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Chelsye Bond Jennifer FougereJessica MacLean Joseph Ratnasothy
Refusing Administration Refusing Administration
ofof
Blood ProductsBlood Products
Seminar Objectives1. Define indications of blood products.2. Identify reasons for refusal of blood products. 3. Demonstrate the historical influences of blood transfusion. 4. Illustrate the current present day influences of blood
transfusion. 5. State the policy surrounding the administration and refusal
of blood products. 6. Distinguish supporting and opposing arguments in regards
to refusal of administration of blood products. 7. Explain the health care provider’s role in terms of caring for
the patient who refuses a blood tranfusion.
Relevant Terms Competency Incompetency Right to autonomy and self-determination Principle of do no harm Advanced directive Bioethics Bill Informed Consent
Purpose
…to review refusal of blood products as a pertinent nursing health issue, and to discuss the ethical and legal implications of blood product administration refusal for client and for nurse as health care provider
Issue Statement The ethical dilemma arises when a
competent, informed patient in need of a blood transfusion, refuses.
Further, the ethical dilemma becomes more difficult when a the patient is incompetent, or a child is involved.
An Ethical Dilemma for Nurses
… a situation arising when equally compelling ethical reasons both supporting and opposing a particular course of action are recognized
(CNA, 2008)
Competency vs. Incompetency Competency: Ability to express a choice Understand choices of treatment/ no treatment Appreciate implications of treatment/ no treatment
Incompetency: Substitute Decision-Maker (NOK) Power of Attourney
(McInroy, 2005)
What is a blood transfusion
Receive a blood component intravenously
Components are red blood cells, platelets, plasma, albumin, and clotting factors
(Capital Health, 2007)
Why might a blood transfusion be needed
1. To increase red blood cells
2. To replace clotting factor or platelets in your blood
3. To replace blood loss
4. To replace blood loss resulting from treatment or procedure
(Capital Health, 2007)
Why might a person refuse a blood transfusion
Religious, spiritual beliefs
Individual preference
(Capital Health, 2007)
To the Jewish nation He repeatedly said,
‘The life of every living creature is the blood, and I have forbidden the Iraselites to eat the blood of any creature, because the
life of every creature is its blood’(Leviticus 17:14)
(Wade, 2005)
Jehovah Witnesses
Refuse the following:
Whole blood, RBCs, WBCs, PLTs Preoperative autologous blood donation
(The Watchtower Bible and Tract Society, 2010)
Jehovah's Witnesses Con’tWill accept the following:
Blood conserving methods
Most diagnostic and therapeutic procedures
Non-blood volume expanders
Pharmacologic agents that do not contain blood components or fractions
(The Watchtower Bible and Tract Society, 2010)
Jehovah’s Witnesses Con’tThe following is treatment made by personal decision
(acceptable to some, declined by others):
Blood cell salvage
Hemodialysis
Transplants
Acute normovolemic hemodilution (ANH)
(Capital Health, 2007)
Historical Influence William Harvey (1578-1657)
English physician, first to describe in detail the properties of blood and the systemic circulation
Jean-Baptiste Denys (1640-1704) French physician, administered the first fully documented human
blood transfusion (the 15-year-old patient subsequently died) The French Parliament, the Royal Society, and the Catholic
Church issues general prohibitions on blood transfusion James Blundell (1791-1878)
English physician, in 1818 performed the first successful transfusion of blood to a patient for treatment of a hemorrhage
Historical Influence Dr. Charles Drew (1904-1950)
Revolutionized the understanding of blood plasma, and a system for the long-term preservation of blood plasma
Invention of blood banks (first director for the Red Cross’ system of blood banks)
CPDA-1 (anticoagulant preservative) Introduced in 1979, which increased the blood supply and
facilitated resource-sharing among blood banks
Current Influence
Treatment refusals by: Competent adults
Incompetent adult with advance directive
Incompetent adult without advance directive
Mature minors/minors
Current Influence
Legal precedents… Cases presented to the courts regarding children and regarding competent adults guide current practice
Medical Decisions Facilitations Act Protecting physicians
The Supporting Arguments Choice
Dignity
Justice
Advocacy
Professional misconduct
(CNA, 2008)
(Effa-Heap, 2009; McInroy, 2005)
The Opposing Arguments
Code of Ethics
Best care possible and at the same time advocate
Saving lives
(CNA, 2008)
Alternatives
Preoperative Period: Iron therapy
Vitamin B12
Folate
Erythropoietin
Autologous Donation of own blood
(Capital Health, 2007)
Alternatives Con’t
Intra-operative Period:
Antifibrinolytic drugs
Acute normovolemic Hemodilation
Volume Expanders
Hypotensive Anesthesia
Hypothermia
Cell Salvage Device
Endoscopic and Laparoscopic Surgery
(Capital Health, 2007)
Perioperative Blood ManagementProgram (PBMP)
Purpose: To decrease and/or eliminate the need for blood transfusion
during elective or scheduled surgery
To educate patients about the risks and benefits of blood transfusions
Educate about available blood alternatives available
(Capital Health, 2007)
New Technologies Blood Substitutes Preventing Bleeding Replacement Fluids Intra-operative Blood Collection Autologous RBC
Nursing Role
Keep in mind that blood is not always needed
Remember that transfusion carries risks as well as benefits
Seek to understand the patient and develop good rapport
Access available resources
(Effa-Heap, 2009; McInroy, 2005; Rogers, Kendall, & Crookston, 2006)
Nursing Role
Limit blood draws and consider alternatives to blood products
Explore the treatment possibilities
Ensure confidentiality
Document carefully
Make contingency plans in advance
(Effa-Heap, 2009; McInroy, 2005; Rogers, Kendall, & Crookston, 2006)
Nursing Role Respect patient’s individual choices
Practice in coordination with Nursing Code of Ethics and Standards of Practice
Obtain informed consent prior to procedure or treatment
Be trustworthy; advocate on behalf of patients’ wishes
(McInroy, 2005)
Nursing Role Consider that quality of life is ‘subjective’
Consider that the values of patients, relatives, and healthcare staff, may differ
Encourage fair, non-judgemental decisions
Lobby for clearer policies
(McInroy, 2005)
Discussion
Can a patient demand a PARTIAL treatment that the doctor considers futile and could even cause them harm?
Patients have the right to refuse a treatment, but does he have a right to refuse part of it?
If the patient’s wishes are paramount, is the emotional impact on the nursing staff as important?
Should a patient, on religious grounds or otherwise, have the right to more expensive treatment than others?
Questions