy. Further reference can be made to: http://tis/documents/consentpolicy.pdf http://tis/documents/guidelinesonperioperativemanagementofanaemiainsurgica lpatients.pdf The Policy for Intra-Operative Cell salvage is currently in draft format 3.SCOPE This policy relates to all professional, administrative and support staff employed by Tameside & Glossop Integrated Care Hospital NHS Foundation Trust and to all locum, agency, temporary/bank and voluntary staff. The scope of this policy is Trust wide. 4.POLICY DEVELOPMENT AND CONSULTATION This policy was written with full discussion and imput from the Hospital Transfusion Committee and staff members of the Blood Transfusion Laboratory. The policy was widely distributed to stakeholders including all matrons, clinicians and a patient representive from the Hospital Liaison Committee for Jehovah s Witnesses for consultation and comments before the policy was finalised. 5.IMPLEMENTATION The Hospital Transfusion Committee will launch the policy following approval. The policy will be uploaded onto the Intranet site and all wards and departments will be notified of the policy s launch. Version 3.0 September 2016 Page 4 of 19

6.REVIEW This policy will be formally reviewed in 2 years, or earlier depending on the results of monitoring. The policy may also be reviewed after change in legislation or updated guidance. 7.DEFINITIONS Blood Product Blood Component Any therapeutic substance prepared from human blood. Platelets, Red Cells, Fresh Frozen Plasma Cryoprecipitate and White Cells. DDAVP (1 deamino 8 D arginine vasopressin). Raises circulating Factor 8 and von Willibrand Factor. 8.DUTIES CHIEF EXECUTIVE The Chief Executive has overall responsibility for ensuring that the Trust meets its statutory and non-statutory obligations in respect of maintaining appropriate standards contained in this policy. The Chief Executive devolves the responsibility for monitoring and compliance to the Hospital Transfusion Committee. DIRECTORS Directors are responsible for ensuring that the requirements of the Trust s Policy for the treatment of patients who have indicated that they do not wish to receive blood or blood components are effectively managed within their Directorate and their staff are aware of, and implement, those requirements. HOSPITAL TRANSFUSION COMMITTEE The Hospital Transfusion Committee is responsible for ensuring that Trust staff upholds the principles and guidelines within this policy and that appropriate polices and procedures are developed, maintained, and communicated throughout the organisation and that those policies and procedures are developed and implemented in co-ordination with other relevant organisations and stakeholders. DIVISIONAL RESPONSIBILITIES Any incident arising from this policy should be reported to the Quality & Governance Department and the Specialist Practitioner of Transfusion for investigation. Any lessons to be learnt should be shared at the Hospital Transfusion Committee. MATRON/WARD MANAGER/DEPARTMENTAL MANAGER RESPONSIBILITIES It is the Ward Manager or Departmental Managers responsibility to ensure that staff are made aware of the Trust processes for the correct administration of blood and blood components. These procedures should be included in the induction of all staff who may be involved in the care of the patient. MEDICAL STAFF RESPONSIBILITIES All medical staff should ensure that they are familiar with the Trusts procedures for treating patient s who refuse blood and blood components. These policies and Version 3.0 September 2016 Page 5 of 19

procedures include the Consent to Treatment and Examination Policy. Senior medical staff responsible for the supervision and training of doctors in training should ensure that junior medical staff are competent to undertake procedures within this policy. Any incident arising from this policy should be reported to the Quality & Governance Department and the Specialist Practitioner of Transfusion for investigation. Any lessons to be learnt should be shared at the Hospital Transfusion Committee. ALL STAFF It is the responsibility of every Registered Nurse, support worker or other member of staff given responsibility of caring for a patient who has refused blood and blood components that they follow the procedures laid down in this policy. Any incident arising from this policy should be reported to the Quality & Governance Department and the Specialist Practitioner of Transfusion for investigation. Any lessons to be learnt should be shared at the Hospital Transfusion Committee. 9.POLICY STATEMENT To ensure that all staff involved in the treatment of patients declining blood and blood components are fully conversant with the standards and procedures at all times. To facilitate safe practice within all clinical areas and ensure the safety of the patient. To act as a reference source for guidance and information. The policy is dynamic and at appropriate intervals new guidelines will be added to the policy. 10.EQUALITY AND DIVERSITY Tameside & Glossop Integrated Care NHS Foundation Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. 11.IMPLEMENTATION PLAN The policy will be advertised and held on the Intranet Relevant parts of the policy will be presented at regular training sessions for nursing, support and medical staff. The policy will be promoted by the Consultant Haematologists, Haematology Specialists Nurse, Specialist Transfusion Practitioner and Biomedical Scientists when discussing and advising on transfusion requests. 12.MONITORING The Hospital Transfusion Committee will monitor compliance to this policy through incident reporting. Any deficiencies will result in an action plan being developed and presented to the Hospital Transfusion Committee. Version 3.0 September 2016 Page 6 of 19

13.CONTACT DETAILS Consultant Haematologist 0161 922 6501/07768460463 Blood Transfusion Laboratory 0161 922 6391 Departmental Manager 0161 922 6318 Senior BMS, Blood Transfusion 0161 922 6391 Specialist Practitioner of Transfusion 0161 922 5484/07759260044 Member of the Hospital Liaison Committee for Jehovah s Witnesses 0161 480 1511/07875740172 078025519999 0161 643 9281/07770937099 24 hour Hospital Liasion Committee contact number - 07850408158 14.THE LAW RELATING TO CONSENT/REFUSAL OF TREATMENT INCLUDING BLOOD AND BLOOD COMPONENTS If you have a patient who is 18 or over and who you deem to have mental capacity, that patient can consent to or refuse any treatment. If the patient refuses treatment, you must ensure they have received an explanation in terms that they can understand and the subsequent consequences. They must also understand the risks and benefits or any alternative options to the treatment advised. If you have a patient of 18 and over who you think lacks mental capacity, you must treat that patient in accordance with his / her best interests. Close relatives and friends may be able to give you information about the patient s known views on transfusion-related issues. Please refer to the Mental Capacity Act Policy. (http://tis/documents/mentalcapacityactpolicy.pdf) For further advice please contact the Quality & Governance Department. If your patient is under 18 then anyone with parental responsibility can consent on behalf of the patient. If the parents are married on or after the 1 st December 2003 the father s name appears on the child s Birth Certificate then both the mother and the father will normally have parental responsibility. Before December 2003 only the mother of unmarried parents automatically had parental responsibility and although it was a simple procedure for the father to obtain it, provided the mother was agreeable, few fathers did so. Unless there is something that should arouse your suspicions, you can rely on what the parents tell you as to the family circumstances when deciding who has parental responsibility. Where there are unresolved differences of opinion between parents and child nearing adulthood who has mental capacity, these should be referred to the Court of Protection. If your patient is 16 or 17, then you can also obtain consent from the patient provided you are satisfied that the patient has mental capacity. If the patient is under 16 but you are satisfied that he or she is of sufficient age and understanding to appreciate the nature and implications of treatment, once again you can also obtain consent from the patient. If you are obtaining consent from a patient who is under 18, you should also normally make sure that someone with Version 3.0 September 2016 Page 7 of 19

parental responsibility agrees to the treatment unless it is an emergency or there is an issue of confidentiality between the patient and the individuals with parental responsibility. Wherever it is appropriate, consent to, or refusal of treatment must be appropriately documented in the patient s health records. If necessary the patient can be asked to check and countersign the entry. This documentation should normally include a brief note of the risks and benefits of and any alternative options to the treatment that have been explained to the patient. Where there is an appropriate Consent Form, this should always be fully completed. Advance Directive Document and Living Wills relating to refusal of blood and blood components have been tested and upheld in law, and Jehovah s Witness patients will generally carry such a document, as well as lodging copies with their GP and family. (See page 16/17 for an example of this type of form). If an applicable Advance Directive exists, then this should be acted upon. When a patient refuses blood and/or blood components, having had the possible consequences explained to them and understood and the Consultant in charge of the patient genuinely believes the procedure cannot be safely performed under the conditions the patient stipulates, then the Consultant has no obligation to proceed with the treatment. The patient must then be referred to an appropriate colleague or back to the General Practitioner so he/she can obtain further advice. In the event of the patient being a Jehovah s Witness contact with the Hospital Liaison Committee can be made. They hold a list of clinicians willing in prinicple to accept the patient. Remember to make sure that the patients realise that they can change their mind at any time. In an emergency situation where there is uncertainty about a patient s wishes, any urgently required treatment should be given in accordance with normal good professional practice. If you are not sure what to do and if time allows you should consult the Duty Trust Manager and / or obtain advice from the Trust s legal team. 15.CLINICAL INDICATION TO TRANSFUSE In any procedure where blood transfusion is possible / indicated the following procedure must be adopted: The risks and benefits of blood transfusion must be explained to the patient. The National Blood Service leaflet Will I need a blood transfusion? should be given to the patient. The implication of refusing a transfusion must be clearly explained in a nonconfrontational manner. It must be made clear to the patient that in certain circumstances refusing to accept a transfusion could be fatal. It is essential in the management of any patients refusing a blood transfusion to determine this at the earliest possible stage in their treatment (see flow chart). Version 3.0 September 2016 Page 8 of 19

16.DETERMINE REASON FOR REFUSAL Patients can refuse a blood transfusion for many reasons. Every effort must be made to determine why they refuse, in a non-confrontational manner. e.g.: Religious belief Safety Aspects Development of Antibodies Previous transfusion reactions to blood/blood components Bad experience last time, cannula not sited correctly etc. Having determined a reason for refusal, it is essential that efforts be made by the Trust to resolve the problem. For example, if the patient is worried about a transfusion- transmitted infection, is there somebody else in the hospital able to talk to the patient and reassure them (Consultant, Transfusion Specialist etc.) Documentation in the patient s health records is essential. All actions / discussions with patients and family members must be documented clearly, must be signed and dated clearly by the person managing the patient and must be signed and dated by another member of staff who has witnessed the events. The following documentation/consent form(s) must be completed: For surgical patients the Trust s Consent Form 1 Patient Agreement to Investigation or Treatment must be completed. The gold copy must be attached to the patient s health records and the white copy given to the patient. For all patients, documentation must be made in their health records by the person managing the patient, another member of staff who has witnessed the events and the patient themselves. For any patient who refuses a blood transfusion for any reason, Consent Form 1 Patient Agreement to Investigation or Treatment and Consent Form 5 (page 18) must be completed, detailing what products the patient is willing / unwilling to accept. A copy must be placed in the patients records and a copy given to the patient. 17.ALTERNATIVES TO BLOOD AND BLOOD COMPONENTS Where possible and/or if the situation allows, an alternative strategy should be discussed with the patient/guardian. See below for a list of alternative strategies that could be used depending on the patient s clinical condition and which may be acceptable to the patient; Acute Normovolaemic Haemodilution (autologous) Post operative cell salvage (autologous) Intra-operative cell salvage (autologous) Pre-deposit autologous transfusion (NOT acceptable to Jehovah s Witnesses) Iron tablets (prescribed at pre-op clinics) Intravenous iron (prescribed at pre-op clinics) Novo-seven (clotting agent) Recombinant Clotting Factors Version 3.0 September 2016 Page 9 of 19

Erythropoietin (EPO) Tranexamic acid DDAVP Aprotinin Topical Haemostatic agents Tissue sealants / adhesives 18.ALTERNATIVES TO BLOOD TRANSFUSION FOR PATIENTS HAVING SURGERY a. Erythropoietin Do not offer Erythropoietin to reduce the need for blood transfusion in patients having surgery, unless: The patient has anaemia and meets the criteria for blood transfusion, but declines it because of religious beliefs or other reasons or The appropriate blood type is not available because of the patient s red cell antibodies. b. Intravenous and Oral iron Offer oral iron before and after surgery to patients with iron-deficient anaemia. Consider intravenous iron before or after surgery for patients who: o Have iron deficiency anaemia and cannot tolerate or absorboral iron, or are unable to adhere to oral iron treatment o Are diagnosed with functional iron deficiency o Are diagnosed with iron deficiency anaemia, and the interval between the diagnosis of anaemia and surgery is predicted to be too short for oral iron to be effective. 19.MANAGEMENT OF PATIENTS REFUSING BLOOD AND BLOOD COMPONENTS Having established the reason for not receiving a blood transfusion and which (if any) alternative strategies are acceptable to the patient; clearly document this in the patient s health records. The patient, person involved in the care of the patient and another member of staff who has witnessed the refusal must sign, print their name and date in the patient s health records. Ensure all teams (A+E/Surgical, Doctors/Consultants/Nurses/Carers etc) dealing with the patient are absolutely clear on what treatment the patient will or will not accept. In life threatening situations all staff in the Trust must be professional in their attitude and care that they extend to the patient irrespective of whether they agree or not. The patient s health records must be clearly documented. Version 3.0 September 2016 Page 10 of 19

The patient, person involved in the care of the patient and another member of staff who has witnessed the refusal must sign, print their name and date the entry into the health records. The appropriate consent form must be completed. Jehovah s Witness patients usually carry an Advanced Decision Document. Copy and attach to the patients health records. This document is renewed periodically. Please Note: The patient has the right to change their mind at anytime during treatment. 20.TREATMENT OF CHILDREN See page 8 for the general position regarding consent to and refusal of treatment for patients who are under 18. It is advisable to involve senior Trust Management and the Trust Legal Team at an early stage where the possible refusal of treatment for a child is concerned. The doctor should use best practice to respect the wishes of the parents. Consent form 2 should be used for parental consent for a child or young person. For elective surgery in children, a full and frank discussion should take place between the surgeon and the parents of the child; the relevant anaesthetist may also need to be directly involved at this stage. Either parent may sign the consent form permitting a transfusion. Most operations on children do not require or involve blood transfusion. If, in the opinion of the surgeon, the child is extremely unlikely to need transfusion as a result of the procedure, the usual arrangements should be made to proceed with the operation. The parents should be invited to sign signifying their objection to blood transfusion. Recognising that misjudgements will occur and that occasionally a transfusion will unexpectedly become necessary, the surgeon may choose to say to the parents, I will not allow your child to die for want of a blood transfusion ; unless it is indeed an intention to withold blood under all circumstances. Most parents will find this accepatable. Some operations carry a significant risk of needing blood transfusion. This can be divided into three groups. 1. Those which are absolutely indicated and urgent 2. Those which are absolutely indicated and non-urgent 3. Those which are not absolutely indicated. In group 1, if the surgeon feels it would be unreasonable to proceed without the freedom to transfuse, the help of the Safeguarding Children s Team or the on call for Social Services should be sought in obtaining a Specific Issue Order from the Courts. In an emergency, when there is no time to obtain a Specific Issue Order, the use of blood and blood products in life-threatening situations should be based on the Version 3.0 September 2016 Page 11 of 19

judgement of the clinician in charge of the patient. In group 2, the patient could be transferred to the care of a surgeon who is prepared to operate even under these constarints. In group 3, a no-operative choice may be appropriate. In groups 2 and 3, if these alternatives are not clinically appropriate, the surgeon should proceed as in group 1. At times it may be judged that the patient is competent to make the necessary decisions, in which case his/her wishes must be respected. A child may not be competent to make the necessary independent decisions if unduly influenced by another person. At all times the surgeon must respect the beliefs of the family. Every effort should be made to avoid the perioperative use of blood or blood products. Nevertheless, the wellbeing of the child is paramount. 21.LIFE THREATENING EMERGENCY IN A CHILD In an imminently life-threatening situation, where the delay of blood might be fatal, a decision to proceed with treatment against the parent(s) or guardian(s) wishes is a clinical decision by the medical staff / team managing the patient. The Consultant must be informed at the earliest moment possible. Wherever possible another Consultant should be consulted and a joint decision made. If time allows an application must be made for a Specific Issue Order. However in an imminently life threatening situation the Trust has a duty of care towards that child. All actions must be documented in the patient s health records clearly. Only justifiable blood / blood components must be used to save the patient s life. The patient s health records must be signed and dated by both Consultants involved in the case. The Consultants names must be printed clearly in the patient s health records. Important note: Legally, only one parent/guardian needs to consent. 22.WOMEN IN PREGNANCY Objections to blood and blood components should be determined at the booking clinic for antenatal patients. The Consultant Obstetrician and the team managing the patient must be informed immediately and the health records clearly annotated. Guidelines for management of women who decline blood transfusions is accessible in the Obstetric and Gynaecology Guidelines on the Intranet. Please note: The patient has the right to change her mind at any time during treatment. Version 3.0 September 2016 Page 12 of 19

23.ELECTIVE SURGERY Objections to blood and blood components should be determined at the earliest possible moment in the management of any patient going for elective surgery, where there is the possibility that a transfusion of blood or blood components may be necessary (i.e. Pre-Op clinics). This policy should be followed, please note these additional points: The Consultant responsible for the patient must be informed about the patient s wishes. Management of the patient must be discussed with the Consultant, the team looking after the patient and the patient / patient s relatives. The patient must be made aware of the potential consequences in the event of a major blood loss. The agreed threshold for intervention could be lower than in other patients, however this is a clinical decision determined by the Consultant managing the patient and the patient. It is essential that all parties involved in patient care are aware of the patient s decision about blood transfusion. Documentation of event/procedures etc. is essential. The patient, person involved in the care of the patient and a member of staff who has witnessed the refusal must sign, print their name and date the entry into the patient s health records. The appropriate consent forms (Consent Form 1 and 5) must be completed. If the patient s haemoglobin concentration is low and there is insufficient time for an alternative treatment to be effective (e.g. iron tablets), the procedure should be deferred until the consultant has been informed and has discussed the situation with the patient. If a patient refuses blood and blood components, having the possible consequences explained in a manner that they can understand and if the Consultant in charge of the patient genuinely believes the procedure cannot be safely performed under the conditions the patient stipulates, the Consultant has no obligation to proceed with the treatment. The following must be undertaken: Explain the problems clearly to the patient in a professional manner. Refer patient back to their General Practitioner. The patient may wish to consider with the General Practitioner being referred to another Consultant/Trust. Document the events clearly in the patient health records. Ensure they are signed and dated. 24.TRAUMA/EMERGENCY ADMISSION If treatment is to be withheld on the basis of an Advance Medical Directive / Release (Living Will) you must be satisfied that: - It is signed by the patient. It is a recent document that expresses the patient s current views. That the document covers clearly and precisely the circumstances in which the Version 3.0 September 2016 Page 13 of 19

patient now finds himself or herself. A casual reading of the document is not sufficient. If you are uncertain then you should consult a senior colleague and/or Trust Manager who can obtain advice from the Trust s solicitors. When it is established that the patient has refused a transfusion of blood or blood components, which (if any) alternative strategies they will accept, the main principle of management is to avoid delay. Rapid decision-making may be necessary, particularly for surgical intervention. If the patient is a Jehovah s Witness, they should carry an Advanced Decision document. It is important that a copy of this document is attached to the patient s notes as a permanent record. Ensure the Consultant Surgeons and Anaesthetists are aware of the situation. The Consultant Haematologist should be informed, although the options for treatment may be severely limited. It is essential to keep the patient informed in a professional manner. It is important to maintain their trust. The agreed threshold for intervention should be lower than in other patients. Intravenous crystalloids and colloids should be used for fluid replacement. Some religious or other beliefs may preclude the use of certain animal derived colloids (although Jehovah s Witnesses have no religious objection to them). Avoid the use of Dextran if possible, as it may affect haemostasis. If the patient survives the acute episode and is transferred to Intensive Care, management should include erythropoietin, parenteral iron therapy and adequate protein for haemoglobin synthesis. No other person is legally able to consent to treatment or refuse treatment on the patient s behalf. It is therefore, important when a patient refuses a blood and blood components to ensure another person is not pressuring them. 25.REFERENCES Management of Anaesthesia for Jehovah s Witnesses 2 nd Edition November 2005 The Association of Anaesthetists of Great Britain and Ireland Clinical Strategies for Managing Haemorrhage and Anaemia without Blood Transfusion Jan 2003 Hospital Information Services (Britain) for Jehovah s Witnesses Clinical Strategies for Avoiding and Controlling Haemorrhage and Anaemia without Blood Transfusion in Obstetrics and Gynaecology Jan 2004 Hospital Information Services (Britain) for Jehovah s Witnesses Code of Practice for the Surgical Management of Jehovah s Witnesses 2002 The Royal College of Surgeons of England Guideline for the Treatment of Patients who have indicated that they do not wish to receive blood or blood components. 2005 Salford Royal NHS Trust NICE Guideline ng24 Blood Transfusion Version 3.0 September 2016 Page 14 of 19

APPENDIX 1 REFUSAL OF BLOOD AND BLOOD COMPONENTS FLOW CHART Clinical indication / plan to transfuse Discuss with patient Patient agrees to transfusion - END Patient refuses Blood and Blood Components Determine reason for refusal: Religion Safety aspects Antibodies Previous reaction Bad experience Assess patient s competence: Over 18 Minor but Gillik competent Minor-clinical decision duty of care to child Discuss alternatives to blood transfusion: Cell salvage (Intra/post) Haemodilution Oral Iron Intravenous iron Erythropoietin, etc. Discuss/resolve problem Implement patient s wishes document details If the patient refuses any treatment Explain consequences to patient Inform all care teams Document clearly in notes Patient, member of staff and witness (staff member) must sign, print name and date entry in the patient s health records. If patient a minor: Clinical decision to transfuse Keep relatives informed Trust has a Duty of Care to the child The member of staff and witness (staff member) must sign, print name and date entry in the patient s health records. Version 3.0 September 2016 Page 15 of 19

ADVANCE DECISION DOCUMENT (PAGE 1) APPENDIX 2 Version 3.0 September 2016 Page 16 of 19

ADVANCE DECISION DOCUMENT (PAGE 2) Version 3.0 September 2016 Page 17 of 19

CONSENT FORM 5 APPENDIX 3 CONSENT BY AN ADULT WHO INDICATES THAT THEY DO NOT WISH TO BE ADMINISTERED ANY BLOOD COMPONENTS I, District Number,, Date of Birth,, of have given my consent for a procedure/investigation/operation on the appropriate department of health consent form, the nature and purpose of which have been explained to me by Dr/Mr... and to the administration of general, local or other anaesthetic. I also give my consent to the performance upon me of any other operative procedure which in the opinion of the surgeon it may be necessary to perform upon me, without having obtained my express consent, during or by reason of the said operation/procedure or anything connected with it; except that, although it has been explained to me that in the course of or by reason of the said operation/procedure it may be necessary to give me a blood transfusion (red cells, white cells, plasma or platelets) so as to render the operation/procedure successful, or to prevent injury to my health, or even to preserve my life, I hereby expressly withhold my consent to and forbid the administration to me of a blood transfusion in any circumstances or for any reason whatsoever and I accordingly absolve the surgeon, the hospital and every member of the medical staff concerned from all responsibility, and from any liability to me, or to my estate, or to my dependants, for any damage or injury which may be caused to me, or to my estate or to my dependants, in any way arising out of or connected with this my refusal to consent to any such blood transfusion. I hereby expressly withhold consent for the following components to be used: Packed Red Cells Platelets Fresh Frozen Plasma White Cells Intra operative Cell Salvage Post operative Cell Salvage Recombinant Clotting Factors Date... Signed... (Patient) Witness to Patient s Signature... (Health Professional)... (Witness present at interview) PHOTOCOPY ACCEPTED BY PATIENT: YES / NO (PLEASE CIRCLE) Version 3.0 September 2016 Page 18 of 19

EQUALITY IMPACT ASSESSMENT APPENDIX 4 Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture No No No No No Religion or belief Yes Jehovah s Witness patients believe in not being treated with any blood component. Although this policy is to assist in the treatment of ALL patient who refuse blood components. Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems No No No 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? Yes Yes 5. If so can the impact be avoided? N/A No Jehovah s Witness patients believe in not being treated with any blood component. Although this policy is to assist in the treatment of ALL patient who refuse blood components. The justifiable exception is due to the religious believes of the Jehovah s Witnesses. Although this policy will aid in the care of all patients refusing blood components 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A Version 3.0 September 2016 Page 19 of 19