Refusing a Blood Transfusion
Mr. Whitfield, 62, is admitted with a GI bleed. Hemoglobin is 6.8 g/dL; he is pale, tachycardic at 118/min, and reports dizziness. The provider orders a transfusion of 2 units of packed red blood cells. Mr. Whitfield states clearly, 'I don't want blood. It's against my beliefs. I understand I could die.' He is alert, oriented, and has capacity. His adult son arrives and demands that the nurse 'just do it - he's not thinking straight.' The provider is in another building.
1. What is the nurse's response to the son, and what is the legal basis?
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The nurse should respect the patient's refusal and explain to the son, calmly and privately, that his father has decision-making capacity and the legal right to refuse treatment, even if that refusal could lead to death. The nurse should not attempt to override the patient or allow the son to pressure him.
Legal basis: Informed refusal is grounded in the patient's right to autonomy and self-determination. A competent adult may refuse any treatment. The son is not the decision-maker unless the patient lacks capacity and has a documented surrogate.
Reasoning: The nurse's duty is to the patient. Family pressure does not change the legal and ethical obligation to honor a capacitated refusal.
2. What must the nurse document and do to ensure the refusal is valid and safe?
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Documentation and actions:
- Confirm and document that the patient has capacity (alert, oriented, understands risks and alternatives).
- Document the refusal in the patient's own words, that risks and benefits were explained, and that the patient understands the possible consequence (death).
- Notify the provider of the refusal.
- Offer and document alternatives (e.g., iron, erythropoietin, volume expanders, close monitoring) if clinically appropriate.
- Continue monitoring and provide supportive care.
Reasoning: A valid refusal requires capacity, information, and voluntariness. Documentation protects the patient's autonomy and demonstrates that the nurse fulfilled the duty to inform and escalate.
3. The patient later becomes confused and hypotensive. How does this change the situation?
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Loss of capacity changes the decision-making framework. If the patient can no longer make informed decisions, the nurse must act to preserve life and notify the provider immediately, initiating emergency measures per protocol. The prior refusal does not automatically bind care once capacity is lost, particularly in an emergency; the surrogate decision-maker (if documented) or the provider's process for emergency treatment applies.
Reasoning: Autonomy requires capacity. When capacity is lost, beneficence and the patient's previously expressed wishes guide care, but the nurse must escalate and follow the institution's process rather than act unilaterally.