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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 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.

Not quite. Try again.
  • Accept
  • Refuse

Clotting Factors

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

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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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  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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. 

Not quite. Try again.
  • Accept
  • Refuse
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

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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. 

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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.

Not quite. Try again.
  • Accept
  • Refuse

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.

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.