SCGOPHCG : Refusal of Blood and Blood Products: Management Policy

Assessment Overview 

Introduction

Competent adults have the legal right of autonomy or self-determination,⊃1; and therefore the legal right to decline medical treatment, including the transfusion of blood and blood products. Declining consent may be based on personal beliefs or experiences, most commonly Jehovah’s Witnesses (JW) who have specific beliefs regarding blood and transfusion. Acceptance of products, especially plasma fractions, may vary according to an individuals’ personal conscience.
SCGOPHCG are committed to respecting patients’ rights without prejudice, and ensuring best care is provided by partnering with the patient in planning their care.

Risk Statement

Non-compliance with this policy will:

Management of Competent/concious Patients Refusing Blood and Blood Products

• Identify the patient’s directive regarding acceptance of receiving blood/blood products – copy of AHD should be filed in the medical record (AHD should be advised if not already in place)
• Complete the Refusal to Consent to Blood Products (Form D) with the patient-patient and medical officer to complete sections as indicated
• Review non-blood medical alternatives and determine treatment plan with patient
• For patients undergoing procedures with a high risk of blood loss, consult Haematology for advice. Arrange blood testing per PBM guidelines:
  a. FBC, Iron Studies, U&Es, LFTs, CRP, Vitamin B12, and folate.
  b. All requests for the use of erythropoietin must be discussed with Haematology.
•  If patient is a JW, the SCGOPHCG JW liaison can be contacted via switch to assist in communication and understanding alternative treatment options.
• IN AN EMERGENCY:
  a. An adult patient who is conscious and able to write should complete the ‘Refusal to Consent to Blood Products (Form D)’. It is medical staff’s responsibility to explain this form to ensure legal validity.
  b. If the patient is conscious and competent, but unable to write/or emergency precludes the formality of Form D completion, and a consent discussion has occurred in the emergency setting – verbal refusal of blood products obtained by a medical officer with another medical officer as a witness, should be documented in the patients’ medical record with names and signatures of both.

Management of Unconscious or Incompetent Patients Who May Refuse Blood Products

• If an unconscious/not competent adult patient had previously completed an AHD, it should be sought to guide treatment decisions. Upon confirmation of patient ID, clinical staff should check the patients My Health record, and/or wallet/purse for a current AHD. The AHD must comply with the requirements of the Guardianship and Administration Act 1990.
• The AHD should clearly state the patients’ choices on the use of blood products, including which treatments they consent to, and which treatments they refuse.
• The AHD should be copied and filed into the patients’ medical record and a medical officer should also document the same, including the patients accepted transfusion treatment options.
•  If an AHD is not located, patient ID has been confirmed, and it is firmly believed that the patient would decline the use of blood/blood products, attempts to confirm patients’ treatment decisions should be sought. Attempts should be made to contact patients next of kin, enduring guardian, GP, Church Minister or the JW Hospital Liaison.
•  If attempts to contact are futile, attempts should be made to locate a substitute decision maker as defined by the Guardianship and Administration Act 1990 Section 110 ZJ: Order of priority of persons who may make treatment decision in relation to patient (p.101) and 110 ZD: Circumstances in which person responsible may make treatment decision (p. 95).
•  If the substitute decision maker has not been given the Enduring Power of Guardianship or is the Guardian appointed by the State Administrative Tribunal (SAT), an application to the SAT should be considered.
• IN AN EMERGENCY: If unable to gain transfusion refusal information, treat as clinically necessary in accordance with the Division 2- Provision of treatment, section 110ZJ ‘Urgent treatment generally’ provisions set out in the Guardianship and Administration Act 1990 (page 100) which states:

• 110ZI. Urgent treatment generally:
  (1) Subsection (2) applies if —
  (a) a patient needs urgent treatment; and
  (b) the patient is unable to make reasonable judgments in respect of the treatment; and
  (c) it is not practicable for the health professional who proposes to provide the treatment to determine whether or not the patient has made an advance health directive containing a treatment decision that is inconsistent with providing the treatment; and
  (d) it is not practicable for the health professional to obtain a treatment decision in respect of the treatment from the patient’s guardian or enduring guardian or the person responsible for the patient under section 110ZD.

  (2) The health professional may provide the treatment to the patient in the absence of a treatment decision in relation to the patient.

  And, in accordance with the WA Health Consent to Treatment policy:
  Treatment without consent must be:

  • reasonably required to meet the emergency
  • in the patient’s best interests
  • the least restrictive of the patient’s future choices

  The rationale for treatment without consent must be clearly documented in the patient’s medical record. The medical record must state details of attempts made to contact the substitute decision maker.

Guidelines for the Emergency Treatment of Patients Under 18 Years Whose Parents Refuse Blood and Blood Products

The Human Tissue and Transplant Act 1982 addresses the removal of blood and the administration of blood and/or blood product transfusion to a child in the absence of parental consent.
Human Tissue and Transplant Act 1982 Part II Division 5 Section 21 (subsection 1-2) states:

• A medical practitioner may perform a blood transfusion upon a child without the consent of any person who is legally entitled to authorise the blood transfusion if:
  a) such person:
  i. fails or refuses to so authorise the blood transfusion when requested to do so; or
  ii. cannot be found after such search and enquiry as is reasonably practicable in the circumstances of the case; and
  b) the medical practitioner and another medical practitioner agree:
  i. as to the condition from which the child is suffering; and
  ii. that the blood transfusion is a reasonable and proper treatment for that condition;
  iii. that without a blood transfusion the child is likely to die; and
  c) the medical practitioner who performs the blood transfusion on the child

General Principles

• A fully informed, competent adult is entitled to accept or reject medical treatment.
• Patients must be provided with information to enable them to make an informed decision regarding blood transfusion and have an opportunity to ask relevant questions.
• Exercising self-determination and rejecting specific medical treatments may have consequences upon the nature and extent of treatment options that may be available.
• Jehovah’s Witnesses (JW) generally DO NOT accept whole blood or major blood components; however, the acceptance of blood fractions varies according to the individual. Clearly establish the patient’s current directive on each hospital admission.
• Many JW carry a signed Advanced Health Directive / No Blood card which should be consulted to view the patient’s wishes regarding treatment options. The card contains the name of an alternative contact/substitute enduring guardian.
• The SCGOPHCG JW liaison can be contacted via Switch for patient assistance and can provide advice in locating medical staff at other facilities to consult on alternative care.

Note: If medical or nursing staff have any difficulties or queries regarding the treatment or course of action, they should contact the Hospital Executive Director of Clinical Services or delegate for further advice.

Assessment requirements brief summary

Purpose: Demonstrate knowledge and practical application of SCGOPHCG policy and relevant law for managing patients who refuse blood and blood products, ensuring patient rights, safety and legal compliance.

What to cover (key pointers):

• Distinguish management of competent/competent adults who refuse transfusion (AHDs, Form D, documentation requirements).
• Steps for conscious patients in emergency (written Form D if possible; if not, witnessed verbal refusal recorded).
• Procedures for unconscious or legally incapable patients: locate AHD/My Health Record, contact next of kin, enduring guardian, JW liaison; identify and apply substitute decision-maker rules (Guardianship & Administration Act).
• Emergency authority to treat under urgent-treatment provisions (Guardianship & Administration Act s.110ZI) and WA Health Consent to Treatment policy — criteria and documentation requirements.
• Children (under 18): legal basis for treating despite parental refusal (Human Tissue & Transplant Act provisions) and required medical agreement.
• Clinical pathway for preparing for procedures with high blood loss: consult Haematology, order PBM tests (FBC, iron studies, U&Es, LFTs, CRP, B12, folate), discuss erythropoietin use with Haematology.
• Cultural/faith liaison (Jehovah’s Witnesses): establish patient-specific directives about blood fractions; use JW liaison for communication.
• Record-keeping, consent forms, escalation (SAT applications, substitute decision-maker processes), and audit/compliance obligations.

How the Academic mentor guided the student step-by-step process

1. Policy & Legislation review

   • Read SCGOPHCG policy and the cited statutes (Guardianship & Administration Act; Human Tissue & Transplant Act; WA Health Consent policy). Mentor highlighted critical clauses (urgent treatment, substitute decision-maker order, AHD requirements).

2. Issue identification & mapping

   • Spot key decision points: competent vs incompetent, adult vs child, emergency vs elective, availability of AHD, presence of substitute decision maker. Mentor helped map these into a flowchart.

3. Documentation and evidence practice

   • Teach how to complete and file Form D, where to locate/copy AHDs (My Health Record, wallet), and how to document witnessed verbal refusals. Mentor reviewed sample entries to ensure legal sufficiency (names, signatures, timestamps).

4. Clinical alternative planning

   • Mentor guided the student to develop a checklist for pre-op PBM investigations and steps for discussing non-blood options with patient and Haematology (including when erythropoietin may be considered).

5. Legal escalation & substitute decision-making

   • Role-played contacting next of kin, enduring guardian, or applying to SAT. Mentor explained order of priority under the Guardianship Act and when to proceed under urgent-treatment provisions.

6. Special cases: minors & emergency

   • Reviewed legal criteria for transfusing a child without parental consent (Human Tissue & Transplant Act) and practiced documenting the required agreement between two medical practitioners.

7. Communication & cultural sensitivity

   • Practised patient conversations and use of JW liaison resources. Mentor emphasised asking precise questions about which blood products/fractions are acceptable to the patient.

8. Simulation & audit trail

   • Ran simulated emergencies to test decision timing and record-keeping. Student prepared an audit log template and a post-event report format for compliance review.

9. Final review & refinement

   • Mentor performed a compliance checklist review: legal citations, Form D sample, AHD filing procedure, PBM orders, liaison contacts, and a clear escalation pathway for SAT applications.

Outcome achieved

• Student delivered a policy-aligned care pathway package that included:
  • A decision flowchart (competent → unconscious → minors).
  • Completed Form D example and AHD filing protocol.
  • Preoperative PBM checklist and Haematology consultation checklist.
  • Verbal-refusal documentation template and witness statement example.
  • Communication script for culturally sensitive conversations and JW liaison contact procedure.
  • Emergency legal-action checklist (when to treat under urgent-treatment provisions and how to document rationale).
  • Audit/reporting template for post-event review and compliance.
• The deliverables were clinically practical, legally defensible, and formatted for immediate use in ward training and the patient medical record.

Learning objectives covered

• Apply SCGOPHCG policy and relevant WA statutes to real clinical scenarios.
• Distinguish patient categories (competent adult, incompetent adult, child) and implement correct legal pathways.
• Complete and manage essential documentation (AHD, Form D, witnessed verbal refusals, My Health Record checks).
• Plan and order appropriate PBM investigations and liaise with Haematology for non-blood options.
• Communicate effectively and sensitively with patients (including Jehovah’s Witnesses) about transfusion choices.
• Implement lawful emergency treatment when consent is unobtainable and document legal justification.

Establish escalation steps (contacting substitute decision-makers, SAT applications) and maintain an audit trail for compliance.

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