Patients needing blood transfusions should be told about risks and benefits of the procedure so they can give informed consent before it is undertaken
Transfusion of blood and blood products is a common procedure that has significant benefits but is also associated with serious risks. Patients needing blood transfusion require full information on these benefits and risks in order to make informed consent. This article, the first in a five-part series, discusses the process of gaining consent and resources available to support patients and health professionals in this.
Citation: Whitmore E et al (2014) Blood transfusions 1: gaining informed consent for blood transfusion. Nursing Times; 110: 36, 12-14.
Authors: Emma Whitmore is Patient Blood Management practitioner; Rebecca Gerrard is national lead; Kairen Coffey is education and audit lead; all at NHS Blood and Transplant Patient Blood Management Team.
- This article has been double-blind peer reviewed
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The government’s vision for the NHS is one that puts patients first, where “no decision about me, without me” is the norm. In a time of great change and scrutiny in the NHS, an ever-greater emphasis is being placed on the patient’s experience, putting the patient first, safeguarding the patient and person-centred care. At the same time, patients increasingly wish to be active participants in their own care. This article addresses fundamental aspects of patient safety and patient awareness when a blood transfusion is being considered.
The National Institute for Health and Care Excellence (NICE, 2012) recommends that “patients are supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences”; this includes blood transfusion.
Patients should be given oral and written information as well as support to allow them to actively participate in their care and self-management (NICE, 2012). This principle is at the heart of the National Blood Transfusion Committee’s (2014) Patient Blood Management (PBM) initiative. Supported by NHS England, the initiative is being promoted by NHS Blood and Transplant (NHSBT) and implemented across England and North Wales. PBM aims to ensure that patients who may need a blood transfusion as part of their treatment receive the best possible care.
The initiative recommends that:
- Any medical procedure, including blood transfusion, that takes place in a non-emergency situation, needs the patient or a representative to give informed consent;
- In an emergency, someone else may have to make this decision for the patient if the patient is incapable of giving consent;
- If the patient or relatives have any questions, concerns or objections, they have the opportunity to discuss them with a health professional before their treatment starts.
NHSBT provides a range of education resources related to transfusion, including a series of free patient-information leaflets (PILs) for adults and children. Many transfusion practitioners keep a stock of these but they are also available online; further information of how they can be obtained is outlined in Box 1. NHSBT’s PILs are designed and updated by a subgroup of the National Blood Transfusion Committee, which includes members of the NHSBT Patient Blood Management Team, transfusion consultants, hospital-based transfusion practitioners and patients. The leaflets are reviewed annually and amended to ensure they contain current and accurate information. They are classed as “controlled documents” so new editions are clearly marked with the date and version number - old versions must not be used.
In clinical situations patients may forget or misunderstand verbal explanations because they are anxious or unfamiliar with medical language. PILs provide the information needed to give them the time to consider the treatment options available and think of any questions they would like to ask.
Consent for blood transfusion
Despite the wealth of information available, patients are not always:
- Given information on the risks, benefits and alternatives to transfusion, or the right to refuse this treatment;
- Made aware they have received a transfusion;
- Made aware they can no longer donate blood as a result of this treatment. This step was implemented by all four UK Blood Services in August 2004. It is a precautionary measure against the possible risk of variant Creutzfeldt-Jakob Disease (vCJD) being transmitted by blood and blood products. This condition is thought to be the consequence of eating contaminated beef, related to bovine spongiform encephalopathy (“mad cow disease”) in UK cattle after 1980. Fortunately, vCJD is extremely rare but there is evidence that it may be transmitted from an infected blood donor to a patient, via transfusion.
There is evidence of inconsistent practice around information and consent across the UK (Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO), 2011). SaBTO advises UK government ministers and the devolved administrations, as well as UK health departments, on the most appropriate ways to ensure the safety of blood, cells, tissues and organs for transfusion or transplant. As an outcome of a public consultation in 2010, a series of recommendations were proposed and supported by the SaBTO committee relating to all aspects of consent, including:
- Clinical practice;
- Patient information;
- Health professionals’ education (SaBTO, 2011).
SaBTO recognised that the General Medical Council already has in place a generic standard for consent (GMC, 2008). However, it identified a need to strengthen the governance and the overseeing of consent for blood transfusion (SaBTO, 2011).
It is a general, legal and ethical principle that valid consent should be obtained from patients before they are treated (SaBTO, 2011). Valid consent can be defined as “an ongoing agreement by a person to receive treatment, undergo procedures or participate in research, after the risks, benefits and alternatives have been adequately explained to them” (Department of Health, 2009).
Health professionals should document valid consent for blood-component transfusion (red cells, platelets, fresh frozen plasma, cryoprecipitate and/or granulocytes) in patients’ clinical records (SaBTO, 2011). Patient do not need to give written consent, although trusts and other healthcare providers should have policies and procedures in place that explain how consent is obtained and recorded within their organisation. It is also recommended that transfusions be recorded in discharge summaries (NHSBT, 2013).
Patients who require long-term, regular transfusions - for example, those with haemoglobinopathy or haematology conditions - need to have updated information and regular reviews of consent for the transfusions they receive, reflecting any changes in the risks of transfusion or in their condition or treatment options. Details of consent requirements for these patients should be explicit in local transfusion policies (SaBTO, 2011).
Patients who are not able to give valid consent before having a transfusion - for example, in an emergency situation - should be provided with information retrospectively. This should include advice that the patient will no longer be eligible to donate blood, which should also be documented in the patient’s clinical record.
All health professionals caring for patients who may need a transfusion should be able to answer questions they may have about the transfusion process. LearnBloodTransfusion is a nationally recognised e-learning package developed by the UK Blood Services to provide regular transfusion training to all NHS health professionals involved in the transfusion process. As a direct result of the SaBTO recommendations, a new e-learning module called Consent for Transfusion is available to help health professionals ensure valid consent is obtained. This module, which has been developed by clinicians and nurses, covers the background and rationale for consent for transfusion. It should be used in conjunction with modules on Safe Transfusion Practice and Blood Components, and Indications for Use.
Individual trusts will have their own local policy on obtaining informed consent; transfusion practitioners should be able to direct health professionals to these policies and implement them.
Additional resources developed by SaBTO to help support consent for blood transfusion include:
- An action plan to support the delivery of the 2011 SaBTO recommendations on consent;
- A standardised information resource for clinicians, indicating the key issues to be discussed when obtaining consent for a blood transfusion from a patient;
- A good-practice guidance document on providing retrospective information to patients who were unable to give consent before a transfusion was carried out;
- A PowerPoint presentation developed by the NHSBT PBM Team to enable health professionals to cascade the key messages and impact of the SaBTO recommendations is available.
Further guidance on general consent is available from documents published by the GMC (2008) and Nursing and Midwifery Council (2012).
The process of involving patients in their care, informing them of the risks, benefits and alternatives to transfusion, and then obtaining their consent for treatment (including the right to refuse), should be a routine part of clinical care. Staff involved in any stage of the transfusion process must accept responsibility and accountability for the care of the patient, even if they themselves are not authorising or administering the transfusion.
- Patients have the right to take part in decisions about their treatment and should be given information to promote active participation
- NHS Blood and Transplant provides a range of transfusion-related resources
- Valid consent must be gained from a patient or their representative before treatment
- Documented valid consent is required for every blood transfusion. When this is not possible, patients should be given information retrospectively
- Involving patients in their care and obtaining consent should be a routine part of practice
Advisory Committee on the Safety of Blood, Tissues and Organs (2011) Patient Consent for Blood Transfusion.
Department of Health (2010) Equity and Excellence: Liberating the NHS.
Department of Health (2009) Reference Guide to Consent for Examination or Treatment.
General Medical Council (2008) Consent Guidance: Patients and Doctors Making Decisions Together. London:GMC.
National Blood Transfusion Committee (2014) Patient Blood Management.
National Institute for Health and Care Excellence (2012) Patient Experience in Adult NHS Services: Improving the Experience of Care for People using Adult NHS Services. Clinical Guidelines 138.
NHS Blood and Transplant (2013) Transfusion Matters: Patient Involvement and Empowerment.
Nursing and Midwifery Council (2012) Consent.