Blood Products & Transfusion

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Every question is optional. No one has to retell painful events, name a diagnosis, or choose a religion or identity to begin.

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Stop at any point. Nothing is sent anywhere, and nothing is shared unless the person chooses it in the sharing review.

Whose words

Record who said each thing: the person, a caregiver or surrogate, or a professional. A caregiver's needs get their own field.

Support to take part

Extra time, a quieter place, pictures, an interpreter or a trusted person can help someone say what matters. Ask what helps.

Barriers are not preferences

Cost, travel, work, housing, caring for others and digital access are written down as barriers, not as what the person wants.

Meaning, religious or not

Hope, purpose, faith, relationships and identity can be part of the conversation if the person wants. None is assumed.

• Surgeon or physician: The treatment plan and what each choice could mean.
• Anesthesiologist: Options during surgery and the risks of each.
• Patient blood management or transfusion specialist: Anemia treatment and blood-sparing methods, where such roles exist.
• Nurse: Recording choices and checking them before procedures.
• Chaplain or spiritual-care provider: Meaning, distress, hope and relationships, for people of any faith or none.
• Interpreter or communication specialist: Language and communication support so the person's own words come through.
• People the person chooses: Family, friends, or a community or faith contact, only if the person wants them. Never assumed safe, available or wanted.

Roles, titles and training differ by country and service. Not every role exists everywhere.

A small set of places chosen for contrast, not a ranking or a representative survey: Global, Japan, South Korea, Spain, Germany, Chile, Nigeria, Australia, Israel, Brazil, United States. Each example states what its source establishes and what it does not. Policy on paper is not proof that a service is available.

Guidance, not outcomes:

Shows what is written or recommended. It does not show that it is followed or what results.

Policy, not outcomes:

Shows what is written or recommended. It does not show that it is followed or what results.

Our translation:

The source is not in English. The quote is our own translation, not an official one.

Abstract only:

Read from the abstract. The full paper may add or qualify this.

Service as described:

Describes a service when the source was written. Whether it still runs is not verified.

Place from authors:

The place is taken from the authors' affiliations, not from where data were collected.

• Global · Guidance · 2024

  WHO guidance on implementing patient blood management states that consent or refusal should always be documented and that informed consent is a process of communication starting at the first encounter, not just a signed form.

  Limits: Guidance, not outcomes

  What others could learn: A care team can treat the documented decision as the output of a communication process that starts at the first encounter, rather than as a form signed once. The guidance does not say what a record of refusal should list.

  Conditions, limits and source

  Conditions that matter:

  Needs a hospital-level patient blood management task force, legal and ethics input, clinician education on shared decision-making, and a documentation process that links clinicians and patients. The guidance also asks for communication that avoids pressure to accept or to decline treatment.

  Cannot be inferred:

  Does not show that any country or hospital has adopted this process or that it changes outcomes. Does not address specific fractions, cell salvage or advance directives item by item. Says nothing about what any patient group believes.

  Limits:

  Normative guidance for ministries of health and health care organizations, not an evaluation of any program. The footnote does not say which products, fractions or procedures a record of refusal should list. The IRIS item date (2024-12-31) is the repository date issued; the document itself is dated 2024. The shorter 2021 WHO policy brief on patient blood management (10665/346655) was also read; it lists informed consent and shared decision-making as one of several principles without this detail.

  Source: World Health Organization, Guidance on implementing patient blood management to improve global blood health status (Step 12.4 'Developing a communication strategy to empower the public and patients on blood health', footnote 1 (PDF p. 78); see also step 5.3.3 'Informed consent and choice'). Where: Global. Population: Patients facing anemia, blood loss or coagulopathy, including those who decline a treatment option. Published 2024-12-31; retrieved 2026-10-11.

• Japan · Measured outcome · 2020

  In a 2017 mail survey, most Japanese lawyers (83.2%) and doctors (76.8%) answering the item called a 'relative transfusion-free' policy 'unavoidable'; 81.6% of 38 U.S. ethics committee heads called it a rights violation.

  What others could learn: Surveyed Japanese lawyers and doctors mostly saw a policy of transfusing only to save life as unavoidable, while most U.S. ethics committee heads who responded called it a rights violation. Asking a hospital early what it does if it cannot honor a patient's limits, including transfer, gives patients time to decide.

  Conditions, limits and source

  Conditions that matter:

  Hospital ethics committees or equivalent (95.0% of clinical training designation hospitals reported one), and published guidelines (about 63% of responding doctors judged government or academic guidelines not effective in clinical practice), and a transfer pathway to a hospital that can honor the patient's limits.

  Cannot be inferred:

  Not representative of Japan, of all Japanese lawyers or doctors, or of the U.S. Does not describe any patient's wishes or what the law requires. Does not show what policy any given hospital follows or that a policy is ethically or legally correct.

  Limits:

  Opinion survey with low response rates: 268 of 2,484 lawyers (10.8%), 1,080 of 4,953 Japanese questionnaires overall (21.8%), 42 of 244 U.S. committee heads (17.2%). Lawyers came from four prefectural bar associations; U.S. heads came from hospitals on a published list of leading hospitals. Refusal on religious grounds was used as one example of a clinical ethics issue. The survey reports professional opinion, not patient experience or outcomes.

  Source: Nagoya University Hospital (authors); Nagoya Journal of Medical Science, The ethics of blood transfusion refusal in clinical practice among legal and medical professions in Japan (Abstract (PubMed 32581400); policy definition and Table 7 in the PMC full text (PMC7276408), section 'Evaluation of "Relative Transfusion-Free" Policy'). Where: Japan (with U.S. comparison). Population: Japanese lawyers and doctors, and U.S. hospital ethics committee heads, asked about patients who refuse transfusion on religious principles. Published 2020-05; retrieved 2026-10-11.

• South Korea · Measured outcome · 2026

  At one Seoul center offering transfusion-free care, 21 of 205 women classed as Jehovah's Witnesses were in the high-risk hemorrhage subgroup and managed without transfusion; outcomes were comparable to matched women, with limited statistical power.

  What others could learn: At one experienced center that documents each patient's accepted and declined products before delivery and runs a blood-conservation protocol, the 21 high-risk JW women had no transfusion and outcomes comparable to matched women, with limited power. Teams could ask early in pregnancy exactly which products a patient accepts.

  Conditions, limits and source

  Conditions that matter:

  Per the Methods: at the first antenatal visit or before delivery, patients completed consent documentation that indicated refusal of transfusion and specified acceptable blood products or alternatives, recorded in the electronic medical record. Also IV iron, tranexamic acid, uterine tamponade, interventional radiology, fibrinogen concentrate and prothrombin complex, with cell salvage available for selected high-risk patients (prepared but not used).

  Cannot be inferred:

  Not generalizable to other Korean hospitals or to settings without an experienced program. Not proof that any patient is safe without transfusion. Says nothing about patients who decline blood for other reasons.

  Limits:

  Retrospective, single institution; the authors state rare outcomes such as maternal death may be underrepresented and that most participants were low to moderate risk. Differences in blood loss and severe postpartum anemia did not reach statistical significance. The study treats all women classed as Jehovah's Witnesses as refusing transfusion; individual choices about specific products are not analyzed here. The authors say power was limited by the small high-risk subgroup (21 JW women) and findings need caution. The center is described as a transfusion-free center and women often traveled from distant regions, so the sample may be selected.

  Source: Seoul National University Graduate School of Public Health (authors); Journal of Preventive Medicine and Public Health, Obstetric Outcomes of Jehovah's Witness Women Under Patient Blood Management: A Single-center, Propensity Score-Matched Cohort Study in Korea (Abstract, Results (PubMed 41531156); Methods in PMC full text (PMC13084232) describe the consent documentation). Where: South Korea (Seoul, single hospital). Population: Women with singleton pregnancies delivering 2018 to 2023; study classes 205 as Jehovah's Witnesses who refuse transfusion, compared with 601 matched others. Published 2026-03; retrieved 2026-10-11.

• Spain · Policy · 2002

  Spain's Constitutional Court annulled homicide convictions of parents whose 13-year-old refused authorized transfusions and died. Because they had let the authorities act, requiring them also to persuade him or permit transfusion contradicted the core of their religious freedom, it held.

  Limits: Policy, not outcomes · Our translation

  What others could learn: In one country's constitutional case law, a family's decision and the protective steps public authorities may take are treated separately. Because the record shows days passing between two judicial authorizations, a team could plan in advance how to reach a judge quickly if a minor's treatment is contested.

  Conditions, limits and source

  Conditions that matter:

  A functioning on-call judicial route for authorizing treatment, hospital legal support, clinicians willing to proceed or to stop when a minor strongly resists, and agreed alternatives. In this case no alternative treatment was known to the doctors.

  Cannot be inferred:

  Does not state what Spanish clinicians must do today, and does not apply to adults or to other countries. Does not describe what any family believes beyond what the Court recorded. Says nothing about current Spanish practice or any later amendment.

  Limits:

  A single 2002 ruling on parental criminal liability, not a clinical standard. In fundamento 10 the Court also said the minor's own opposition did not by itself have legal effect, because the act was irreversible; it is not a ruling that minors may refuse. The facts record a delay of several days between a first and second judicial authorization. The ruling predates Ley 41/2002 (14 November 2002). The BOE consolidated text of that law (last update published 1 March 2023) says every patient has the right to refuse treatment except in cases set by law, with refusal recorded in writing (art. 2.4), and sets rules for consent by representatives of minors (art. 9); it was read for context only and not analyzed.

  Source: Tribunal Constitucional de España (Pleno), Sentencia 154/2002, de 18 de julio (recurso de amparo 3.468/97) (Fundamentos jurídicos 15 and 17 and Fallo; BOE núm. 188, Suplemento, 7 August 2002, pp. 51-63). Where: Spain. Population: Parents of a minor who refused a prescribed transfusion; the minor. Published 2002-08-07; retrieved 2026-10-11. Source in Spanish; summarized from our own translation, not an official one.

• Germany · Reported experience · 2016

  An ethnographic study (nine months, mainly Berlin, 2010 to 2012) reports that Jehovah's Witness Hospital Liaison Committee members often helped patients seeking transfusion-free care by providing names of physicians willing to refrain from transfusion.

  Limits: Abstract only · Service as described

  What others could learn: Patient-side liaison groups can act as a referral route to clinicians and hospitals that will care without transfusion. A team could ask whether a patient wants such contact, and clinicians could know which local contacts exist before an urgent situation.

  Conditions, limits and source

  Conditions that matter:

  An organized liaison network, hospitals willing to provide transfusion-free care, and a health care policy that, as the author describes it, favors mediation over malpractice litigation. The author also argues that DRG financing and patient blood management practices work together in ways liaison committees use.

  Cannot be inferred:

  Does not show how many patients use such committees, how well they work, or that they exist outside Germany. Not a statement about all Jehovah's Witnesses or about what any patient accepts. Does not establish that physicians referred this way deliver better outcomes.

  Limits:

  Abstract only; full text not retrieved. The account rests on what committee members and others told the researcher, not on measured outcomes. The article is mainly about health care financing reform. One city, 2010 to 2012.

  Source: Adam Mickiewicz University (author); Social Science & Medicine, Health care reform and Diagnosis Related Groups in Germany: The mediating role of Hospital Liaison Committees for Jehovah's Witnesses (Abstract (PubMed 27542103)). Where: Germany (mainly Berlin). Population: Jehovah's Witnesses, including Hospital Liaison Committee members, and German physicians interviewed. Published 2016-10; retrieved 2026-10-11.

• Chile · Policy · 2018

  A 2018 review of Chilean court decisions on patients rejecting transfusion found the dominant jurisprudence did not recognize a right to refuse, with two 2008 exceptions; the few rulings after the informed consent law (Law 20.584) followed suit.

  Limits: Abstract only · Policy, not outcomes

  What others could learn: In some systems a written refusal and a signed informed consent form may not settle what happens in an emergency, because hospitals or families can still seek a court order. Teams there could tell patients early what the local legal position is and who to call.

  Conditions, limits and source

  Conditions that matter:

  Depends on how courts interpret statutory informed consent rights, whether hospitals file protection claims, and how fast courts decide.

  Cannot be inferred:

  Does not describe Chile after 2018, other Latin American countries, or what any ruling said. Not evidence about clinical outcomes. The statement that patients 'do not have such a right' is the author's reading of the cases, not a statement of statute.

  Limits:

  Abstract only; the cases, courts and dates were not read. The abstract says most cases precede Law 20.584 and that the few later cases follow the same doctrine. Secondary legal commentary, not the rulings themselves. Case law may have changed since 2018 and this was not checked.

  Source: Universidad Diego Portales (author); Revista Médica de Chile, [The jurisprudence about blood transfusion and informed consent of Jehovah witnesses] (Abstract (PubMed 30534892; Spanish-language article with English abstract)). Where: Chile. Population: Patients who rejected blood transfusion in cases brought as protection claims (the cases concerned Jehovah's Witnesses). Published 2018-07; retrieved 2026-10-11.

• Nigeria · Measured outcome · 2009

  In a low-resource hospital (authors affiliated with a Nigerian teaching hospital), 17 of 20 women who refused blood transfusion (identified as Jehovah's Witnesses) survived emergency laparotomy for ruptured uterus with hemorrhagic shock without transfusion.

  Limits: Abstract only · Place from authors

  What others could learn: A refusal documented on arrival need not rule out emergency surgery. In one low-resource setting, teams proceeded with surgery, and a care conversation can still cover surgical technique, anesthesia and other measures to limit blood loss.

  Conditions, limits and source

  Conditions that matter:

  Surgeons and anesthetists able to operate quickly and limit blood loss; the abstract does not describe iron, drugs or equipment, so those conditions are unknown.

  Cannot be inferred:

  Not representative of Nigeria. Does not show that bloodless management is as safe as transfusion in other conditions. Not a recommendation to withhold transfusion from anyone who would accept it.

  Limits:

  Small, retrospective, one hospital, abstract only. The abstract reports similar demographic and obstetric characteristics but no adjusted analysis; three of the 20 died of peritonitis; in the transfused group six died of peritonitis and one of disseminated intravascular coagulopathy. It does not list which blood-conservation measures were used. Women who reached theater alive are a selected group.

  Source: Abia State University Teaching Hospital (authors); Archives of Gynecology and Obstetrics, Lessons learned from the outcome of bloodless emergency laparotomies on Jehovah's Witness women presenting in the extremis with ruptured uterus (Abstract, Results (PubMed 18677500)). Where: Nigeria (author affiliation; study site not named in the abstract). Population: Women with ruptured uterus and hemorrhagic shock, 2000 to 2006; 20 who refused blood and 45 who were transfused. Published 2009-04; retrieved 2026-10-11.

• Australia · Measured outcome · 2018

  At a Melbourne major trauma center, 34 patients who identified as Jehovah's Witnesses were managed with several blood-sparing strategies; three received red cells and two synthetic oxygen carriers (reasons not stated). The authors found strategies applied inconsistently.

  Limits: Abstract only

  What others could learn: Trauma services could prepare a standard blood-sparing pathway and a quick way to record, at first contact, what each patient accepts. Without one, the review found use of strategies varied from patient to patient.

  Conditions, limits and source

  Conditions that matter:

  Trauma registry data, access to tranexamic acid, iron and erythropoietin, and (as the authors suggest) a shared resource for managing anemia when blood is not an option. Acceptability of products such as hemoglobin-based oxygen carriers varies by patient and must be asked.

  Cannot be inferred:

  Does not show the outcome of any one strategy. Not representative of Australian trauma care or of the National Blood Authority guidelines, which were not retrieved. Says nothing about patients who accept blood.

  Limits:

  Abstract only. Very small, descriptive, single center. The percentages in the abstract use different denominators that the abstract does not explain. The abstract does not say why three patients received red cells (for example, patient choice, capacity, or product acceptance), so it must not be read as overriding a refusal.

  Source: National Trauma Research Institute, The Alfred (authors); Vox Sanguinis, Management of injured patients who were Jehovah's Witnesses, where blood transfusion may not be an option: a retrospective review (Abstract, Results (PubMed 29392737); 'employed inconsistently' appears in the Conclusions). Where: Australia (Victoria, single trauma center). Population: Injured patients who identified as Jehovah's Witnesses, presenting January 2010 to January 2017 (n=34; 50% major trauma). Published 2018-04; retrieved 2026-10-11.

• Israel · Policy · 2002

  A 2002 article says Israel's 1996 law created statutory ethics committees that may approve treatment against a patient's will in defined emergencies or threats to life, a power once held by courts; the author says use should be rare.

  Limits: Abstract only · Policy, not outcomes

  What others could learn: A national law can move urgent override decisions from ad hoc court orders to a standing committee with defined conditions. A hospital could know in advance how to reach such a body and what it must document.

  Conditions, limits and source

  Conditions that matter:

  A standing, reachable committee (the abstract does not state availability or composition), defined emergency criteria, and clinicians who know the route.

  Cannot be inferred:

  Does not show how often committees approve treatment against a patient's will or how Israeli hospitals act today. Not evidence about other Middle East and North Africa countries.

  Limits:

  Abstract only; the statute and committee procedures were not read. Secondary 2002 article about one case. The law may have been amended since and this was not checked. The 'should be used only in extreme circumstances' view is the author's.

  Source: International Center for Health Law and Ethics, Haifa University Law School (author); Medicine and Law, Treating acute anaemia in a Jehovah's Witness in Israel: an innovative approach to a medical and legal challenge (Abstract (PubMed 12437199)). Where: Israel. Population: Patients who refuse treatment in an emergency, illustrated by one patient who refused transfusion for acute anemia. Published 2002; retrieved 2026-10-11.

• Brazil · Service described in 2026

  At a São Paulo public hospital, all 26 cardiac surgery patients (2015 to 2023) the study classes as Jehovah's Witnesses had individualized consent discussing and documenting acceptable and non-acceptable blood products and hemostatic agents.

  What others could learn: A consent conversation can go product by product and agent by agent, with the answers written in the chart before surgery, rather than treating refusal as one yes or no. The same service also stated a contingency pathway for life-threatening situations (multidisciplinary discussion and ethical review; no case arose). Whether such a pathway is lawful and fits a patient's documented wishes is a local legal and ethical question.

  Conditions, limits and source

  Conditions that matter:

  Cell salvage available to every patient in the group, selective iron or erythropoietin before surgery (10 of 26), an experienced surgeon, multidisciplinary and ethics review, and a public system with waiting times. The paper states these were routine public-hospital conditions.

  Cannot be inferred:

  Does not show what any patient or group accepts or declines, how consent is handled elsewhere in Brazil, or what Brazilian law and medical council rules require (primary legal texts were not reachable). Does not show that documentation changed outcomes. Small, single-site, not evidence of safety for rare events.

  Limits:

  Retrospective, single center and single surgeon; the consent practice is described by the authors and was not audited. The authors state that no standardized registry allowed them to determine how many patients explicitly consented to transfusion in life-threatening situations. Which products individual patients accepted is not reported. 'Transfusion' in the analysis means red blood cell transfusion only; plasma, platelets and other agents were not analyzed. All 26 had cell salvage available versus 43 of 78 controls, which the authors say may favor the first group. Outcome estimates are imprecise and described as hypothesis-generating. The paper classes participants by religion; individual choices were recorded in each chart and are not analyzed here.

  Source: Heart Institute (InCor), University of São Paulo (Brazilian Journal of Anesthesiology), Coronary artery bypass grafting in Jehovah's Witness patients: a retrospective propensity matched cohort study (Methods, 'Ethics approval and consent'). Where: Brazil (São Paulo, single public hospital). Population: 26 consecutive patients the study classes as Jehovah's Witnesses and 78 matched other patients, all adults having first-time isolated coronary artery bypass grafting. Published 2026-05-13; retrieved 2026-10-11.

• United States · Measured outcome · 2014

  At one U.S. academic hospital, 294 inpatients who did not accept allogeneic blood transfusion were compared with 1,157 matched patients who did. After risk adjustment, bloodless care did not independently predict death or morbid events.

  Limits: Service as described

  What others could learn: A program can tailor blood conservation to each person (treating anemia before surgery, reducing blood loss and draws, tolerating lower hemoglobin) and still report outcomes comparable to matched patients. The program offered hemodilution to select cancer-surgery patients who wished to avoid transfusing salvaged blood, so another setting could ask which conservation steps each person accepts and document the answers, starting before planned procedures.

  Conditions, limits and source

  Conditions that matter:

  A dedicated multidisciplinary team, iron and erythropoietin available before elective surgery, cell salvage and hemodilution capacity, small-volume (pediatric) blood draw tubes, and a blood management database for tracking. Funding and staffing are not described.

  Cannot be inferred:

  Not representative of U.S. hospitals or of other bloodless programs. Not a trial, so it does not show that the program caused the outcomes. Does not show what any individual accepts or declines beyond allogeneic transfusion, or how consent was documented. Says nothing about emergencies. Minors were held in provisional status for transfusion because the hospital could not legally deny it if life was threatened; the abstract does not address minors' outcomes separately. Does not show the program still operates in this form.

  Limits:

  One program in its first year; the authors name the sample size and the mix of medical and surgical patients as limits. Matching did not use primary diagnosis or procedure. Some patients evaluated for surgery did not have it because it was judged too risky without transfusion, so results describe those treated. Unadjusted mortality was 0.7% versus 2.7% (p = 0.046), mainly in the surgical subgroup; costs were 12% and 18% lower (total and direct), also mainly surgical. Retrospective; control patients differ in ways matching cannot remove.

  Source: Johns Hopkins Medical Institutions (Transfusion), Risk-adjusted clinical outcomes in patients enrolled in a bloodless program (PMC author manuscript, Abstract, Results). Where: United States (Maryland, one academic hospital). Population: 294 inpatients enrolled in a bloodless medicine and surgery program (196 medical, 98 surgical) and 1,157 matched controls who accepted transfusion. Of 297 enrolled, 262 (88%) were baptized Jehovah's Witnesses and 20 were minors.. Published 2014-10; retrieved 2026-10-11.

• Brazil · Measured outcome · 2010

  In a questionnaire study published in 2010, 83% of 150 Jehovah's Witnesses attending Kingdom Halls in Brazil's Federal District said dentists do not ask patients about religion, while 71% said physicians do.

  Limits: Abstract only

  What others could learn: In participants' reports, whether a clinician asks about beliefs can differ by profession, and asking about religion is not the same as asking about specific products. A care team could ask each person which products and procedures they accept, rather than infer from group membership. The authors read varied answers on blood fractions as personal understandings.

  Conditions, limits and source

  Conditions that matter:

  A routine point in the visit to ask about product acceptance in every specialty, including dental care, and a place to record each answer. Language and trust between congregation and clinic are not described.

  Cannot be inferred:

  Not representative of Brazil or of all Jehovah's Witnesses, and not a picture of current practice (2010 data). Does not show how clinicians actually behaved, only what participants said. Gives no list of products to ask about. Does not describe what any religion requires.

  Limits:

  Abstract only; full text not read and open-access status not checked. Published 2010, older than the 2015 preference, and the abstract gives no recruitment method or response rate. Participants were congregation members, not necessarily patients in treatment. Findings are self-reported accounts of clinicians' behavior. The abstract also contains the authors' statements about the basis for refusing blood and about what is permitted; this record repeats none of them and takes no position on them.

  Source: Universidade de Brasília (Revista da Associação Médica Brasileira), [Jehovah's Witnesses attitude towards hemocomponents and hemoderivatives] (PubMed abstract (English), Results). Where: Brazil (Distrito Federal). Population: 150 Jehovah's Witnesses attending Kingdom Halls (Salões do Reino); not selected as current patients. Published 2010-11; retrieved 2026-10-11.

• The sourced examples include guidance, measured outcome, policy, reported experience, service description. Each quote was matched to the source text; that is not independent expert review.
• The prompts and fictional case are original. They have not been tested with patients, caregivers or clinicians.
• Whether this workflow helps anyone is an open research question.
• Content is in English. Interface translations are not reviewed for this topic.