Blood Transfusion Refusal

AHN will accommodate patients who opt out of receiving blood products during their care. Please complete the form below prior to a planned admission. It can also be completed after admission in the case of an emergency.

This form is an advance directive for patients who choose to decline all or specific components of blood. This document records your wishes regarding blood components, minor blood fractions, equipment, and related procedures.

For assistance with this form, please contact the AHN Office of Bloodless Medicine and Patient Blood Management at 412-359-8787.

Refusal Form

Patient Name

Date of Birth

Email Address

Phone Number

Name of Person Filling out Form

Relationship to Patient

Blood Components

Whole Blood

Contains all its original components; red blood cells, white blood cells, platelets, and plasma, with no parts having been separated or removed. Whole blood carries oxygen and allows blood clots to form to stop bleeding.

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Red Blood Cells

Are responsible for transporting oxygen from your lungs to your body's tissues. Your tissues produce energy with oxygen and release a waste, identified as carbon dioxide. Your red blood cells take the carbon dioxide waste to your lungs for you to exhale.

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Plasma

The liquid component of blood that contains clotting factors needed to stop bleeding.

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Platelets

The smallest component of your blood that control bleeding, they cluster together to form a clot and prevent bleeding at the site of an injury.

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Cryoprecipitates

Cryoprecipitates are clotting factors, including fibrinogen, taken from pooled plasma, and are used to stop bleeding. Each bag of cryoprecipitate contains about one to four teaspoons of plasma.

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White Blood Cells

Also known as leukocytes are a part of your immune system that protects your body from infection. These cells circulate through your bloodstream and tissues to respond to injury or illness by attacking any unknown organisms that enter your body.

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Minor Blood Fractions

Albumin

A protein made by the liver. Albumin helps keep fluid in the blood from leaking out into the tissue and helps maintain blood volume. A small amount of albumin may be used to buffer other medications, including some versions of erythropoietin.

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Clotting Factors

Clotting factors are proteins found in plasma and are used in some medications to help control bleeding.

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Immune Globulins

Immune globulins are antibodies and proteins that are found in plasma. They are used in medications to fight viruses and bacteria. These are also found in the tetanus vaccine and antivenom agents for patients bitten by a venomous animal.

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Erythropoietin

Erythropoietin is used in medications (erythropoiesis stimulating agents) to help build red blood cells in anemic patients, and some versions of the medication contain albumin.

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Topical Agents, Sealants and Sutures

Topical agents are medications that contain minor blood fractions, such as clotting factors, which can be applied internally or externally to control bleeding. Sealants and sutures are used in the OR, and some contain clotting factors or albumin.

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RhoGAM

RhoGAM contains immune globulins and is given to pregnant women who have a negative blood type when the baby has a positive blood type.

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Procedures and Equipment Using Your Own Blood:

Cell Saver

Cell saver is a machine used in surgery to collect blood lost during surgery from the surgical site. The blood is then filtered, washed, mixed with a blood thinner and returned to the patient in a closed circuit

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Heart-Lung Machine

This machine is used during open-heart surgery to maintain blood flow throughout the body. The blood runs through the machine, which gives it oxygen, and returns the blood to the patient’s body in a closed circuit.

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Hemodialysis

A treatment required in patients with kidney failure, where blood is removed from the body and circulated through a machine that filters and clears blood of toxins before returning the blood to the body in a closed circuit.

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Hemodilution

Blood is removed from the patient before the start of surgery and replaced with intravenous fluid (volume expander). The removed blood is stored in the same closed circuit and is returned to the patient during or at the end of surgery.

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Cell Tagging

This is a diagnostic tool that might be used to help find a bleeding source or cancer. A small amount of blood is withdrawn from the patient and mixed with nuclear material that allows for tracing through the body. The blood is then injected back into the patient for imaging.

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Epidural Blood Patch

This procedure is performed by an anesthesiologist to treat a headache that may develop after a lumbar procedure. One to two tablespoons of blood are removed from the patient and injected into the epidural space of the spine.

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Platelet Gel

Platelet gel is used in surgery to seal incisions. A small amount of the patient’s blood is removed from the cell saver machine and immediately spun to separate platelets. The platelets are then mixed with a clotting factor to form a gel, which is applied to an incision.

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Apheresis

A procedure where the patient’s blood is removed and run through a machine to separate the desired cells. The blood then flows back to the patient through an uninterrupted circuit.

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Signature

Signature (Write your Full Name here)

My signature above signifies that:

I have read this document or have had it read to me and I understand and agree to the statements in this document.
I have had the opportunity to ask questions and / or receive any additional information that I would require in order to make an informed decision.
All blanks or statements requiring completion were filled in before signed.
I fully understand the choice(s) that I have selected and accept any and all risks whether known or unknown, foreseeable or unforeseeable, including death, that may be involved.
I understand that not all listed blood components, minor blood fractions, equipment, or procedures may apply or be available at every Allegheny Health Network location.
I release all physicians, anesthesia personnel, Allegheny Health Network and its agents, servants and/or employees from any/all liability for damages that may be caused by my refusal of blood.