Microsoft word - cp 3-116 blood and blood component 2-10.doc
Transfusion-Free Medicine Program (TFMP): Enrollment
1. To describe the operational process for enrollment in the Transfusion-Free Medicine Program (TFMP).
2. To identify persons who refuse blood product administration and to respect their convictions regarding
1. Each patient has the right to participate actively in decisions regarding his/her medical care. To the extent
permitted by law, this includes the right to refuse treatment.
2. The facilities respect the right of the competent adult patient to refuse blood transfusions and the
administration of blood-related components and procedures.
3. Each physician and hospital employee will adhere to the ethical and legal principles involved when
4. The patient will be encouraged to make their wishes known in writing through an Advance Health Care
Directive and a signed informed refusal ("Refusal to Permit Blood Transfusion" form).
5. Patients who communicate their decision not to receive blood components at a time when they have the
capacity to make decisions and who subsequently lose their decision making capacity will have their prior expressed wishes honored. The patient's expressed decisions are not subject to change by any surrogate decision maker.
6. In emergency situations where the patient is known/believed to be a Jehovah's Witness or is
known/believed to have refused transfusion in the past but the physician has not had the opportunity to determine the patient's wishes related to blood/blood components administration, all efforts will be made to progress with treatment avoiding blood/blood components transfusion. If circumstances arise that in the physician's opinion blood/blood components are required in order to save the patient's life and the patient's wishes have not been determined - the physician will proceed in a manner that is in the best interest of the patient. In cases such as these the physician will document the critical need for transfusion and the details as to why doubt exists as to the patient's wishes related to transfusion. A copy of the critical need for transfusion must be sent to the Blood Bank before transfusion.
7. Minors or minor patients who are under guardianship will be treated in accordance with “Blood and Blood
Component Administration/Refusal: Minor Patients” Policy.
Green Sticker with "No Blood Products" Symbol
Transfusion-Free Medicine Program (TFMP): Enrollment Process
Green “Patient Refuses Blood and Blood Products” Sticker for Kardex
Product/Treatment and Procedure Acceptance Form
Refusal to Permit Blood Transfusion Form
Patient Informational Handouts: A Patient’s Guide to Blood Management Options USCUH/Norris
• Medical Record Face Sheet & Bloodless Flag
1. Pre-Operative Assessment and Center for Education (PACE)
a. If patient is seen in PACE prior to admission the PACE staff will complete the following:
i. Identify patient as a person refusing blood and/or blood products
iii. Have patient sign the “Refusal to Permit Blood Transfusion” Form. This form must be completed to
iv. Flag face sheet with “Bloodless Flag” in flag section
v. If patient requests information regarding the TFMP, provide informational handouts. If additional
information is requested contact TFMP Director at x25263.
vi. Assist patient to complete the Product/Treatment and Procedure Acceptance Form
vii. Fax completed “Refusal to Permit Blood Transfusion” Form and Product/Treatment Procedure
Acceptance Form to Blood Bank at x28746.
viii. Assemble chart and file Refusal & Product/Treatment Forms under Advance Directive tab.
ix. Send chart to pre-op by 5 pm day prior to surgery.
2. Admitting Department or Nursing Supervisor
a. Identify patient as a person refusing blood and/or blood products.
c. Have patient sign the "Refusal to Permit Blood Transfusion" form. This form must be completed to be
d. Flag face sheet with “Bloodless Flag” in flag section.
e. Provide TFMP informational handouts. If additional information is requested, contact the TFMP Director
Transfusion-Free Medicine Program (TFMP): Enrollment Process
Fax completed “Refusal to Permit Blood Transfusion Form to Blood Bank at x28746 (UH) or x50216 (Norris) and document that form was faxed.
g. Place completed form inside the green packet.
h. Obtain from the patient their signed "Durable Power of Attorney for Health Care" or AHCD form (if
available), make a copy of this form and send to nursing unit with other admission paper work. If the patient does not have this form with them, the admitting clerk will notify social services.
3. Nursing Units
a. During initial nursing assessment, confirm patient’s decision to participate in the TFMP.Ensure green
b. Respect that the Jehovah's Witness WILL NOT ACCEPT:
vii. NOTE: See attached "Jehovah's Witnesses Religious and Ethical Position on Blood."
d. Ensure that “Product/Treatment and Procedure Acceptance” Form is completed and fax completed form
to Blood Bank at x28746 (UH) or x50216 (Norris) and scan to Pharmacy.
e. Place “Refusal to Permit Blood Transfusion” and “Product/Treatment and Acceptance” Forms under
Document the patient’s transfusion free status on the Kardex using the blood products refusal sticker.
4. Operating Room
a. The following information is required to be available on the patient's medical record prior to any invasive
i. Signed "Refusal to Permit Blood Transfusion" form
ii. Green "No Blood Products" sticker on front of chart
and Procedure Acceptance” form. Transfusion-Free Medicine Program (TFMP): Enrollment Process
b. Participation in TFMP will be determined for every patient scheduled for a surgical procedure.
c. Designate "Transfusion-Free" on Surgery Schedule.
d. Post green “No Blood Products” notice on the door to the appropriate operating suite or procedure
5. Blood Bank
a. Blood Bank will identify transfusion-free/blood refusal patient according to surgery schedule in addition
to faxed “Refusal to Permit Blood” form.
b. If the blood bank technician receives a request for blood for a person designated as transfusion-free,
he/she will attempt to resolve or clarify the issue with the person ordering the transfusion. If the technician is unable to resolve the issue on their own, the director and/or supervisor of the Blood Bank will be contacted.
c. If a transfusion-free patient consents to transfusion of blood or blood components, a copy of the consent
6. Health Care Provider Expressed Concerns
In situations where a health care provider has differing opinions such that he/she is unable to provide care in accordance with the patient's convictions, that individual is to seek assistance from his/her immediate supervisor.
7. Patient Experiencing Personal Conflict/Program Dis-enrollment
a. In situations where a patient is expressing that he/she is experiencing conflict with their own prior
expressed convictions, contact Social Services and TFMP Director to visit the patient.
b. In any situation where any transfusion free patient desires transfusion, an informed consent will be
obtained by the physician/surgeon and a signed consent for blood/blood product transfusion must be obtained. This consent may be obtained using the "Authorization for and Informed Consent to Surgery or Special Diagnostic or Therapeutic Procedures." The Blood Bank will request a copy of the consent to verify prior to releasing the blood.
8. If at any point the patient changes their decision to receive blood or blood products, the medical record
will be placed in a standard chart and the green armband will be removed.
9. Admitting will be notified to remove the “Bloodless Flag” from the face sheet and print a revised face
10. Pharmacy will be notified of change in program enrollment by TFMP Director or designee.
Transfusion-Free Medicine Program (TFMP): Enrollment Process ATTACHMENT(S)
• "Jehovah's Witnesses Religious & Ethical Position on Blood"
Effective/Revision Dates for Policy # CP 3-116
06/28/2005 Tissue & Transfusion/Governing Board
12/27/2005 Tissue & Transfusion/Governing Board
Blood, blood component, blood refusal, Jehovah’s Witness, transfusion, transfusion-free
JEHOVAH'S WITNESSES RELIGIOUS & ETHICAL POSITION ON BLOOD WITNESSES DO NOT ACCEPT
Any technique that involves blood storage
WITNESSES DO ACCEPT Surgical Devices Blood-Oxygen Monitoring Devices & Techniques
Pediatric ultra-micro-sampling equipment
Volume Expanders Operative & Anesthetic Techniques for Surgery HEMOSTATIC AGENTS FOR BLEEDING/CLOTTING Topical Injectable THERAPEUTIC AGENTS & TECHNIQUES FOR ANEMIA
Perfluorocarbon solutions (Fluosol DA-20)
Granulocyte-Colony Stimulating Factor (G-CSF)
AREAS OF PERSONAL DECISION
Erythropoietin, thrombolytic enzymes (contains albumin)
Immune Globulins (minor blood fractions)
Topical Procoagulants (Tisseel, fibrin glue, thrombin)
Plasma Protein Fractions (Cryoprecipitate)
Recombinant Factor VIII, IX and VIIa (may contain human albumin)
Dialysis and Heart-Lung equipment (non-blood primed)
Intraoperative Blood Salvage (Cell Saver) where extracorporeal circulation is a closed circuit without blood storage
Plasmapheresis (without fresh frozen plasma infusion, but does contain albumin)
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