Informed Refusal of Blood and Blood Products

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Informed Refusal of Blood and Blood Products

Patient and Administrative Information

Statement of Refusal

I, the undersigned patient, exercise my right of autonomy and informed refusal under applicable law and medical ethics to decline the administration of blood and primary blood components to my person. This refusal applies under all clinical circumstances, including life-threatening anaemia, haemorrhagic shock, multi-organ failure, intraoperative haemorrhage, obstetric emergencies, and trauma, even if my attending physicians believe that transfusion is necessary to preserve my life. This directive shall remain in force and effect unless I explicitly rescind it in writing with full capacity and before the clinical event requiring transfusion.

Scope of Refusal (Select All That Apply)

[ ] Absolute Refusal: I refuse ALL whole blood, red blood cells, white blood cells, platelets, and plasma under any circumstances, including life-threatening emergencies.
[ ] Absolute Refusal EXCEPT I will accept the following minor blood fractions: albumin, immunoglobulins (IVIG), clotting factor concentrates, fibrinogen concentrate, erythropoietin.
[ ] I accept intraoperative cell salvage (autologous blood recycled in a closed circuit during surgery).
[ ] I accept preoperative autologous blood donation (my own blood stored ahead of surgery).
[ ] I accept hemostatic agents, tranexamic acid, and synthetic volume expanders (crystalloids, colloids).

Medical Risks of Refusing Blood Transfusion

Severe anaemia: haemoglobin concentrations below 5 to 6 g/dL cause profound tissue hypoxia, leading to altered consciousness, myocardial ischaemia, cardiac arrhythmia, and multi-organ failure. Without transfusion, death may result from cardiac or neurological failure in anaemia of this severity.
Uncontrolled surgical or traumatic haemorrhage: if surgical bleeding cannot be controlled by pharmacological haemostasis, direct pressure, or electrosurgery, the patient faces a risk of haemorrhagic shock and death without allogeneic blood product replacement.
Obstetric haemorrhage: postpartum haemorrhage is a leading cause of maternal mortality worldwide. Refusal of blood products in the setting of obstetric haemorrhage substantially increases the risk of maternal death.
Coagulopathy in surgery: in the absence of FFP, cryoprecipitate, and platelet transfusions, uncontrolled coagulopathy (e.g. in hepatic failure, massive haemorrhage, or anticoagulant overdose) may lead to uncontrollable diffuse bleeding and death.
Compromised surgical planning: the attending surgical and anaesthesia team may need to modify the planned surgical approach, limit the scope of surgery, or decline certain high-risk procedures in patients with absolute blood refusal given the risk of perioperative mortality from potential haemorrhage.

Bloodless Medicine and Surgery Measures the Team Will Implement

The medical team will make every effort to minimize blood loss and optimize haemoglobin and coagulation through the following bloodless medicine strategies: preoperative iron therapy and erythropoiesis-stimulating agents to maximize haemoglobin; meticulous surgical haemostasis and minimally invasive techniques to minimize blood loss; intraoperative and postoperative cell salvage systems (autologous blood recycling) if accepted; use of antifibrinolytic agents (tranexamic acid, aminocaproic acid) to reduce surgical bleeding; permissive anaemia tolerance if haemodynamically stable; and correction of coagulation defects with accepted plasma-derived or recombinant clotting factor concentrates where available.

Release of Liability

I expressly release the attending physician, surgical team, anesthesia team, nursing staff, and healthcare facility from any liability for adverse health outcomes, complications, or death that results directly or indirectly from my refusal to accept blood or blood products. I understand that my refusal may be contrary to the medical advice of my treating team and that they bear no legal or professional responsibility for consequences arising from my autonomous decision.

Declaration of Decisional Capacity

I declare that I am of legal age (18 years or older), that I am making this decision voluntarily and free from coercion, and that I have sufficient decision-making capacity to provide this informed refusal. If I become incapacitated and unable to communicate, this document shall serve as a binding advance directive unless I have previously documented otherwise with my legal representative or healthcare proxy.

Language Access and Interpreter Services

If English is not your primary language or if you require assistance communicating, a qualified medical interpreter is available to you at no cost before you sign this document. This is a legally significant document and you have the right to fully understand it in your preferred language before signing.

Copy of Refusal Document Acknowledgment

I acknowledge that I have been offered a signed copy of this informed refusal document for my own records and advance medical directives. I understand I may request an additional copy from the facility at any time.

Signatures and Witness Verification

Patient Signature
Physician Signature (Acknowledging Refusal)
Independent Witness 1 Signature (Non-family member)
Independent Witness 2 Signature
Date and Time
Document ID: CC-PENDING
CONSENTCOLLECT