We do the sorting. You do the medicine.
OSCE: actor and procedure stations · Core05 / 22

Jehovah's Witness refusing blood before revision hipActor: a 64-year-old woman, a Jehovah's Witness, booked for revision hip arthroplasty with high expected blood loss

Actor: refusal of blood, advance decision and blood-sparing options

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Any adult with capacity may refuse transfusion, whatever the reason.
  • Discuss each product with her directly, not through relatives, and document it.
  • Some accept albumin, factor concentrates, or salvage and ANH kept in a continuous circuit.
  • Optimise Hb first: high-dose erythropoietin, IV iron, B12 and folate.
  • Minors: an urgent court application is appropriate.

The patient

Actor: a 64-year-old woman, a Jehovah's Witness, booked for revision hip arthroplasty with high expected blood loss. She has capacity and carries an advance decision refusing blood. Her son waits outside. Hb 104 g/L. Task: discuss blood and blood-sparing options and agree a plan.

The examiner asks

Answer aloud, then press Show.

  1. Open

    How do you open?

    Show the answerHide the answer
    • I'm meeting her before a bloody revision hip operation, to plan her care without blood. Patient
    • Would you be happy to talk with just me first? Your son can join later if you like. Communication
    • Tell me what you will and won't accept. Beliefs differ, so I want your own view.

  2. Explain

    Go through the options with her.

    Show the answerHide the answer
    • Revision hips can bleed heavily, so let's go product by product and record your wishes. (Communication)
    • Red cells, plasma and platelets: would you accept any of these, even to save your life?
    • Albumin or clotting factors made from blood: some Witnesses accept these. Would you?
    • Cell salvage returns your own blood through a closed loop. Is that acceptable to you?
    • Before surgery, iron through a drip and a medicine that helps your body make blood will raise your blood count.
    • On the day: a senior surgeon, careful technique, and tranexamic acid to reduce bleeding.

  3. Respond

    She asks: 'What happens if I'm dying from bleeding?'

    Show the answerHide the answer
    • I'll be honest: with severe bleeding, refusing blood could mean you die. (Communication)
    • We would use every other measure, but we would respect your decision and not transfuse.
    • Knowing that, is this still your choice? You can change your mind at any time.

  4. Respond

    Later her son comes in and urges her to accept blood.

    Show the answerHide the answer
    • I can see how worried you are for your mother. That's natural. (Communication)
    • She has full capacity, so the choice is hers. Consent can't be obtained by pressure.
    • Could I speak with her alone again, to be sure this is still her own decision?

  5. Close

    How do you close?

    Show the answerHide the answer
    • I'll record each product you accept or refuse, and file your advance decision in your notes. Communication
    • With your permission, I'll contact the Hospital Liaison Committee to support the plan.
    • If anyone on the team couldn't follow your wishes, we'd find someone who can.
    • I tell the surgeon, theatre team and blood bank that she is not to receive blood. After surgery

Fatal mistakes

  • Transfusing against a valid refusal.
  • Coercion, or letting family pressure decide.
  • Not discussing each product one by one.

Checked against: Miller 10e · Barash 9e · Saudi Guidelines for Informed Consent, First Edition 1440H (2019)

Report a problem with this case

Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.

All OSCE: actor and procedure stations casesBack to today