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INTERDISCIPLINARY CLINICAL MANUAL Policy & Procedure TITLE: Section: Source: Distribution: Patient Identification for Refusal of Blood/Blood Components/Products Blood/Blood Products All NUMBER: CC 75-010 Date Issued: July 2007 Date To Be Reviewed: Issuing Authority: July 2010 Heather Francis Health Services Director POLICY 1. Capital Health respects a person’s autonomy in making important decisions about his or her own health care and treatment. This includes active respect for the right of adult patients who have capacity to refuse transfusion of blood components/products when these are clinically indicated. 2. The attending physician (Surgery, Medicine, and Anesthesia) is to document the patient's refusal to blood components/products in the appropriate medical record and obtain the signature on the Refusal of Blood Transfusion - Risk Management (CD0738MR). 3. Patients refusing blood components/products are to wear a “No Blood” armband and the health record is to be labeled indicating blood refusal. 4. A patient’s “No blood” status is to be reviewed on each care encounter (inpatient and outpatient) as required and the patient’s wishes are to be documented in the health record and/or the electronic medical record once a healthcare provider identifies the patient. 5. If a healthcare provider removes the “No Blood” armband for the purposes of facilitating treatment or therapy, or notes that the band is absent or incorrect, that healthcare provider is to ensure that a new “No Blood” armband is placed on the patient as soon as is possible. 6. ABO Type and Antibody screen and/or Group and Cross match will not be drawn on patients who are identified as refusing all blood components/products. If patient agrees to accept blood components, a Type and screen will be drawn. 7. Blood components/products will not be administered to a patient who: 7.1. is wearing a “No Blood” armband 7.2. has given informed consent to refusal of blood components/products, except as is consistent with the patient’s expressed wishes Patient Identification for Refusal of Blood/Blood Components/Products CC 75-010 Page 1 of 6 Interdisciplinary Clinical Manual 7.3. has indicated on a legally valid advance directive that blood components/products is not to be given 7.4. signed the Refusal of Blood Transfusion form. GUIDING PRINCIPLES 1. The wearing of “No Blood” armbands is strongly encouraged but not required. If the patient’s health condition precludes application of the armband to one of the patient’s upper extremities, the armband can be attached to another visible part of the patient’s body using tape appropriate to the patient’s condition/allergies. See Patient Identification and Same Name Alert CH 70-040. DEFINITIONS Blood Component: A therapeutic component of blood intended for transfusion (e.g., red cells, granulocytes, platelets, plasma, cryoprecipitate, cyrosupernatant plasma) that can be prepared using the equipment and techniques available in a blood centre.2 Blood Product: Any therapeutic product derived from human blood or plasma, and produced by a manufacturing process that pools multiple units (usually more than 12) e.g. human serum albumin, immunoglobulin preparations, and coagulation products(factors VIII and IX, fibrinogen, anti-thrombin III, etc.).2 Advance Directive: A document in which a capable person sets out what, how or by whom health care decisions are to be made in the event that he or she is not capable of making health care decision on his /her own. Two types of advance directives are instruction directives and proxy directives: • Instruction directives- a directive in which the maker specifies what type of health care and treatment he or she wishes to receive or not receive. • Proxy directive- a document (sometimes referred to as an “enduring” or “durable” power of attorney for health care decisions) in which a capable person of 19 years or older names a proxy to make health care decisions for him/her in the event that he or she is not capable of making those decisions on his/her own. Proxy directives must be in writing, must be dated and signed by the maker; and must be witnessed by someone other than the proxy or the proxy’s spouse. Substitute Decision Maker: A person who has legal authority and willingness to make health care decisions for the patient when the patient does not have the capacity to make his/her own decisions in the following order of priority: • A person named as a proxy in an advance directive or in a medical power of attorney; • the patient's court-appointed guardian; Patient Identification for Refusal of Blood/Blood Components/Products CC 75-010 Page 2 of 6 Interdisciplinary Clinical Manual • the spouse or common law partner who is cohabitating with the patient in a conjugal relationship; for a common law partner, this relationship must have been of at least two years duration; • an adult child of the patient; • a parent or a person who stands in loco parentis; • an adult brother or sister of the patient; • another adult next-of-kin; and • the Public Trustee Other than a proxy, medical power of attorney, guardian and the Public Trustee, the substitute decision maker must have been in personal contact with the patient over the preceding twelve months. Capacity: A capable patient must be able to understand: the condition for which the treatment is proposed; the nature and purpose of the treatment; the risks involved in undergoing the treatment; and the risks involved in not undergoing the treatment. Any assessment of capacity includes a determination as to whether or not the patient’s ability to consent or dissent is affected by his/her medical condition(s). A person is presumed to be capable unless assessed as being incapable by an attending physician, in consultation with a psychiatrist as necessary, or deemed to be incapable by the court under the provisions of the Guardianship Act or the Incompetent Persons Act. Where a patient’s capacity is difficult to assess, or is not agreed upon by those providing health care to the patient or the family of the patient, or there is dispute as to who has the right to make substituted health care decisions for the patient, a psychiatrist’s assessment as to the patient’s capacity is required. Healthcare Provider: A healthcare provider is a medical or allied health professional who offers services for the prevention, treatment, and management of illness and the preservation of mental and physical well-being.4 Invasive Procedure: An invasive procedure is defined as any procedure excluding venipuncture and IV therapy which involves puncture or incision of the skin or insertion of an instrument or foreign material into the body, including, but not limited to, percutaneous aspirations and biopsies, cardiac and vascular catheterizations, internal laser procedures, endoscopies, angioplasties, and implantations. 4 Treatment: The application of medical care to cure diseases, heals injuries, or ease symptoms.4 Extracorporeal Circulation: Diversion of blood flow through a circuit located outside the body but continuous with the bodily circulation.5 Patient Identification for Refusal of Blood/Blood Components/Products CC 75-010 Page 3 of 6 Interdisciplinary Clinical Manual EQUIPMENT 1. 2. 3. 4. 5. 6. 7. “No Blood” Armbands (S6058954) “No Blood” stickers for spine (S1020991) “No Blood” stickers for front of patient’s health record (S1020993) Refusal of Blood Transfusion - Risk Management (CD0738MR). PeriOperative Assessment/Observations (CD0128MR) Notification of Refusal of Blood Components/Products form (CD1298MR) Preoperative Checklist Record (CD0608MR) PROCEDURE General 1. Capable patient or substitute decision maker indicates refusal to receive blood components/products. 2. At the time of admission, the healthcare provider documents the patient’s refusal to blood components/products in the progress notes of the patient’s health record, including where the healthcare provider has confirmed through an informed consent process that the patient’s wishes about blood transfusion have not changed. 3. The attending physician or resident provides information to ensure the patient has made an informed choice about the refusal of blood components/products. 3.1. The physician documents the patient's refusal to accept blood components/products in the health record and obtains the patient’s or substitute decision-maker’s (SDM) signature on the Refusal of Blood Transfusion - Risk Management (CD0738MR). The physician contacts the proxy decision maker if one has been identified. 4. The health care provider: 4.1. Places a copy of an advance directive – if the patient has one - on the patient’s health record. 4.2. At the time of admission to hospital, places the “No Blood” armband on any patient who has been identified as refusing blood components/products. Exception: In situations where the healthcare provider deems it inappropriate from a clinical perspective to identify the patient through the use of an armband, place the armband on the patient’s health record. 4.3. Places a “No Blood” sticker on both the front and spine of patient's health record upon admission for any patient who has been identified as refusing blood components/products. 4.4. Notifies the Perioperative Blood Management program (PBMP) when a patient is identified as refusing blood components/products. Fax the Notification of Refusal of Blood Components/Products form (CD1298MR) {includes patient’s name, medical record number (MRN), attending physician, today’s date, nurse signature, and patient unit}to 4735804 (PBMP). Patient Identification for Refusal of Blood/Blood Components/Products CC 75-010 Page 4 of 6 Interdisciplinary Clinical Manual 5. The Registered Nurse documents refusal of blood components/products on the Preoperative Checklist Record (CD0608MR). 6. Any healthcare provider with questions as to whether human products are in certain drugs prescribed, may call pharmacy or BTS for clarification e.g. IV products that are immune globulins, vaccines or produced by recombinant DNA technology. Revocation of Refusal to Accept Blood Components/Products 1. Where a patient (or their SDM) indicates to a healthcare provider a wish to change a “No Blood” designation, the healthcare provider advises the patient’s attending physician of the patient’s desired change. 1.1. The treating physician ensures that the patient is giving informed consent to receive blood components/products. 1.2.The treating physician or healthcare provider notes the withdrawal of the refusal on the patient’s Refusal of Blood Transfusion - Risk Management (CD0738MR) and has the patient sign the withdrawal. 1.3. The treating physician or healthcare provider ensures that the change is noted in the patient’s health record, that the “No Blood” stickers are removed and the “No Blood” armband is removed. 2. Notify the PBMP at 473-3117 if a patient consents to change their “No Blood” designation or if further information is required. Perioperative Services 1. Follow the General procedures as applicable. 1.1. The Registered Nurse documents refusal of blood components/products on the PeriOperative Assessment/Observations (CD0128MR) form. 1.2. If the “No Blood” identification band is removed, the healthcare provider places it in a clear plastic bag with the patient label on the front of the patient’s health record. 1.3. The Registered Nurse or delegate replaces the “No Blood” armband on admission to Post Anesthesia Care Unit (PACU) and Intensive Care Unit (ICU), RELATED CAPITAL HEALTH DOCUMENTS Policies Blood/Blood Product Transfusions CC 75-005 Patient Identification and Same Name Alert CH 70-040 Advance Directives CC 90-005 Forms Refusal of Blood Transfusion - Risk Management (CD0738MR). Preoperative Checklist Record (CD0608MR) Patient Identification for Refusal of Blood/Blood Components/Products CC 75-010 Page 5 of 6 Interdisciplinary Clinical Manual PeriOperative Assessment/Observations (CD0128MR) Notification of Refusal of Blood Components/Products form (CD1298MR) REFERENCES Shander, A., Rijhwani, T.S., Bloodless medicine and surgery: one arm of blood management. Current reviews in clinical anesthesia. Lesson 19, vol. 25 April 21, 2005. Canadian Standards Association (2004). CSA Standard Z902-04 Blood and blood components. Mississauga: ON. Web References: 1. http://cdhaintra/departmentservices/riskmanagement/Advance%20Directives.doc last accessed April 5, 2006 2. http://www.dictionary.com last accessed April 5, 2006 3. http://medical-dictionary.com/dictionaryresults.php last accessed April 5, 2006 HISTORICAL DATES New – July 2007 Armband Identification Blood Patient Identification for Refusal of Blood/Blood Components/Products CC 75-010 Page 6 of 6