Authors: Tim D. Jorgenson, M.D. et al
ASA Monitor 06 2017, Vol.81, 48-50.
Blood transfusion is the most common invasive procedure performed in the United States.1 Studies have shown that augmenting the necessary consent discussions with simplified written materials can improve patient recall, comprehension and satisfaction.2 No standardized resources have been implemented, however. We suggest that a standardized patient information worksheet and a consent form clearly documenting a patient’s wishes, particularly those patients for whom blood transfusion is not an option, will help facilitate safe care across the entire health care team, increase anesthesiologist comfort in obtaining consent, and improve patient understanding and satisfaction.
Whether in perioperative management, trauma or obtaining consent, the challenges presented by patients who decline blood are significant. Fortunately, blood conservation methods such as cell salvage, acute normovolemic hemodilution, and newer pharmacotherapies such as prothrombin complex concentrates and recombinant products, have given physicians and patients more treatment options than ever before. Discussing these with patients can at times be difficult for anesthesiologists. Some may feel there is not enough time to discuss a more extensive list of treatments and alternatives, while others may not be familiar with the most up-to-date advances in transfusion medicine.
Patients with whom these discussions take place may choose not to consent for transfusion for a number of reasons, including religious beliefs, fear of contamination and other personal objections. The majority of these patients are Jehovah’s Witnesses, a Christian group with nearly 2 million self-identifying members in the U.S. 3 and over 8 million worldwide.4 While it is well recognized within the medical community that adherents are prohibited from accepting blood transfusion, what may be less well known is that this proscription does not apply to all blood components. According to their beliefs, Jehovah’s Witnesses make a distinction between what they refer to as “major fractions” (erythrocytes, leukocytes, platelets and plasma) and “minor fractions” (those components resulting from further fractionation, such as coagulation factors concentrates or albumin). “Major fractions” are forbidden, even when there is a potential risk to limb, organ or life. However, the decision to accept “minor fractions,” recombinant products or other transfusion strategies is a conscientious decision left to each well-informed patient.5
To help address these challenges, improve transfusion education and streamline the consent process, we have constructed a “Standardized Blood Transfusion Consent Form.” It is a two-page document written at a sixth- to seventh-grade reading level,6 making it accessible to a broad population. The first page is a worksheet detailing the more commonly used blood components and blood conservation modalities. Each item contains a brief description of its function and when it might be used, with an accompanying pair of “accept” and “decline” checkboxes for the patient to indicate preference. Color-coded groupings divide the blood products by origin – whole blood components (“major fractions”), fractionated components (“minor fractions”), recombinant products (synthetic) and closed-system autologous blood treatment modalities (e.g., cell salvage, autologous blood, cardiopulmonary bypass).
Proposed “Standardized Blood Transfusion Consent Form” for use with adult patients for whom blood is not an option. This template would undergo final revision and approval prior to publication.
The patient reads the description of the blood component or treatment modality and then chooses to “accept” or “decline” it. Moving down the list, the blood-derived components become more fractionated and their color lightens. This visually distinguishes each component’s origins, augmenting the textual information. The worksheet’s structure also benefits anesthesiologists, as the “accept” and “decline” boxes are aligned in a single column, allowing one to quickly scan for any divergence. The worksheet further serves as a general consent checklist for anesthesiologists.
The second page provides signatory confirmation that the patient has discussed the use of blood products and other options with the anesthesiologist and understands the risks, benefits and alternatives. Furthermore, in signing this page, the patient confirms the choices indicated on page one.
“Blood conservation methods, recombinant products and novel alternative therapies have made inspiring progress in meeting the challenges posed by patients for whom blood is not an option.”
The two pages can be used in tandem as a consent form. Alternatively, the first page can be utilized independently, serving as an education resource and means of recording the patient’s blood transfusion preferences for future use. This ensures that the information is not only delivered but that it is also correct.
It should be noted that this worksheet is intended for use only with adults who are legally competent to provide informed consent, including denial of treatment. In pediatrics, this form would not be appropriate given the medical, ethical and legal complexities surrounding this issue.7 A standardized blood transfusion consent form can still be valuable in these situations, though, by serving as an educational tool and aid to discussions about alternative therapies with parents or legal guardians.
Blood conservation methods, recombinant products and novel alternative therapies have made inspiring progress in meeting the challenges posed by patients for whom blood is not an option. The use of a standardized blood transfusion consent form, available to anyone and modifiable as needed, would help further this progress by improving communication and efficiency. Just as important, by supporting patient understanding and participation, the form would instill a sense of empowerment for patients, improve patient-anesthesiologist communication and trust, and increase patient satisfaction.
As the Agency for Healthcare Research and Quality (AHRQ) notes, “… studies have shown that improved communication between practitioners and patients leads to improved patient outcomes, less [sic] medical errors, and lower rates of malpractice claims. Adequacy of the informed consent process has been more firmly linked to patient satisfaction.”2 Whether used as a consent form, an educational tool or both, we are optimistic that the “Standardized Blood Transfusion Consent Form” will help meet an under-recognized need and be a valuable resource for anesthesiologists and the entire health care team.
Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. 2015 Procedures—Clinical Classification Software (CCS): #222 blood transfusion. https://www.hcup-us.ahrq.gov/toolssoftware/ccs/CCSUsersGuide.pdf. Updated March 2016. Accessed April 24, 2017.
Cordasco KM. Obtaining Informed Consent from Patients: Brief Update Review. In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2013:461–71.
US Census Bureau. Table 75: Self-Described Religious Identification of Adult Population: 1990, 2001, 2008. https://www.census.gov/library/publications/2011/compendia/statab/131ed/population.html. Revised September 30, 2011. Last accessed April 18, 2017.
About Jehovah’s Witnesses. Jehovah’s Witnesses website. https://www.jw.org/en/jehovahs-witnesses/. Last accessed April 18, 2017.
Fractions, Blood and Procedures, Surgical . In: Keep Yourselves in God’s Love. Wallkill, NY: Watchtower Bible and Tract Society of New York; 2016:215–218.
Free Text Readability Consensus Calculator. Readability Formulas website. http://www.readabilityformulas.com/free-readability-formula-tests.php. Last accessed April 18, 2017.
Woolley S . Children of Jehovah’s Witnesses and adolescent Jehovah’s Witnesses: what are their rights? Arch Dis Child. 2005;90(7):715–719.