Download Refusing Administration of Blood Products

Refusing Administration of
Blood Products
Chelsye Bond
Jessica MacLean
Jennifer Fougere
Joseph Ratnasothy
Seminar Objectives
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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.
Relevant Terms
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Competency
Incompetency
Right to autonomy and self-determination
Principle of do no harm
Advanced directive
Bioethics
Bill
Informed Consent
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
Issue Statement
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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.
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)
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)
What is a blood transfusion
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Receive a blood component intravenously
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Components are red blood cells, platelets,
plasma, albumin, and clotting factors
(Capital Health, 2007)
Why might a
blood transfusion be needed
1.
To increase red blood cells
2.
To replace clotting factor or platelets in your blood
3.
To replace blood loss
4.
To replace blood loss resulting from treatment or
procedure
(Capital Health, 2007)
Why might a person
refuse a blood transfusion
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Religious, spiritual beliefs
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Individual preference
(Capital Health, 2007)
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)
Jehovah Witnesses
Refuse the following:
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Whole blood, RBCs, WBCs, PLTs
Preoperative autologous blood donation
(The Watchtower Bible and Tract Society, 2010)
Jehovah's Witnesses Con’t
Will accept the following:
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Blood conserving methods
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Most diagnostic and therapeutic procedures
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Non-blood volume expanders
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Pharmacologic agents that do not contain blood components
or fractions
(The Watchtower Bible and Tract Society, 2010)
Jehovah’s Witnesses Con’t
The following is treatment made by personal decision
(acceptable to some, declined by others):
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Blood cell salvage
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Hemodialysis
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Transplants
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Acute normovolemic hemodilution (ANH)
(Capital Health, 2007)
Historical Influence
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William Harvey (1578-1657)
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Jean-Baptiste Denys (1640-1704)
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English physician, first to describe in detail the properties of
blood and the systemic circulation
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)
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English physician, in 1818 performed the first successful
transfusion of blood to a patient for treatment of a hemorrhage
Historical Influence
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Dr. Charles Drew (1904-1950)
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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)
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Introduced in 1979, which increased the blood supply and
facilitated resource-sharing among blood banks
Current Influence
Treatment refusals by:
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Competent adults
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Incompetent adult with advance directive
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Incompetent adult without advance directive
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Mature minors/minors
Current Influence
Legal precedents…
Cases presented to the courts
regarding children and regarding competent adults
guide current practice
Medical Decisions Facilitations Act
 Protecting physicians
The Supporting Arguments
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Choice
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Advocacy
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Dignity
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Professional misconduct
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Justice
(CNA, 2008)
(Effa-Heap, 2009; McInroy, 2005)
The Opposing Arguments
Code of Ethics
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Best care possible and at the same time
advocate
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Saving lives
(CNA, 2008)
Alternatives
Preoperative Period:
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Iron therapy
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Vitamin B12
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Folate
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Erythropoietin
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Autologous Donation of own blood
(Capital Health, 2007)
Alternatives Con’t
Intra-operative Period:
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Antifibrinolytic drugs
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Hypothermia
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Acute normovolemic Hemodilation
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Cell Salvage
Device
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Volume Expanders
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Hypotensive Anesthesia
Endoscopic and
Laparoscopic
Surgery
(Capital Health, 2007)
Perioperative Blood Management
Program (PBMP)
Purpose:
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To decrease and/or eliminate the need for blood transfusion
during elective or scheduled surgery
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To educate patients about the risks and benefits of blood
transfusions
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Educate about available blood alternatives available
(Capital Health, 2007)
New Technologies
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Blood Substitutes
Preventing Bleeding
Replacement Fluids
Intra-operative Blood Collection
Autologous RBC
Nursing Role
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Keep in mind that blood is not always needed
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Remember that transfusion carries risks as well as
benefits
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Seek to understand the patient and develop good
rapport
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Access available resources
(Effa-Heap, 2009; McInroy, 2005; Rogers, Kendall, & Crookston, 2006)
Nursing Role
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Limit blood draws and consider alternatives to blood products
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Explore the treatment possibilities
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Ensure confidentiality
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Document carefully
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Make contingency plans in advance
(Effa-Heap, 2009; McInroy, 2005; Rogers, Kendall, & Crookston, 2006)
Nursing Role
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Respect patient’s individual choices
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Practice in coordination with Nursing Code of Ethics and
Standards of Practice
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Obtain informed consent prior to procedure or treatment
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Be trustworthy; advocate on behalf of patients’ wishes
(McInroy, 2005)
Nursing Role
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Consider that quality of life is ‘subjective’
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Consider that the values of patients, relatives, and healthcare
staff, may differ
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Encourage fair, non-judgemental decisions
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Lobby for clearer policies
(McInroy, 2005)
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?
Questions