Refusal of Blood Transfusion With Hemoglobin 6.4 g/dL
A 68-year-old Jehovah's Witness is admitted with a GI bleed. Hemoglobin is 6.4 g/dL, heart rate 112, blood pressure 96/58, respirations 24, temperature 36.8°C. The client is alert and oriented, has an advance directive refusing all blood products including packed red cells, and has signed a hospital-specific refusal form. The client reports dizziness when standing and fatigue. The provider writes an order for 'type and crossmatch, transfuse 2 units PRBC.' The client's adult daughter, who is the healthcare proxy, says at the bedside, 'My mother is confused; please give her the blood, I'm making the decision.' The client turns to the nurse and says clearly, 'I know what I'm saying. No blood.'
1. How should the nurse respond to the daughter, and what is the ethical and legal reasoning?
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The nurse should acknowledge the daughter's distress, then explain that the client's own clearly expressed decision takes precedence while the client has decision-making capacity. The nurse should not administer the transfusion.
Reasoning:
- Capacity is decision-specific. This client is alert, oriented, and able to state the decision and its rationale; a proxy's authority generally activates only when the client lacks capacity.
- Refusal of a specific treatment is not equivalent to refusing all care. The nurse must continue all other interventions and should not abandon the client.
- The signed refusal form documents the decision but is not the source of the right; the client's informed choice is.
- The nurse should notify the provider that the order conflicts with the client's directive and request that the order be clarified or canceled, and involve the ethics consult team if there is continued conflict.
- The nurse should not pressure, shame, or covertly transfuse. Deception would be battery and a serious breach of trust.
Document the client's own words, the daughter's request, the provider notification, and the ethics referral.
2. The provider says, 'Just hang it; the family will sign.' What should the nurse do, and what non-transfusion measures should be anticipated?
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The nurse should decline to administer the transfusion and escalate: state that the client has capacity and has refused, request a written clarification or cancellation of the order, and notify the charge nurse and risk/ethics. If the provider insists, the nurse follows the chain of command and documents each step. Administering over a capacitated refusal is battery.
Anticipated supportive measures:
- Oxygen as needed and continuous cardiac monitoring.
- IV crystalloid resuscitation and treatment of the underlying GI bleed.
- Iron, erythropoietin, and vitamin supplementation as appropriate.
- Minimize phlebotomy losses and use pediatric tubes.
- Fall precautions, gradual position changes, and assistance with ambulation.
- Early discussion of goals of care and code status.
The nurse's role is to protect autonomy while aggressively pursuing every acceptable alternative.
3. Two hours later the client becomes lethargic and disoriented, with blood pressure 78/44 and heart rate 128. What changes, and how does the nurse proceed?
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The change is that the client may no longer have capacity; a new, acute delirium from hypoperfusion means the earlier refusal cannot be assumed to represent a current informed choice.
Nurse actions:
- Treat the physiologic emergency: call rapid response, give oxygen, start or widen IV access, and begin crystalloid boluses per protocol.
- Notify the provider immediately and request an urgent capacity assessment and ethics involvement.
- Contact the documented healthcare proxy - the daughter - and clarify the client's previously expressed wishes, including any written directive.
- Do not independently decide to transfuse. The proxy and provider, guided by the client's known wishes and hospital policy, determine the plan; the nurse advocates for the client's stated values.
- Continue all non-transfusion support and document findings, notifications, and the client's mental status over time.
Key judgment: reversible causes of incapacity must be addressed before a surrogate decision is treated as final, and the nurse's duty shifts from honoring a contemporaneous refusal to safeguarding the client's previously expressed wishes.