If an incapacitated patient arrives with no family members and a card refusing blood transfusions, do we still administer a blood transfusion?

Respecting Advance Directives in Incapacitated Patients

When an incapacitated patient arrives with no family members present but has a card refusing blood transfusions, this advance directive should be respected and blood transfusions should not be administered, even in life-threatening situations. 1

Legal and Ethical Framework

The Association of Anaesthetists of Great Britain and Ireland guidelines clearly state that patients who anticipate losing capacity may prepare an "advance decision" (also known as advance directive or living will) stating which treatments they would refuse if their treating team considers them indicated 1. These advance directives must be respected as they represent the patient's autonomous choice made while they had capacity.

Key considerations:

• Advance directives are legally binding documents that express a patient's wishes regarding medical treatment
• They apply when a patient loses capacity to make decisions
• They represent the patient's right to refuse specific treatments, including blood transfusions

Decision-Making Process for Incapacitated Patients

When faced with an incapacitated patient with an advance directive refusing blood transfusions:

1. Verify the advance directive:

   • Confirm the card appears authentic
   • Check it applies to the current clinical situation
   • Verify it hasn't been revoked (though this may be difficult without family)

2. Consider alternative treatments:

   • Implement blood conservation strategies
   • Use blood alternatives if available and acceptable to the patient's documented wishes
   • Focus on other resuscitation measures that don't violate the directive

3. Document your decision-making process:

   • Record the grounds for determining incapacity
   • Document the presence of the advance directive
   • Note all treatment decisions made in light of the directive

Best Interests vs. Autonomy

While the Mental Capacity Act emphasizes making decisions in the patient's "best interests" when they lack capacity 1, an advance directive takes precedence as it represents the patient's autonomous choice made while they had capacity. The courts have made clear that best interests involve consideration of the patient's "welfare in the widest sense, not just medical but social and psychological" 1.

In this situation:

• The patient's previously expressed wishes (refusing blood) must be respected
• Medical "best interests" do not override a valid advance directive
• Respecting autonomy is paramount in this scenario

Special Considerations

Emergency Situations

Even in emergencies requiring immediate intervention, a valid advance directive refusing blood transfusions should be respected. The American Heart Association guidelines support that family members should be given options regarding presence during resuscitation 1, but this does not extend to overriding a patient's documented wishes.

Documentation Requirements

The Association of Anaesthetists guidelines specify that when a patient lacks capacity, practitioners must make a clear record of:

• The grounds for determining incapacity
• The treatment that will be undertaken
• How this treatment is in the patient's best interests 1

In this case, documentation should include the presence of the card refusing blood transfusions and how this informed treatment decisions.

Alternative Management Approaches

When blood transfusion is refused but required clinically:

• Focus on volume resuscitation with crystalloids/colloids
• Consider erythropoietic agents if time permits
• Implement blood conservation strategies
• Minimize iatrogenic blood loss
• Consider hemostatic agents for bleeding control

Pitfalls to Avoid

1. Ignoring the advance directive: This violates patient autonomy and may have legal consequences
2. Assuming family members can override an advance directive: A valid advance directive takes precedence over family wishes
3. Failing to document the decision-making process: Thorough documentation is essential in these ethically complex situations
4. Delaying other appropriate treatments: While blood transfusion may be refused, other life-saving interventions should still be provided if not specifically refused

Remember that respecting a patient's autonomous choice, even when it conflicts with what healthcare providers believe is medically indicated, is a fundamental ethical principle in medicine. The patient's right to refuse specific treatments, including blood transfusions, must be honored even when they are incapacitated if they have a valid advance directive.