Chelsye Bond Jennifer Fougere Jessica MacLean Joseph Ratnasothy

1. Refusing Administration of Blood Products Chelsye Bond Jennifer Fougere Jessica MacLean Joseph Ratnasothy

2. Seminar Objectives • Define indications of blood products. • Identify reasons for refusal of blood products. • Demonstrate the historical influences of blood transfusion. • Illustrate the current present day influences of blood transfusion. • State the policy surrounding the administration and refusal of blood products. • Distinguish supporting and opposing arguments in regards to refusal of administration of blood products. • Explain the health care provider’s role in terms of caring for the patient who refuses a blood tranfusion.

3. Relevant Terms • Competency • Incompetency • Right to autonomy and self-determination • Principle of do no harm • Advanced directive • Bioethics • Bill • Informed Consent

4. 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

5. 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.

6. 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)

7. 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)

8. What is a blood transfusion • Receive a blood component intravenously • Components are red blood cells, platelets, plasma, albumin, and clotting factors (Capital Health, 2007)

9. Why might a blood transfusion be needed • To increase red blood cells • To replace clotting factor or platelets in your blood • To replace blood loss • To replace blood loss resulting from treatment or procedure (Capital Health, 2007)

10. Why might a person refuse a blood transfusion • Religious, spiritual beliefs • Individual preference (Capital Health, 2007)

11. 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)

12. Jehovah Witnesses Refuse the following: • Whole blood, RBCs, WBCs, PLTs • Preoperative autologous blood donation (The Watchtower Bible and Tract Society, 2010)

13. Jehovah's Witnesses Con’t Will 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)

14. Jehovah’s Witnesses Con’t The 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)

15. 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

16. 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

17. Current Influence Treatment refusals by: • Competent adults • Incompetent adult with advance directive • Incompetent adult without advance directive • Mature minors/minors

18. Current Influence Legal precedents… Cases presented to the courts regarding children and regarding competent adults guide current practice Medical Decisions Facilitations Act • Protecting physicians

19. Choice Dignity Justice Advocacy Professional misconduct The Supporting Arguments (CNA, 2008)

20. (Effa-Heap, 2009; McInroy, 2005)

21. The Opposing Arguments Code of Ethics • Best care possible and at the same time advocate • Saving lives (CNA, 2008)

22. Alternatives Preoperative Period: • Iron therapy • Vitamin B12 • Folate • Erythropoietin • Autologous Donation of own blood (Capital Health, 2007)

23. Intra-operative Period: Antifibrinolytic drugs Acute normovolemic Hemodilation Volume Expanders Hypotensive Anesthesia Hypothermia Cell Salvage Device Endoscopic and Laparoscopic Surgery Alternatives Con’t (Capital Health, 2007)

24. 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)

25. New Technologies • Blood Substitutes • Preventing Bleeding • Replacement Fluids • Intra-operative Blood Collection • Autologous RBC

26. 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)

27. 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)

28. 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)

29. 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)

30. 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?

31. Questions