Refusing a blood transfusion
A 68-year-old woman with a Jehovah's Witness background is admitted with a gastrointestinal bleed. Haemoglobin is 62 g/L, she is tachycardic at 112/min and has postural hypotension. She is alert and orientated. She states clearly that she will not accept red cell transfusion under any circumstances, including if her life is at risk, and she has a signed advance decision document. Her son, who is present, is distressed and asks the team to 'do whatever it takes' including transfusing her 'while she doesn't realise'. The consultant is off-site; the registrar is considering whether to proceed with transfusion as a life-saving measure.
1. How should the team respond to the son's request, and what is the legal and ethical status of the patient's refusal?
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Status of the refusal: A competent adult with capacity has an absolute right to refuse specific treatment, even if that refusal will lead to death. The signed advance decision reinforces this. The refusal must be respected.
Response to the son:
- Acknowledge his distress with empathy.
- Explain clearly and privately that his mother has capacity and has made a valid, informed decision that the team is legally obliged to follow.
- Make clear that transfusing her covertly would be battery/assault, a serious professional and legal breach, and would not be done.
- Offer him support (e.g. chaplaincy, patient liaison) and involve him in decisions he can contribute to.
The registrar must not proceed with transfusion against her expressed wishes, regardless of the life-saving intent.
2. Outline the alternative management you would discuss with the patient to optimise her care within her stated wishes.
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Respect the refusal while maximising non-transfusion options:
- Resuscitation: Crystalloid/colloid resuscitation, careful fluid balance, correction of coagulopathy where clinically indicated.
- Haemostasis: Urgent endoscopy for diagnosis and therapy; consider tranexamic acid; interventional radiology (embolisation) if bleeding persists.
- Anaemia support: Iron therapy, erythropoietin where appropriate, folate/B12, minimise iatrogenic blood loss (paediatric tubes, avoid unnecessary phlebotomy).
- Escalation planning: Early senior and critical care involvement; discuss ceilings of care and goals explicitly with the patient while she has capacity; document her wishes.
- Communication: Confirm and document the refusal, capacity assessment and advance decision; ensure the whole team is aware so no one inadvertently orders blood.
This demonstrates that respecting autonomy does not mean abandoning care - it means redirecting it.