Refusal of blood or blood components may arise for many reasons, including religious beliefs or concern about blood-borne infections. Staff at Great Ormond Street Hospital (GOSH) will always try to work with children, young people and families who refuse blood or blood components, and this information explains the policies we will follow.
Which blood components may be refused?
Concern about infection
This has arisen following cases of new variant Creutzfeld- Jacob disease (nvCJD), which may have developed following blood transfusion. Blood and blood components that are likely to be refused are:
- Red cells
- White cells
- Platelets
Fresh Frozen Plasma (FFP) and Cryoprecipitate (Cryo) is sourced from non-UK donors so is not perceived to have the same degree of risk.
Religious belief
The largest group who may refuse blood or blood components due to their religious belief is the Jehovah’s Witnesses. Refusal to accept blood or blood components is based on a literal interpretation of several passages in the Bible. Blood and blood components that are likely to be refused are:
- Red cells
- White cells
- Platelets
- Plasma
Acceptance of blood products such as immunoglobulin and albumin is a matter of individual choice.
Who can decide?
- Any person with parental responsibility can give or refuse consent for a child to receive blood and blood components
- Children 16 years or over can give consent to receive blood and blood components against their parents’ wishes
- Children under 16 years deemed to be competent can also give consent to receive blood and blood components
- However, refusal by children under 18 years old may be overridden by a person with parental responsibility or by the Courts.
Rights and responsibilities
GOSH practises family-centred care, which means that we want you to be involved in your child’s care as much as you feel able. However, along with these rights, you also have responsibilities, as follows;
You have the right to:
- Have full and frank discussions with the clinicians involved in the care of your child
- Discuss fully any techniques or methods that could minimise the risk of blood transfusion
- State on the consent form that you are refusing blood or blood components
- Have independent people at meetings to help explain your views
You have the responsibility to:
- Inform us of your wishes as soon as your child becomes a patient of GOSH
- Discuss fully any techniques or methods that could minimise the risk of blood transfusion
- Accept that GOSH will not allow the death of a child for lack of a blood transfusion if unexpected complications occur
- Attend any planning meetings arranged by the hospital
Reducing the risk of blood transfusion
There are a variety of techniques that can be explored which may reduce the risk of blood transfusion becoming necessary.
Before the operation
Managing any heart, circulation or lung conditions and correcting any anaemia
This is intended to get your child into the best shape possible for surgery, which will reduce the risk of complications.
Nutritional advice
Low red blood cell levels can increase the risk of complications, so extra iron in the form of iron-rich foods or iron tablets may be suggested.
Medicines to improve red blood cell levels
Medicines such as epoetin or ferrous sulphate will need to be taken for two to three weeks before surgery to have an effect.
Stopping medicines that increase the risk of bleeding
These include non-steroidal anti-inflammatories such as ibuprofen and anti-clotting medicines such as warfarin. You will need to make a plan for reducing or stopping these medicines with your doctor a few weeks in advance of surgery.
During the operation
Use of a tourniquet
Particularly for limb surgery, a tourniquet may be recommended. This is a tight band put round the limb to reduce blood flow to the operation site and therefore reduce the risk of blood loss. This will not be suitable for every type of surgery however.
Giving medicines to narrow the blood vessels
Use of medicines such as adrenaline can narrow blood vessels therefore reducing blood flow.
Use of surface dressings to reduce blood loss
These usually work on the principle of applying pressure to the operation site and can reduce blood loss greatly.
Use of alternative anaesthesia
Regional anaesthesia can be used as an alternative to general anaesthesia as it reduces the risk of complications. Another alternative is hypotensive anaesthesia, where the blood pressure is greatly lowered, again reducing the risk of complications.
Blood storage in theatre immediately before surgery
Also known as acute normovolaemic haemodilution, where a volume of blood is drained from the patient before surgery, kept stable during the operation and then infused back into the patient after surgery.
Blood salvage during surgery
It is also possible to salvage blood lost during the operation and then re-infuse it continuously.
Medicines to encourage clotting
These include tranexamic acid which acts against enzymes in the blood that break down blood clots. They can be given during the operation to reduce blood loss.
Decision making for planned surgery
When an operation or procedure is proposed, the hospital will arrange a clinical meeting to decide how best to go ahead. This will usually be arranged for four to six weeks before the planned procedure. The meeting will usually be attended by the lead clinician for your child, other members of the clinical team such as an anaesthetist and haematologist as well as representatives from the Patient Advice and Liaison Service (Pals).
You will be invited to attend this meeting along with any advocates, for example from your religion. The proposed procedure will be discussed, including the potential for blood loss and methods for reducing the risk (as above). The discussions held during the meeting and the final decision whether to proceed or not will be recorded and documented fully.
If a decision cannot be reached at this meeting, the matter will be referred to Court to decide whether or not the procedure can be carried out and with which provisos. An application may be made to the High Court for a declaration that the proposed treatment is lawful notwithstanding the lack of parental consent. The application will be clear about the procedures to be undertaken and any blood or blood components which may be required.
The application may also extend to future treatments and other treating clinicians. Once a decision has been made to seek a declaration the family will be strongly advised to seek separate legal representation and will be kept full informed about the process.
In an emergency
If an emergency situation arises where a child or young person requires blood or blood components to survive, they can be administered despite the parents’ (or child’s) wishes. Two consultants will discuss the need for blood or blood components and document their decision (and how that decision was reached) fully in the child’s medical notes.
If the need is urgent but allows time for consultation with the Legal department, a ‘declaration’ may be sought from the High Court as above. Out of hours, this request should be made to the Clinical Site Practitioners at GOSH.
Further information
- Patient Advice and Liaison Service (Pals) – 020 7829 7862 – Monday to Friday 9am to 5pm
- Hospital Liaison Committee for Jehovah’s Witnesses – 020 8906 2211 – 24 hours a day, seven days a week
Last reviewed by Great Ormond Street Hospital: February 2010
Ref: 09F0980 © GOSH Trust February 2010
Compiled by the Patient Advice and Liaison Service, Legal and Chaplaincy departments in collaboration with the Child and Family Information Group.
This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.
