General Principles of Treatment

Communication

It is crucial that the patient’s wishes are known, acknowledged and communicated to senior members of the relevant clinical team as early as possible to allow appropriate planning and subsequent action to take place.

The wishes of the patient must not be assumed and consent to treatment options must be sought in a thorough and confidential manner [4].

The different blood products and interventions available, and the risks and benefits associated with consenting to, or refusing these products and interventions, should be discussed as part of the informed consent & management planning process. Use the form C30042 Caring for Patients Who Decline Blood Products. Once completed the form should be filed in the clinical record under consents and a copy should be provided to the patient.

Health-Care Directives

JW patients may hold a Health-Care Directive/advance directive that documents their rejection of blood components and/or products. Any patient may make and use an advance directive. An advance directive may be written or oral, and documents the patient's choice about a possible future health care procedure (Right 7(5) of the Code of Rights). An advance directive is intended to be effective only when the patient is not competent.

If a patient has made an advance directive that includes a refusal of blood products or specific interventions, the clinician responsible for the patient's care should discuss the patient's directive with them, to ensure a clear understanding of the circumstances in which the patient intends the directive to apply, and any limitations on the directive. A copy of the directive should be filed in the clinical notes, and all staff involved in the patient's care should be made aware of the directive, and when and how the directive is to apply. In the case of a patient who is unconscious, the treating clinician should discuss with the patient’s relatives and ask if an advance directive exists. In the absence of an advance directive, knowledge of the patient’s wishes must be considered when acting in the best interests of the patient (Right 7(4) of the Code of Rights).

Blood Products and Alternatives

Transfusion of red cells, platelets, fresh frozen plasma, and cryoprecipitate are usually unacceptable to JWs.

Non-recombinant coagulation factors (e.g. Prothrombinex VF and RiaSTap (fibrinogen)) or other plasma-derived products (e.g. intravenous immunoglobulin), recombinant products (e.g. erythropoietin) as well as the options of cell salvage, haemodialysis/haemofiltration or cardiac bypass (where albumin solution can be used for priming the circuit) may elicit different responses in terms of acceptability and all these should be discussed with the patient.

Some drugs/contrast agents contain human serum albumin, which may be unacceptable for certain JW patients. The formulations of recombinant human erythropoietin (Epo) available within the CDHB do not contain human albumin [5].Most of the various radio-labelled agents used in nuclear medicine do not contain human serum albumin, however, MAA (macroaggregated albumin) used in the perfusion part of lung perfusion scans contains human serum albumin and this should be communicated to the patient.

Haemoglobin-based oxygen carriers are being developed and may become an option in the future.

Documentation and Liaison

The results of all discussions, including the patient’s understanding of the potential outcomes of refusing blood products i.e. including the possibility of death, should be documented in the clinical notes.

There is a local Hospital Liaison Committee for Jehovah’s Witnesses who, with the patient’s consent, can be contacted to assist with the treatment of JW patients. This committee consists of several selected ministers who are happy to be called upon to provide pastoral and practical assistance to patients and help to resolve spiritual or ethical questions related to their care. Patients should be encouraged to discuss their care with this representative. See

Hospital Liaison Committee contacts.


About this Canterbury DHB document (47837):
Document Owner:	Julia Czuprynska and Richard Seigne (see Who's Who)
Last Reviewed:	June 2019
Next Review:	June 2022
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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Topic Code: 47837