Informed Consent OSCE - Blood Transfusion Consent

Case Overview

• Age/Sex: 55-year-old male
• Occupation: Sedentary office manager
• Setting: Surgical ward, pre-procedure consent discussion
• Chief complaint: "They want me to sign for blood before they do anything"

Patient Script

Who I Am

I'm a 55-year-old office manager who was brought in a couple of days ago after feeling weak and having dark stools.

What Brings Me In

They said I need a blood transfusion before they do the endoscopy and wanted me to sign a consent form.

My Story

I started noticing black stools about a week ago, but I thought it was just my stomach. Over the last 3 days I've been much more tired, and I felt dizzy when I stood up for the last 2 days, so my wife brought me to hospital. I was admitted 2 days ago. They did some tests and told me my blood was very low — they said my haemoglobin was 65 g/L. The doctors here told me that they want to give me blood before doing a camera downwards (endoscopy) to find where I'm bleeding. I'm a Jehovah's Witness and I was brought up not to accept blood transfusions. I have never had blood given to me before and I don't think I want it now, but I wanted to talk it through properly before I say no.

My Medical Background

• Past medical history: none significant apart from long-term smoking (about 20 cigarettes/day)
• Medications: takes over-the-counter ibuprofen occasionally for back pain (a few times a week); no regular prescription medicines
• Allergies: none known
• Social: lives with wife, sedentary job, drinks 1–2 beers at weekends, smokes 20/day
• Family history: father had colon cancer in his 70s
• Religious/values: Jehovah's Witness — generally do not accept whole blood transfusions (I want you to ask me exactly what I would or would not accept)

What I Think & Worry About

• I think this is about my stomach bleeding and them trying to make me strong enough for tests.
• I'm worried they will give me blood against my beliefs and that I might die without it.
• I expect you to explain what the transfusion will do, what the risks are, and what alternatives there might be.

If You Ask Me About Other Symptoms...

• Chest pain: I get a bit of chest tightness when I'm breathless but no crushing chest pain (I had a bad chest infection years ago but no heart attack).
• Breathlessness: I get short of breath on small exertion over the last few days; worse than usual.
• Bleeding: Mostly black stools (old blood). No nosebleeds or haematemesis.
• Recent procedures: I had a tooth extraction last year, no problems.
• Previous transfusion: never had a blood transfusion before.
• What I might accept: I don't know exactly what blood components I would accept — some of the elders at my church said some "fractions" might be okay but I'm not sure; I want you to ask me and write it down.
• Red herrings I might mention: I had a skin rash last week that went away; I took antibiotics for a chest infection two months ago — I don't think they are related.

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Clinical Summary

Examination

• General: alert but tired, appears pale
• Observations: temperature 36.8°C; HR 110 bpm (sinus tachycardia); BP 95/60 mmHg with a postural drop of 15 mmHg; RR 18 /min; SpO2 98% on air
• Cardiorespiratory: clear chest, no added heart sounds, no signs of heart failure
• Abdomen: soft, non-tender, no palpable masses
• Per rectum: stool dark (melaena) on examination
• Other: conjunctival pallor, capillary refill slightly delayed

Investigations

• CBC: Hb 65 g/L (normocytic 82 fL), WBC 8.5 x10^9/L, Platelets 240 x10^9/L (seems consistent with acute blood loss)
• Renal function: Creatinine 90 µmol/L, eGFR >60 mL/min/1.73m2
• Coagulation: INR 1.0, APTT normal
• Iron studies: ferritin 18 µg/L (suggestive of iron deficiency if chronic component)
• Group and Save / Crossmatch: Group A, crossmatch completed for 2 units (units currently allocated)
• FOBT: positive for blood
• ECG: sinus tachycardia, no ischaemic changes

Diagnosis

• Primary: Symptomatic acute gastrointestinal blood loss with severe anaemia (Hb 65 g/L) requiring discussion of blood transfusion; significant because the patient is a Jehovah's Witness and expresses likely refusal of allogeneic blood.

  • Evidence: history of melaena for 1 week, admission 2 days ago, Hb 65 g/L, tachycardia and orthostatic hypotension consistent with symptomatic anaemia/volume loss.

• Differential diagnoses (relevant to cause of anaemia):

  • Peptic ulcer disease/upper GI bleed — consistent with melaena and acute drop in Hb
  • Lower GI sources (diverticular bleed or colorectal malignancy) — family history of colon cancer makes this a consideration
  • Chronic iron deficiency anaemia superimposed with acute bleed — low ferritin supports iron deficiency
  • Haemolysis or marrow failure — less likely given normal platelets, WBC and no haemolysis markers

Management

• Immediate/practical steps:
  • Assess decision-making capacity formally regarding transfusion consent; if capacity intact, respect his wishes.
  • Ask detailed questions about his religious stance: what specific blood components (if any) he would accept (some patients accept blood fractions, others do not) and document his explicit choices in the chart.
  • Explain clearly, in lay terms, the indication for transfusion, likely benefits (improve oxygen carrying capacity, stabilise for endoscopy), possible risks (allergic reaction, transfusion reaction, infection — small risk), and reasonable alternatives.
  • Offer alternatives where appropriate: IV iron (if time allows and acceptable), erythropoietin-stimulating agents, tranexamic acid if indicated, and measures to minimise transfusion (restrictive transfusion thresholds, endoscopic control of bleeding). Discuss feasibility and limitations given acute presentation.
  • Involve senior clinician and the surgical/gastroenterology consultant to review urgency and to support discussion.
  • Offer involvement of hospital chaplain/faith representative and the patient’s chosen community elders, if he wishes.
  • If the patient refuses transfusion and has capacity: document the refusal in the medical record (verbatim if possible), have the patient sign a refusal form, inform the team and consider escalation to the consultant and ethics/legal team if necessary.
  • Proceed with definitive management of bleeding source (urgent endoscopy as per surgical/gastroenterology plan) and close monitoring of vitals, urine output and Hb.

Key Learning Points

• Always assess capacity and obtain informed consent (or document informed refusal); consent requires explanation of benefits, risks, and reasonable alternatives.
• Respect patient autonomy: a capacitated patient may refuse even life-saving blood transfusion; document the discussion thoroughly and involve senior staff, chaplaincy, and ethics where appropriate.
• For patients who decline transfusion, explore acceptable alternatives (cell salvage, blood fractions, IV iron, erythropoietin) and tailor the acute management plan to control bleeding and optimise haemoglobin while minimizing need for transfusion.