• All patients who will likely, or, will receive a transfusion of blood components e.g.:
  
  • where transfusion might occur during a procedure where the patient is incapacitated, e.g. where blood is routinely requested before surgery
  • where a group and screen or crossmatch sample taken pre-procedure

Retrospective information

• Inform patients who were unable to give informed and valid consent before receiving a transfusion, of the transfusion provided with relevant paper or electronic information before discharge
  
  • trauma transfer patients may have had blood products at another hospital or during transfer from scene of accident

• It is the responsibility of the healthcare professional authorising transfusion (doctor/non-medical authoriser) to ensure informed and valid consent has been obtained
• Tailor consent to the individual 
  
  • e.g. depending on the clinical situation, consent may be short-term or long-term
• Emphasise shared evidence-based dialogue and decision-making element of the consent process, rather than on obtaining patient’s signature

Areas to discuss

• Indication for transfusion, including component type being advised
• Benefits e.g. symptom relief of heart failure/angina symptoms, reduction in risk of major bleeding
• Risks with mitigating actions 
  
  • human error. Emphasise importance of correct patient identification at every step of the transfusion pathway 
• Acute transfusion reactions, febrile, allergic, or hypotensive reactions -1 in 8000 (approximate risk per component risk based on UK haemovigilance data from SHOT 2011–2020) are unpredictable, so close observation 
• Respiratory complications including fluid overload
  
  • transfusion-associated circulatory overload (TACO) (1 in 25,000 with highest morbidity of all transfusion reactions)
    
    • possibly preventable
    • risk reduced through single unit policy, restrictive transfusion thresholds, TACO checklist, rate/volume of transfusion, diuretics, close observation, clinical review after each unit transfused 
  • transfusion-related acute lung injury (TRALI) (1 in 400,000. More common in plasma products. Approximate risk per component risk based on UK haemovigilance data from SHOT 2011–2020)
• Delayed transfusion reactions including:
  
  • antibody formation 
    
    • 1 in 100 risk of formation (higher if already has antibodies)
    • may impact future pregnancy (risk haemolytic disease of the fetus and newborn) and delay future transfusion availability
    • risk of haemolytic transfusion reaction is 1 in 57,000 if previous pregnancy or transfusion
    • antibody screen undertaken before every red cell transfusion
    • other risk e.g. hyperhaemolysis especially in sickle cell disease
  • transfusion related infections (e.g. bacterial, viral, other)  
    
    • bacterial contamination (very rare)
    • viral transmission (hepatitis B <1 in 1.2 million, HIV <1 in 7 million, hepatitis C <1 in 28 million)
    • yet unknown infection
    • donor screening and testing at time of donation
    • platelet culture and product recall
  • Alternative treatments available e.g. iron supplementation 
• That they can no longer be a blood donor
• Ask patient to promptly report any symptoms

• Record verbal consent provided by the patient in the patient’s records 
  
  • signed consent for transfusion is not required
• Before transfusion (or retrospectively where not possible), give patient information leaflets (PILs) to patients 
• Include details of the transfusion [type(s) of component], together with any adverse events associated with the transfusion in their hospital discharge summary

• Modified consent required
• Discuss at start of transfusion regimen followed by regular updates (minimally annually)
• Additionally include information regarding: 
  
  • iron overload
  • multiple red cell antibody formation
  • reduced response to platelet transfusion (+/- HLA/HPA antibody formation)
  • other risks (individual) e.g. hyperhaemolysis

• Some patients may refuse blood transfusion based on religious/other grounds e.g. Jehovah Witness (JW) patients 
• Patients may carry an advanced directive stating their refusal to accept blood components
  
  • legally binding and unless patient states otherwise must be adhered to
• Some JW accept use of specific cell salvage techniques and/or plasma products
• Before any surgery or planned birth, full discussion, including alternatives to transfusion and potential consequences of declining transfusion must take place between consultant and patient 
• Documented plan must be put in place to minimise risks 
• 'No blood' wristband must be worn by the patient

• Ensure patient is aware they have received a transfusion and they can no longer be a blood donor
• Include details of transfusion [type(s) of component], together with any adverse events associated with the transfusion in their hospital discharge summary