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Important Notice Regarding Medication Prescriptions for AHN Patients

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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

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


Refusal Form

I direct that no transfusions of:

  • Whole Blood
  • Red Cells
  • White Cells
  • Platelets
  • Plasma 

are to be given to me under any circumstances, even if physicians deem such necessary to preserve my life or health.

 

Minor Blood Fractions

Albumin

A protein made by the liver. Albumin helps keep the fluid from 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 erythropoietin (Procrit©).

 

Not quite. Try again.
  • Accept
  • Refuse

Erythropoietin

Natural erythropoietin is made by the kidneys. Recombinant (synthetic) erythropoietin is used to help build red blood cell volume in anemic patients. Procrit© (brand name) is buffered with a small amount of albumin.

 

Not quite. Try again.
  • Accept
  • Refuse

Immune Globulins

Found in some tetanus shots, also snake or spider-bite anti-venom. Used in medications to fight diphtheria, hepatitis and rabies.

 

Not quite. Try again.
  • Accept
  • Refuse

Human Derived Clotting Factor Concentrates

(may include cryoprecipitate) Used to stop bleeding and in some medical glues to seal wounds.

 

Not quite. Try again.
  • Accept
  • Refuse
Equipment

Heart-Lung Machine

Maintains circulations during surgical procedure. Diverts the patient's blood, oxygenates, and directs it back to the patient.

 

Not quite. Try again.
  • Accept
  • Refuse

Dialysis

Blood circulates through a machine that filters and cleans it before returning it to the patient.

 

Not quite. Try again.
  • Accept
  • Refuse

Hemodilution

During surgery the patient's blood is diverted into bags and replaced with a non-blood volume expander. During, or at the end of the surgery, the blood is returned to the patient.

 

Not quite. Try again.
  • Accept
  • Refuse

Intra-Operative Blood Salvage (cell saver)

Blood is recovered from an incision or body cavity during surgery, washed and filtered, and returned to the patient.

 

Not quite. Try again.
  • Accept
  • Refuse
Procedures

Cell Tagging

A small amount of blood is withdrawn; (usually about an ounce); it may be mixed with medicine, and is then returned to the patient. The time outside the body may vary.

 

Not quite. Try again.
  • Accept
  • Refuse

Epidural Blood Patch

A small amount of the patient's own blood is injected into the membrane around the spinal cord to help seal a spinal fluid leak.

 

Not quite. Try again.
  • Accept
  • Refuse

Autologous Platelet Gel

A small amount of the patient's own blood is withdrawn (usually about an ounce) and concentrated into a solution rich in platelets and white cells. This solution is placed on surgical sites or wounds. Time outside the body may vary.

 

Not quite. Try again.
  • Accept
  • Refuse
Signature

My signature above signifies that:

  1. I have read this document or have had it read to me and I understand and agree to the statements in this document.
  2. 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.
  3. All blanks or statements requiring completion were filled in before signed.
  4. 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.
  5. 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.