Consent and Refusal of Blood

Valid consent for transfusion requires that the patient has capacity, receives enough information about benefits, risks and alternatives, and agrees voluntarily. A competent adult may refuse any blood product, even if refusal is likely to cause death. In an emergency in which the patient cannot consent and no valid refusal is known, treatment is given in the patient's best interests.

Why this matters clinically. Poor consent practice leads to delays, disputes, undetected refusal of blood (including in emergencies) and breakdown of trust.

Risk context. Common errors are assuming consent from a signature on a general form, failing to explore religious or personal beliefs before elective surgery, and failing to document a refusal in a way that is visible to every team.

Special groups.

• Children: a parent or guardian consents, and the child's views are considered in line with age and understanding.

• Unconscious patients: best interests, unless a valid advance refusal exists.

• Pregnant patients: the patient's decision stands, with careful discussion of both lives.

• Patients in transfusion dependent programmes: consent is renewed and documented at defined intervals.

Capacity assessment. The patient must understand the information, retain it long enough to decide, weigh it and communicate a choice. Capacity is decision specific and can fluctuate. Document the assessment.

Information to disclose.

• The reason for the transfusion and the expected benefit.

• Common and serious risks in plain clinical terms: febrile and allergic reactions, circulatory overload, lung injury, haemolytic reactions, infection (very low risk with screened donors) and alloimmunisation.

• Alternatives, including iron, erythropoiesis stimulating agents, cell salvage, tranexamic acid and no transfusion, with the consequences of each.

• The patient's right to refuse.

Documentation. Record the discussion, the information given, questions asked, the decision, and the person who took consent. Record the date and the specific products agreed or refused.

Refusal. Explore the reasons. Jehovah's Witnesses commonly refuse whole blood, red cells, white cells, platelets and plasma. Many accept fractions such as albumin, immunoglobulins and clotting factor concentrates, and procedures such as cell salvage in a continuous circuit, haemodilution or dialysis, but these are individual decisions that must be asked about one by one. Do not assume.

Advance refusal. A valid, clearly worded and current written refusal applies when the patient loses capacity. If validity is uncertain in a life-threatening emergency, decisions are made in the patient's best interests, with senior input and documentation of the reasoning.

Red flags. A refusal found only after bleeding begins, a family member disagreeing with a competent patient's choice, and pressure on a patient to accept blood.

Elective surgery in a patient who may refuse. Ask the question at the first visit. Optimise haemoglobin with iron, vitamin B12, folate and erythropoiesis stimulating agents. Plan for cell salvage, meticulous haemostasis, antifibrinolytic therapy, and a staged or less invasive approach. Agree in advance which products and procedures are acceptable.

Emergency in a patient who cannot consent. Give blood when it is needed to save life, unless a valid refusal is known. Document the emergency, the lack of capacity and the reason.

Children. If a parent refuses life-saving transfusion, involve senior clinicians, the ethics service and hospital management early. Legal routes vary by region, and the hospital's legal advice should be sought.

Practical plan.

1. Establish capacity.

2. Disclose and document.

3. Identify refused and accepted products and procedures.

4. Mark the record clearly.

5. Plan blood sparing measures.

6. Review before surgery and when the situation changes.

Monitoring. Re-ask about consent when the situation changes, and before each course in repeated programmes.

Complications. Transfusion given against a valid refusal, delay in treatment through unresolved disagreement, and distress to the patient or family.

Referral and escalation. Ethics committee, hospital legal advice and senior clinicians for contested refusal, minors and incapacity. Haematology and anaesthesia for blood conservation planning.

Disposition. Keep clear documentation of the decision and the products agreed, and make it visible to the whole team. Any point of Kenyan law or hospital policy must be confirmed locally.