Guideline CCHMC Clinical Practices Guidelines Title: Identification And Use Of Blood Conservation And Bloodless Alternatives (For Prescribers) Effective Date: 8/1/2017 Number: Guide-05 Page: 1 of 3 1.0 SCOPE This is a resource for prescribers providing medical care to adult patients or patients whose parents or guardians request that no blood products be administered during treatment at Cincinnati Children’s Hospital Medical Center (CCHMC). Standard, safe medical practices should be performed for all patients regardless of faith, and the focus should be on providing excellent clinical care in the best interest of minor patients. 2.0 DEFINITIONS 2.1. Prescriber: Healthcare providers and allied health personnel who are authorized to order a transfusion. 2.2. Jehovah’s Witness Hospital Liaison Committee: Lay persons assigned by the Jehovah’s Witness denomination to assist members regarding the issue of the use of blood products. They may provide information about alternatives to transfusion and/or contact information for providers with experience in transfusion free medicine. They are only involved when requested by patient or parent/guardian. 3.0 GUIDELINE Jehovah’s Witnesses, a Christian denomination, are the most likely population to refuse the use of blood products as a form of medical management. Jehovah’s Witnesses refusal of blood products is based on their interpretation of the Bible. Official Jehovah’s Witness Religious Organization teaching prohibits the use of whole blood, red blood cells, white blood cells, plasma and platelets. Their Religious Organization teaches that once blood loses continuity with the body, it should not be returned. This precludes preoperative autologous donation, but not intraoperative cell salvage, cardiac bypass, or normovolemic hemodilution providing the equipment is not primed with blood products. Their Religious Organization leaves the use of minor blood fractions, immune globulins, albumins, erythropoietin, and platelet fractions, to the member’s discretion. It is important to be mindful of this Religious Organization’s religious beliefs and to understand that individual members have varying commitments to official teachings. Therefore, prescribers should actively engage patients and parents/guardians in discussions of the proposed care plan and consider bloodless alternatives as potential forms of medical management. In conversation with the patient and/or family, please clarify whether any of these blood fractions or blood alternatives are acceptable: Blood Fraction or Transfusion Alternative Acceptable Unacceptable Not Applicable Erythropoietin (EPO) (stabilized with traces of albumin)
Identification and use of blood conservation and bloodless alternatives Page 2 of 3 Cryoprecipitate (contains variable amounts of human plasma) Fibrin Glue Plasma derived clotting factor concentrates including Prothrombin Complex Concentrates Albumin Rh immune globulin, intravenous gamma globulin and other gamma globulin preparations Topical Thrombin Hemostatic Agents Other_____________________________ 3.1. Upon admission to CCHMC 3.1.1. Upon admission of a Jehovah’s Witness patient/guardian family please contact the hospital chaplain for the unit or the chaplain on call. The chaplain is familiar with policies and practices related to the care of Jehovah’s Witness patients and can serve as a liaison to the family and the Jehovah’s Witness Hospital Liaison Committee. 3.1.2. Verify with the parents/guardians what blood products they are and are not willing to accept. Please review consent form #J1683 - HIC at earliest opportunity, if not already completed. 3.2. Prior to surgical procedures 3.2.1. During pre-operative evaluation of a Jehovah’s Witness patient/guardian family please contact the hospital chaplain for the unit or the chaplain on call. The chaplain is familiar with guidelines and practices related to the care of Jehovah’s Witness patients and can serve as a liaison to the family and the Jehovah’s Witness Hospital Liaison Committee. 3.2.2. Verify with the parents/guardians what blood products they are and are not willing to accept. Please review consent form #J1683 - HIC at earliest opportunity, if not already completed. 3.2.3. Review plan with anesthesiology. 3.3. Clinical strategies for managing anemia in surgical patients 3.3.1. Strategies to minimize blood loss, including iatrogenic blood loss through laboratory testing, should be considered. 3.3.2. Means of optimizing red cell production pre-operatively should also be considered. Agents, including vitamin and iron supplementation, and hormonal red cell production stimulants, can be used early with understanding of any inherent risks. 3.4. In the event of a possible blood transfusion for a minor 3.4.1. A blood transfusion should be considered if it is immediately necessary to prevent death or serious disability to a minor patient AND no other reasonable options exist. 3.4.2. Medical staff should inform the parent/guardian promptly of the situation 3.4.3. The attending physician should allow parents/guardian to seek a second medical opinion, if time permits. 3.4.4. A member of the medical staff should contact the Legal Department (call 513-636-4707) during normal business hours, or 636-4200 after-hours and asked to be connected with the legal person on-call) to discuss whether court proceedings must be initiated, if time permits. If the blood must be given without delay, the Legal Department can be contacted afterwards when time permits.
Identification and use of blood conservation and bloodless alternatives Page 3 of 3 3.4.5. The prescriber will inform the Chief of Staff and/or the Surgeon In Chief, Pastoral Care, and the administrator on call (if it is outside of business hours) to update them on the discussion regarding court proceedings. 3.5. In the event of a possible blood transfusion for an adult patients 3.5.1. If an adult patient who possesses medical decision making capacity refuses blood products, they should not be given even if it will cause death or serious disability. 3.5.2. If an adult patient lacks medical decision making capacity but has a valid living will refusing blood products, they should not be given even if it will cause death or serious disability. 3.5.3. If an adult patient lacks medical decision making capacity and does not possess a valid living will, or never possessed medical decision making capacity, a member of the medical staff should contact the Legal Department (call 513-636-4707 during normal business hours, or 636-4200 after-hours and asked to be connected with the legal person on-call). 3.6. EPIC requirements 3.6.1. If a patient is identified as Jehovah’s Witness and a provider seeks to order blood a pop up with questions will appear. A response is required before the order can be placed. 3.6.2. EPIC questions: 4.0 REFERENCES 4.1. Enter “Transfusion Alternatives” into the Centerlink search box 5.0 APPROVALS All revisions of this guideline are approved by the CPC. This guideline is reviewed every three years or sooner if deemed necessary. Authority for this document resides with the Department of Pastoral Care. This guideline is approved by the Senior Director of Pastoral Care. HISTORY Original Date 8/1/2017 Revision Date Review Date