Background
Overview
Some Jehovah’s Witnesses believe that blood removed from the body should be disposed of, meaning they cannot accept donated or auto-transfused blood. Some people permit dialysis or cardiopulmonary bypass as long as there is a continuous blood circuit and no blood leaves the system. Never make assumptions and each patient requires individual discussions to determine what is acceptable to them.
Decisions regarding blood transfusions by Jehovah’s Witnesses, like all things in healthcare, must be kept confidential and stay between the patient and the medical team. Some Jehovah’s Witnesses may not believe that receiving blood products is against their religion, whereas others may not believe the same. This may lead to expulsion from their congregation.
What could be acceptable?
Whole blood, fresh frozen plasma, packed red cells, or autologous transfusions are generally rejected, but exceptions can include albumin, immunoglobulins, or replacement clotting factors. Always explore what is acceptable to the patient and consider whether they have an Advanced Decision.
You should be aware of alternative options that may be acceptable, such as recombinant erythropoietin or intravenous iron infusions.
Ethics and law
Just like any other healthcare scenario, if a person has the capacity to consent, then they have the right to refuse treatment, even if this seems unwise and may lead to death. However, your ethical and legal responsibilities do not change. You must ensure that the patient knows the benefits, risks, and the risks of serious complications including death, along with possible alternatives.
If you were to refuse to treat the patient, this would only be appropriate if this posed no additional risk to the patient you can arrange for another colleague to take over their care as soon as possible.
OSCE Tips and Scenarios
Tips for the station
These stations are an extension of testing your ability to assess capacity.
Never make assumptions: having dementia or any other condition that could predispose to lacking capacity does not mean they lack capacity. You must assess capacity each time for every decision, as it is decision-specific.
Use a systematic approach: follow a structured approach when assessing a person’s capacity, working through each principle discussed above. The examiner may ask you to present your capacity assessment, and doing this systematically shows your understanding of the process and ensures nothing is missed. For example “I feel this patient lacks capacity because they cannot understand the information, retain it long enough to make a decision, and cannot weigh up its pros and cons. Even though they can communicate their decision, they do not have capacity as all of these have not been met”. Also re-iterate that you would assess capacity for each intervention separately, as capacity is decision-specific.
Be clear about serious complications and death, don’t beat around the bush: you must actively explore their understanding of serious and life-threatening risks including death. During the station, these phrases, including saying ‘death’ outright, must be said. Being unclear about this may instantly fail you. Discussing death can be awkward or difficult to articulate nicely, however, it is something that must be discussed.
Know what you would do next and the limits of your competence: don’t offer something you are not able to do, and when discussing the next steps, always remember whether you need to discuss this with a senior or another team.
Mistakes people make
Some mistakes made include:
- Not exploring patient perspectives: failing to explore the background leading up to now, the patient’s viewpoints and concerns, and not acknowledging these.
- Not exploring patient expectations and negotiating: failing to explore the patient’s expectations and preferences, and failing to negotiate and suggest a plan of action.
- Lack of clear consultation closure: failing to conclude the consultation with a clear plan moving forward and leaving patients uncertain about the next steps.
- Monologuing and/or jargon: engaging in one-sided communication rather than facilitating dialogue and discussion with understandable language.
- Inadequate responses to questions: struggling to confidently and accurately questions that arise and failing to address concerns, leading to confusion and dissatisfaction.
- Failing to mention death: explaining that a possible decision carries the risk of death can be tricky, however, it is essential the patient understands this risk in scenarios where it may be a possibility and must be said. Do not paraphrase this (e.g. ‘pass away’) and be clear, using the word ‘death’.
- A lack of knowledge and an over-reliance on seniors and leaflets: depending excessively on senior advice or leaflets to compensate for knowledge gaps and underestimating their responsibility in patient care.
- Not understanding professional limits: offering to perform tasks beyond their grade level and not knowing the limits of their competence.
Key Communication Skills
Explaining
Never launch into explaining straight away: keep things patient-centred and use ideas, concerns, and expectations (ICE) throughout. Try to avoid collecting them all at the start and instead, ask about them and address them as they arise.
Chunk and check understanding: after each segment of information, ask if they understand, such as by asking “Does that make sense?” and “Is there anything else you’d like to ask about that part?”.
Avoid all medical jargon – explain everything in words that the general public would understand (e.g. saying an ‘underactive thyroid’ instead of ‘hypothyroidism’).
Be honest, clear, and sensitive, and never beat around the bush: everything the patient needs to know must be said, however, this should be done sensitively. This includes explaining the risks of serious or life-threatening complications and death and actively saying these words.
Empathy
Empathise appropriately and put a positive spin where possible: reflect the patient’s emotions and give reassurance, but do not give false reassurance or promise something you can’t guarantee. Also, reassure the patient that you’ll try your best to help them. For example, if a patient says they are worried about their diagnosis, you could say “It is natural to be worried about a new diagnosis, but we are here to help and address any concerns you might have”.
Acknowledge their feelings but avoid collusion: for example, if a patient is angry towards a colleague, you could say “I can how this situation can make you feel that way”. Avoid taking sides.
Consider the need for a breaking bad news approach: always explore the events leading up to the current situation to gauge what the patient knows and has experienced before explaining anything. For example, a patient has had a series of tests for possible cancer and is anxious about the result but does not know why they were given the tests.
Approach
Introduction
- Wash your hands and introduce yourself: your full name and role:
- Confirm their identity: their full name, date of birth, and preferred name.
- Explain the purpose of the conversation and gain consent: “I’d like to discuss blood transfusions with you. Is that alright?”
- Ask if they would like family, friends, or a religious advisor present: they may be able to provide support with making a decision.
Background
Explore their background:
- Events leading up to now: what has happened so far?
- Their current feelings: how are they feeling now?
Explore their understanding and ICE:
- Understanding: what is their understanding of what’s going on?
- Ideas and concerns: is there anything they are worried about?
- Expectations: what would they like from this consultation?
- Confirm the direction of the conversation: “I would like to discuss your care and get a better understanding of your perspective. Is that alright?”
Explanation and discussion
Transfusions
Explore their understanding and offer to explain, tailoring this according to their ICE and understanding:
- Likely diagnosis: what do they think is going on?
- Transfusion indications: do they know why a transfusion is indicated? Explain that they may feel unwell due to a reduced amount of blood components. For example, anaemia may be contributing to the symptoms they are experiencing.
- Why a transfusion is recommended: explain that the transfusion is the best way to replace blood relatively quickly.
- How do they feel about this and why? – if they haven’t already mentioned.
- Risks of refusal: explain the risks, which can include:
- Their conditioning worsening.
- Complications could arise during a procedure that would need blood (e.g. a hysterectomy).
- Intensive care admission (ICU)
- Death – do not beat around the bush and specifically say this. You may fail instantly if you do not get this across.
- Advanced directive: do they have one? This may have their wishes noted.
Their beliefs
Explore their specific beliefs:
- Acceptable methods: what is acceptable to the patient? (depends on the acuity of the situation):
- Blood products: whole blood, red cells, or platelets?
- Their own blood: using their own blood collected beforehand?
- Cell salvage: collecting blood that may be lost during the procedure?
- Cardiopulmonary bypass: pumping the blood into an external machine and then back to the body?
- Erythropoietin: a hormone that promotes the development of red blood cells?
Negotiations and problem resolution
Suggest some potential compromises, however, do not make promises:
- Pre-operative iron supplements: they could take these before the operation.
- Erythropoietin: we could try discussing with haematology to see if erythropoietin may be appropriate.
- Discussing with Jehovah’s Witness Hospital Liaison Committees: they can help with suggesting permissible options.
- Offer a discussion with your senior.
Their decision
If they still decline:
- Confirm this decision and re-iterate serious risks including death: “Just to confirm, you would refuse the transfusion even if it could prevent death?”
- Signing a separate consent form: inform them that they will have to sign a separate consent form for Jehovah’s Witnesses.
- Inform them you will let their GP know.
- Inform them of their choices: they have a right to list what they are not happy with.
- Reassure them: declining one part of treatment does not mean they will not have proper care, including other treatments. The team will do their best to support them.
Summary and concluding
Summarise and clarify what has been discussed:
- Confirm what has been said, including acknowledging the risks: “So to summarise, you would not like to undergo this intervention and know the risks of doing so, including the risk of death?”.
- Stress that the final decision is against medical advice and lies with them.
Check understanding and ICE:
- ICE: has this been addressed/acknowledged?
- Invite them to ask questions: do they have any?
Advise on self-care measures:
- Safety netting: tell the patient what signs and symptoms to look out for and what to do if they arise. Be specific and avoid being vague (e.g. do not say “If you feel worse, come back”, tell them specific scenarios and where to go).
- Preventing problem recurrence/worsening: such as stopping smoking, taking medication as instructed etc. and offering to help with these.
When finishing:
- Senior discussion: inform them that you will have to discuss this with a senior first.
- Offer time to think: if possible, give them time to think about their decision.
- Let them know they can change their mind: remind them that they can get in touch if they change their mind.
- Offer leaflets, early follow-up, and a future contact: such as yourself or another relevant team member.
- Thank the patient and document the discussion.
