The following points can be documented: |
Discussed the risks and benefits of accepting blood product transfusion. |
Discussed the risks and benefits of NOT accepting blood product transfusion. |
Discussed the risks and benefits of extracorporeal circulatory and salvage techniques. |
Specify whether consent was obtained privately or with family members/others present. |
Patient understands that if clinically significant bleeding cannot be stopped, then the patient will eventually die. |
Patient is aware that blood product refusal may result in organ or tissue damage or even death. |
Patient adamantly refuses the blood component therapies indicated below, even if faced with death. |
Patient realizes that with these restrictions, the care team may be forced to proceed more quickly to definitive procedures that have a chance of stopping the bleeding (bowel resection, cesarean delivery, hysterectomy, amputation, etc) (this is due to the lack of a blood "buffer" that enables the treating team to replace the blood lost during preliminary attempts at hemostasis). |
Patient understands that he or she may reverse these restrictions at ANY time and accept blood. If this occurs, the care team will abide by all patient privacy standards and not discuss the acceptance of blood products in front of family or clergy without patient consent. |
Patient was given the option to allow blood transfusion in extremis if two physicians agree that death is likely imminent. |
Another health care provider was present during the consent process or, alternatively, was present when the patient verbally acknowledged the summary of acceptable and unacceptable products and interventions. |
Patient acceptance (Yes) or refusal (No) of the following items can be documented: |
Allogenic human blood and blood components |
| Yes | No |
| Yes | No |
| Yes | No |
| Yes | No |
- White blood cells (granulocytes)
| Yes | No |
- Blood from specific donor(s)
| Yes | No |
Human blood fractions and medications that contain human blood fractions |
| Yes | No |
- Cryosupernatant ("cryo-poor plasma")
| Yes | No |
| Yes | No |
| Yes | No |
- Human immunoglobulin (eg, Rh immune globulin, IVIG)
| Yes | No |
- Plasma-derived clotting factor concentrates (eg, fibrinogen, factor VIII [F8], factor IX [F9])
| Yes | No |
- Tissue adhesives/fibrin glue
| Yes | No |
Intravenous fluids and medications not derived from human blood |
- Hydroxyethyl starch (eg, hetastarch, pentastarch)
| Yes | No |
| Yes | No |
- Recombinant clotting factor concentrates (eg, factor VIII [F8], factor IX [F9], recombinant activated factor VII [rFVIIa; rF7a])
| Yes | No |
- Recombinant erythropoietin
| Yes | No |
- Antifibrinolytic chemicals (eg, tranexamic acid, aminocaproic acid)
| Yes | No |
- Chemicals to improve clotting (eg, desmopressin [DDAVP], vitamin K)
| Yes | No |
Extracorporeal techniques for blood conservation or treatment |
- Intraoperative hemodilution
| Yes | No |
- Intraoperative blood salvage (cell saver)
| Yes | No |
- Autologous banked blood (self donation)
| Yes | No |
| Yes | No |
- Chest drainage autotransfusion
| Yes | No |
| Yes | No |
| Yes | No |
- Other: ____________________________________________
| Yes | No |