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• To understand why some patients may decline a blood transfusion
• To learn about the patient management strategies that can be used as alternatives to blood transfusion
• To enhance your knowledge of the use of blood components and how to maintain haemostasis
Blood component transfusions are a valuable clinical intervention and are widely used in healthcare. However, some patients may decline transfusion, for example if it conflicts with their religious beliefs or they are concerned about the associated risks. This article details a narrative review that was undertaken to identify what alternative patient management strategies can be used when allogeneic blood transfusion is not feasible, and to explore how these strategies can benefit individuals who decline transfusion and the broader patient population. Searches were conducted to identify articles published between 2013 and 2023. A total of 43 articles were included in the review and thematically analysed. Four main alternative approaches to transfusion were identified from the literature: blood management and conservation; early optimisation; use of synthetic compounds; and proactive management in emergencies. Applying these strategies could reduce risks and costs, enhance the overall use of blood components, and ensure a holistic approach to care and maintaining haemostasis for all patients.
Nursing Standard. doi: 10.7748/ns.2024.e12189
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Hill V (2024) Patients who decline blood component transfusion: a narrative review of alternative management strategies. Nursing Standard. doi: 10.7748/ns.2024.e12189
Published online: 16 September 2024
Blood component transfusions are used routinely in healthcare, with benefits such as increasing circulatory volume and improving oxygenation. The most common clinical indication for transfusion is low haemoglobin (Hb) (anaemia), which is associated with increased morbidity and mortality (Paone et al 2014, Shander et al 2014, Guinn et al 2015, Delaney et al 2016) and should be assessed in conjunction with an objective evaluation of the patient’s overall clinical condition (Yaddanapudi and Yaddanapudi 2014). There are two types of transfusion: autologous, where the patient’s own blood is collected and re-transfused as needed, such as during planned surgery; and allogeneic, where the patient receives blood from a compatible donor (Sam et al 2023).
Some patients will decline transfusion and healthcare professionals need to be aware of alternative management approaches to provide safe, holistic care and maintain haemostasis – the mechanism by which bleeding from a damaged vessel is stopped and the damage repaired through the activation of the clotting cascade (LaPelusa and Dave 2023). One reason for declining transfusion is that it carries inherent risks, including increased morbidity and mortality, prolonged hospital stays and infection (Spahn and Goodnough 2013). Additionally, procedural errors and adverse reactions can contribute to patients’ decisions to decline transfusions (Goodnough et al 2014). Patients may also decline transfusions due to their religious beliefs, notably Jehovah’s Witnesses, of whom there are almost 9 million worldwide (Gemelli et al 2024). Exploring alternative management strategies is crucial to mitigate risk, support patients who decline transfusion and enhance the overall use of blood components, ensuring practical and effective use of this resource without undue waste.
The narrative review detailed in this article focuses on strategies for managing individuals who decline transfusions for any reason. Drawing from the latest literature, it explores the alternative management strategies currently available, their implications for patients who decline transfusion, and their potential effect on future nursing practices. The author also provides some suggestions to guide further research, education and policy development.
To identify what alternative patient management strategies can be used when allogeneic blood transfusion is not feasible, and to explore how these strategies can benefit individuals who decline transfusion and the broader patient population.
A narrative review was selected because it provides a broader, more flexible qualitative synthesis of the literature compared with systematic reviews and meta-analyses, which are designed to answer specific research questions.
The author searched the following databases in January 2023: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and ProQuest. The following search terms were used: decline transfusion, refuse transfusion, decline blood, refuse blood, transfusion management, blood management, risk, and alternatives. Additionally, NHS Blood and Transplant, the National Institute for Health and Care Excellence (NICE) and the World Health Organization (WHO) websites were searched, since they have published guidelines on current transfusion practice.
To ensure the literature was current, the search was restricted to that published from 2013 to 2023, except for influential work and guidelines. English language, qualitative, quantitative and mixed-method studies were searched for, including case studies, clinical reports and review articles. The search primarily focused on studies discussing alternative treatments to blood transfusion and alternative clinical management strategies, alongside articles focused on those who decline blood transfusions and the rationale behind this.
The database search returned 301 articles, of which 189 were removed due to duplication and lack of relevance. This left 112 articles for screening, after which 24 were excluded. The remaining 88 articles, along with 14 articles that were identified from other sources, were assessed for eligibility and 59 of them were excluded. This resulted in a total of 43 articles that were included in the review. The author thematically analysed the articles and assessed their quality.
Four broad approaches to managing patients who decline blood component transfusions were found in the literature: blood management and conservation; early optimisation; use of synthetic compounds; and proactive management in emergencies.
Blood management and conservation is defined as a person-centred, evidence-based approach to improving outcomes through managing and preserving a patient’s blood while promoting their safety (Society for the Advancement of Patient Blood Management 2022). Goodnough et al (2014) argued that it is a key advance in transfusion care over the past half-century. Worldwide, blood management is implemented with the support of transfusion nurse specialists, who have an important role in its establishment and integration (Bielby and Moss 2018). By incorporating this approach into everyday patient care, instances of allogeneic transfusion can be reduced, thereby increasing patient safety (Gwam et al 2017).
Four primary methods of blood management and conservation were identified from the literature: acute normovolaemic haemodilution; cell salvage; preoperative autologous donation (PAD); and holistic approaches.
Acute normovolaemic haemodilution aims to minimise blood loss intraoperatively. Blood is collected using gravity into an anticoagulated bag and is replaced with a crystalloid or colloid solution to restore plasma volume, then the blood removed from the patient is reinfused at the end of the surgery (Lawson and Ralph 2015, Klein et al 2019). Lawson and Ralph (2015) and Roberts et al (2021) recommended the use of this method in those who decline transfusion for religious reasons, provided certain conditions are met, such as a continuous connection to the patient’s circulation. In a meta-analysis of surgeries, Zhou et al (2015) found that those who received acute normovolaemic haemodilution required fewer transfusions, but they recommended further studies to investigate its safety and efficacy.
Cell salvage includes collection, filtration and washing of blood lost during surgery, followed by the transfusion of the treated blood back into the patient (Goel et al 2020). According to Goel et al (2020), this method offers several advantages: it eliminates the need for blood storage, it is more cost-effective than allogeneic blood and, with pre-procedural planning, it can be used in surgeries where significant blood loss is expected.
Several articles reported that patients who declined transfusion for religious reasons accepted cell salvage if there was a continuous connection to their circulation (Jennings and Brennan 2013, Lawson and Ralph 2015, Han et al 2019, Klein et al 2019). NICE (2015) guidelines recommend its use in conjunction with tranexamic acid for surgeries where significant blood loss is expected. Jennings and Brennan (2013) and Han et al (2019) recommended cell salvage in obstetric surgeries for managing bleeding in patients who decline transfusion. Goel et al (2020) noted that the use of cell salvage has reduced in recent years and suggested this is likely due to improvements in blood management and surgical intervention; however, further research is required to confirm this.
• People may decline blood component transfusions for various reasons, including because of the risks associated with the procedure or due to their religious beliefs
• The main approaches to managing patients who decline blood component transfusions are: blood management and conservation; early optimisation; use of synthetic compounds; and proactive management in emergencies
• Blood management and conservation is a person-centred, evidence-based approach to improving outcomes through managing and preserving a patient’s blood while promoting their safety
• Early optimisation could potentially reduce allogeneic blood component transfusions for all patients if adopted as routine clinical practice
According to Goel et al (2020), PAD is an effective blood conservation method in which an individual’s blood is pre-emptively collected before elective surgery, in anticipation of their potential intraoperative needs. While the use of this method may not be possible in cases of unexpected bleeding for those who decline transfusion, PAD can prove valuable in addressing major perioperative bleeding for planned surgeries. However, Shander and Javidroozi (2015) argued that the time and resources spent on blood collection are wasted if the blood is unused. Furthermore, this procedure has the potential to induce anaemia (Vassallo et al 2015). Additionally, patients who decline transfusion for religious reasons might not accept PAD because the blood has become separated from the circulation (Klein et al 2019), so this method could only be used for patients who decline for other reasons.
Like cell salvage, the use of PAD has also reduced in recent years, likely due to various factors including the reduction in risk associated with allogeneic transfusions, improved blood management and increasing costs (Vassallo et al 2015, Goel et al 2020). However, both methods can still be considered viable options for patients who decline transfusion.
In addition to intraoperative strategies for preserving the patient’s blood, blood management and conservation includes a more holistic consideration of the patient’s haemostasis (Klein et al 2019). For example, the literature highlights several effective strategies to prevent and halt the progression of anaemia, thereby avoiding the need for transfusion. These strategies include: obtaining blood samples only when necessary; discouraging recurring blood sample orders; using paediatric sample bottles to minimise blood volume per sample; and employing point-of-care testing (Shander et al 2014, Shander and Javidroozi 2015, Klein et al 2019).
The literature revealed several proactive measures that can be taken to decrease the frequency and necessity of transfusions. Berg et al (2022) recommended antenatal optimisation of Hb for obstetric patients, starting in early gestation. The Royal College of Obstetricians and Gynaecologists (2015) endorsed the early involvement of senior specialists to plan for potential delivery complications and the optimisation of Hb with the use of oral or intravenous (IV) iron. Shander and Goodnough (2018) supported this and emphasised the importance of early preparation in case of postpartum haemorrhage. Such preparation may include determining the patient’s coagulation status early, collaborative patient planning regarding acceptable treatments and advance directives, and early administration of tranexamic acid (Shander and Goodnough 2018).
Shander and Javidroozi (2015) devised an algorithm for patient blood management, highlighting the importance of proactive anaemia screening four weeks before elective surgery to facilitate effective optimisation of Hb.
Several articles identified that early optimisation is effective for individuals who decline transfusion due to religious reasons (Lawson and Ralph 2015, Klein et al 2019, DeLoughery 2020). They recommended proactive measures to achieve optimisation before any surgical intervention, including pre-operative assessment, blood management, the use of synthetic compounds and the involvement of multidisciplinary teams.
Various medicines known as synthetic compounds may be used as alternatives to blood components. Synthetic compounds can include oral and IV iron, erythropoietin (EPO) and Hb-based oxygen carriers (HBOCs).
One primary reason for performing blood transfusions is to treat severe anaemia, which is linked to higher mortality rates (Paone et al 2014, Shander et al 2014, Guinn et al 2015, Delaney et al 2016). Treating anaemia with oral and IV iron is considered acceptable to patients who decline transfusions for religious reasons (Lawson and Ralph 2015). Klein et al (2019) recommended oral iron at least six weeks before surgery if the patient’s Hb is <130g/L. Closer to surgery, IV iron should be administered (Shander and Javidroozi 2015, Klein et al 2019). Additionally, folate and vitamin B12 replacement can be used to help treat anaemia and optimise Hb (Resar and Frank 2014, Langhi et al 2018).
Anaemia can also be treated with EPO (Paone et al 2014, Shander et al 2014, Guinn et al 2015, Delaney et al 2016) – a glycoprotein hormone that regulates the production of red blood cells in the body (Ifeanyi 2015). However, NICE (2015) guidelines state that EPO should only be offered to reduce the need for blood transfusion in patients undergoing surgery if the patient has anaemia and declines blood transfusion despite meeting the criteria for it, or if the appropriate blood type is unavailable for transfusion. Consequently, this has resulted in limited use of EPO in the UK. The Royal College of Obstetricians and Gynaecologists (2015) recommend only using EPO in clinical trials or under the expert advice of a haematologist.
Nevertheless, several studies have demonstrated that the use of EPO has been beneficial in reducing or avoiding the need for allogeneic transfusion (Duce et al 2018, Shander and Goodnough 2018, Cho et al 2019). Shander and Goodnough (2018) argued it is essential for Hb recovery. Moreover, Duce et al (2018) advocated for EPO use preoperatively in patients who are anaemic and decline transfusion for religious reasons, while Cho et al (2019) recommended EPO administration to increase Hb and avoid allogeneic blood perioperatively. However, the use of EPO requires frequent injections over several weeks to induce a rise in Hb (NICE 2014); therefore, while it may be beneficial for early optimisation, it is less useful in emergencies.
HBOCs are synthetic alternatives to red blood cells. They are synthesised from chemically modified human or bovine Hb, or developed through genetic engineering (Meng et al 2018), and can be acceptable to those who decline transfusion for religious reasons (Lawson and Ralph 2015, Weiskopf et al 2017). Although there have been many attempts to recreate a human blood substitute, no such product is widely accepted or used at present (Chen et al 2023). Weiskopf and Silverman (2013) identified that a small number of countries had licensed HBOCs, but many of these products have since been discontinued due to their associated risks – primarily toxicity that may potentially lead to myocardial infarction and pulmonary hypertension (Chand et al 2014, Charbe et al 2022).
Despite these risks, in patients with severe anaemia who are haemorrhaging and are at risk of severe or fatal tissue hypoxia, HBOCs may be considered a viable alternative to blood (Weiskopf et al 2017). Further research is required in this area since the benefits of HBOCs have only been demonstrated by laboratory experiments, and many of them are still undergoing clinical trials in humans (Weiskopf et al 2017, Chen et al 2023). Furthermore, no HBOC has been approved by any British, European or US regulatory body following studies and trials (Belcher et al 2020).
During emergencies or significant haemorrhage scenarios, navigating management without resorting to a blood transfusion becomes challenging. Obstetric haemorrhage is the world’s leading cause of maternal mortality (Berg et al 2022), responsible for almost one quarter of maternal deaths worldwide (WHO 2012). Berg et al (2022) reviewed 52 years’ worth of data on women during labour who declined blood components for religious reasons and identified 15 deaths from haemorrhage. They recommended a low threshold for surgical intervention for patients who cannot be transfused, with hysterectomy considered the primary treatment for those whose Hb level drops below 8-9g/dL (Berg et al 2022). Kim et al (2015) supported this recommendation for those who decline blood component transfusion, and suggested caesarean section, hysterectomy, volume expanders, EPO, tranexamic acid, IV iron and intensive care admission to stop the bleeding, replace volume and provide appropriate aftercare to improve the patient’s chances of survival.
During a haemorrhage, Shander and Goodnough (2018) recommended first stopping the cause of the bleeding. Lawson and Ralph (2015) suggested stopping anticoagulants and replacing deficient clotting factors preoperatively, as well as using vasopressors and volume replacement perioperatively based on the patient’s clinical presentation. Jennings and Brennan (2013) recommended cell salvage in obstetric emergencies.
Multiple pharmacological agents and patient monitoring techniques may be available for use in an emergency, including prothrombin complex concentrate, recombinant factor VIIa, fibrinogen concentrate, thrombopoietin receptor agonists, interventional radiology and thromboelastography (Klein et al 2019, DeLoughery 2020). However, further research is required to determine how frequently they are used and their effect on patient outcomes. Weiskopf et al (2017) argued that when red blood cell transfusion is not an option, HBOCs could be used in life-threatening circumstances; however, clinical trials necessary to prove this remain ongoing (Chen et al 2023).
The British Medical Association (2019) states that, in urgent situations and emergencies, immediate treatment may be necessary when a patient’s wishes are unknown. In such cases, best interests assessments and decisions are used to decide the most appropriate care plan. It is important to involve everyone caring for the individual in the decision and to identify the primary person or people responsible for making the final decision – this will usually be the patient’s assigned doctor. Family members or next of kin cannot legally make such decisions unless designated as a health and welfare attorney or court-appointed deputy, although they must be involved in these decisions. All information about a person’s wishes, feelings, beliefs and current experiences must be carefully weighed against the clinical options and their risks and benefits. The patient’s known views should be given significant consideration, and any deviation from their expressed wishes needs to be justified. In such cases, appropriate support must be provided to individuals who have received a transfusion that they might have otherwise declined (British Medical Association 2019).
This narrative review identified several alternative approaches to managing patients who decline blood transfusion. Patient blood management has emerged as the predominantly used and widely accepted strategy in Europe, the US and Australia, and is recognised for its holistic approach to maintaining haemostasis (Bielby and Moss 2018, Society for the Advancement of Patient Blood Management 2022). This approach can prevent anaemia, thereby reducing the need for transfusions and minimising the demand for blood components while mitigating the risks associated with allogeneic transfusions, such as virus transmission and adverse reactions (Sam et al 2023).
The use of synthetic compounds can reduce instances of allogeneic and autologous blood transfusion and the associated complications (Spahn and Goodnough 2013, Lawson and Ralph 2015, Duce et al 2018). Patients who decline transfusion for religious reasons will usually accept synthetic compounds, suggesting it is a viable option for them (Lawson and Ralph 2015, Duce et al 2018). However, further research and trials are required before some synthetic compounds such as HBOCs can be widely used.
Early optimisation may be beneficial for patients who decline transfusion at the beginning of their care. Antenatal optimisation of Hb, using oral or IV iron, early determination of coagulation status, collaborative patient planning, advance directives, early administration of tranexamic acid, preoperative assessment, blood management, synthetic compounds and multidisciplinary team involvement have all been shown to be beneficial in reducing the need for allogeneic transfusion (Lawson and Ralph 2015, Royal College of Obstetricians and Gynaecologists 2015, Shander and Goodnough 2018, Klein et al 2019, DeLoughery 2020, Berg et al 2022). Early optimisation could potentially reduce allogeneic blood component transfusions for all patients if adopted as routine clinical practice.
In emergencies, early optimisation strategies cannot be employed, and the optimal strategy for correcting critically low blood volume includes blood component transfusion (Shander et al 2014). Patients who decline this procedure might not survive a major haemorrhage. Nevertheless, proactive strategies for minimising bleeding can be used, such as a low threshold for surgical intervention, with hysterectomy as the primary treatment for severe bleeding and anaemia (Berg et al 2022). Additionally, volume expanders, EPO, tranexamic acid, IV iron and intensive care admission can preserve life and improve outcomes (Kim et al 2015). Understanding and applying these strategies could increase patients’ chances of survival in emergencies.
This review focused on alternative management strategies for patients who decline transfusion. However, these strategies can also be applied to the broader patient population to minimise the use of blood components. Doing so could preserve this valuable resource for situations where no alternative options are available, and may reduce the associated risks, costs and potential conflicts with patient preferences. Nurses who are aware of these strategies will be able to provide person-centred care, working in partnership with individuals and respecting their right to decline treatment (Nursing and Midwifery Council 2018).
Furthermore, much of the literature focuses on patients who decline transfusions for religious reasons, particularly Jehovah’s Witnesses. However, patients may also decline for personal or moral reasons (Han et al 2019) or due to concerns about the associated risks (Klein et al 2019). Understanding these other reasons for declining transfusion can support a person-centred and holistic approach to transfusion care.
Further research is needed to improve the understanding and effectiveness of alternative strategies to blood component transfusions for all patients. Nurses and other healthcare professionals who are well-informed about these alternatives and how to integrate them into each patient’s care plan could empower patients to make informed decisions about their care.
Compared with other types of review, narrative reviews use a less structured approach to literature searching and selection, which may have led to the omission of some relevant articles. There was also a risk of potential bias in the author’s interpretation of the findings. Another limitation was the lack of evidence found on patients who decline transfusion for reasons other than religious beliefs. Finally, the included articles were analysed qualitatively and not quantitatively, making this review challenging to replicate in the future.
This narrative review identified the main strategies used to manage patients who decline blood component transfusions for any reason. Patient blood management, the use of synthetic compounds, early optimisation and proactive management in emergencies can collectively contribute to minimising the need for blood component transfusions. When integrated into the patient’s care, these approaches can benefit all those who decline transfusions.
Knowledge of such alternative management strategies and techniques is essential for healthcare professionals, including nurses. All healthcare professionals need to use a person-centred approach in conjunction with their clinical expertise and judgement to implement safe and effective care. The findings of this review could influence healthcare education and the development of policies to incorporate the strategies discussed into everyday practice.
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