36C10A19R0063-007.pdf

Consent for Transfusion of Blood Products

Name: Last, First, Middle

A. IDENTIFICATION

Social Security Number

1. Patient name, Social Security Number and Date of Birth:

2. Decision-making capacity:

The patient HAS decision-making capacity (skip to item 3).

The patient DOES NOT HAVE decision-making capacity. Enter surrogate name and relationship to the patient. (If the patient's surrogate is not established or available, refer to Handbook 1004.1 for guidance.)

RelationshipName: Last, First, Middle

3. Name of the treatment:

Name: Last, First, Middle

4. Practitioner obtaining consent:

Name: Last, First, Middle

5. Supervising practitioner: (if applicable)

6. Additional practitioner(s) performing or supervising the treatment: (if not listed above)

B. INFORMATION ABOUT THE TREATMENT

Date of Birth

Transfusion of Blood or Blood Products

7. Reason for the treatment (diagnosis, condition, or indication):

Transfusions of blood or blood products (components of blood including plasma, platelets, red blood cells, fibrinogen, or others) are provided to increase the amount of these blood products in your blood stream when they are below a reasonable level for your health.

8. Brief description of the treatment:

Transfusions are given by vein (usually a vein in the arm) using a new sterile disposable needle. The transfusion may be made up of red blood cells, plasma, platelets or other specialized products made from blood. Your doctor will decide on the right amount and type of blood product based on your medical condition or diagnosis.

9. Potential benefits of the treatment:

Transfusion of blood or blood products may be necessary to correct low levels of blood products in your body, and may also make you feel better.

10. Known risks and side effects of the treatment:

Known risks of this treatment include, but are not limited to:

§ infection or irritation where the needle is placed § temporary reaction such as a fever, chills, or skin rashes.

Other rare but more serious complications may occur such as allergic reactions, heart failure due to fluid overload, acute pulmonary edema (fluid leaking into the lungs), shock, or death. Transfusions of blood or blood products involve a small risk of transmission of diseases such as Hepatitis B (1 in 137,000), Hepatitis C (1 in 1,000,000), and HIV/AIDS (1 in 1,900,000). There is also a small risk of bacterial infection when blood products are transfused.

11. Alternatives to the treatment:

Blood or blood products are usually provided by either a general supplier like the Red Cross or, depending on your geographic area, a local supplier may be used. Other options for the source of blood products are auto-donation (using your own previously donated blood), directed donation (blood donated by people whom you have asked to donate for you), and intraoperative salvage (your own blood collected during surgery). These options may be available if your health, time, and procedure permit. In addition, medications may be used to reduce the need for blood products. You may also choose not to have any treatment.

This consent form is to be used for blood product transfusions that are performed independent of a surgical procedure. Consent for blood product transfusion as part of a procedure should be documented in form 10-0431a.

10-0431bVA FORM

APR 2008

Practitioner obtaining consent:

§ All relevant aspects of the treatment and its alternatives (including no treatment) have been discussed with the patient (or surrogate) in language that s/he could understand. This discussion included the nature, indications, benefits, risks, side effects, and likelihood of success of each alternative.

§ The patient (or surrogate) demonstrated comprehension of the discussion.

§ I have given the patient (or surrogate) an opportunity to ask questions.

§ I did not use threats, inducements, misleading information, or make any attempt to coerce the patient/surrogate to consent to this treatment.

§ I have offered the patient (or surrogate) the opportunity to review a printed copy of the consent form.

12. Comments

C. SIGNATURES

Signature Date and Time Patient or surrogate:

§ Someone has explained this treatment/procedure and what it is for.

§ Someone has explained how this treatment could help me and things that could go wrong.

§ Someone has told me about other treatments/procedures that might be done instead, and what would happen if I have no treatment.

§ Someone has answered all my questions.

§ I know that I may refuse or change my mind about having this treatment/procedure. If I do refuse or change my mind, I will not lose my health care or any other VA benefits.

§ I have been offered the opportunity to read the consent form.

§ I choose to have this treatment.

Date and Time Signature Witnesses: No witness is required if the patient or surrogate signs their name. Two witnesses are required only when the patient's signature is indicated with an “X” or some other identifying mark.

Date and Time Signature

Date and Time Signature

Witness name (please print)

Witness name (please print)

10-0431bVA FORM

APR 2008

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs Logo.

Consent for Transfusion of Blood Products

A. IDENTIFICATION

1. Patient name, Social Security Number and Date of Birth:

2. Decision-making capacity:

4. Practitioner obtaining consent:

5. Supervising practitioner: (if applicable)

B. INFORMATION ABOUT THE TREATMENT

Transfusion of Blood or Blood Products

7. Reason for the treatment (diagnosis, condition, or indication):

Transfusions of blood or blood products (components of blood including plasma, platelets, red blood cells, fibrinogen, or others) are provided to increase the amount of these blood products in your blood stream when they are below a reasonable level for your health.

8. Brief description of the treatment:

Transfusions are given by vein (usually a vein in the arm) using a new sterile disposable needle. The transfusion may be made up of red blood cells, plasma, platelets or other specialized products made from blood. Your doctor will decide on the right amount and type of blood product based on your medical condition or diagnosis.

9. Potential benefits of the treatment:

Transfusion of blood or blood products may be necessary to correct low levels of blood products in your body, and may also make you feel better.

10. Known risks and side effects of the treatment:

Known risks of this treatment include, but are not limited to:

§ infection or irritation where the needle is placed § temporary reaction such as a fever, chills, or skin rashes.

Other rare but more serious complications may occur such as allergic reactions, heart failure due to fluid overload, acute pulmonary edema (fluid leaking into the lungs), shock, or death. Transfusions of blood or blood products involve a small risk of transmission of diseases such as Hepatitis B (1 in 137,000), Hepatitis C (1 in 1,000,000), and HIV/AIDS (1 in 1,900,000). There is also a small risk of bacterial infection when blood products are transfused.

11. Alternatives to the treatment:

Blood or blood products are usually provided by either a general supplier like the Red Cross or, depending on your geographic area, a local supplier may be used. Other options for the source of blood products are auto-donation (using your own previously donated blood), directed donation (blood donated by people whom you have asked to donate for you), and intraoperative salvage (your own blood collected during surgery). These options may be available if your health, time, and procedure permit. In addition, medications may be used to reduce the need for blood products. You may also choose not to have any treatment.

This consent form is to be used for blood product transfusions that are performed independent of a surgical procedure. Consent for blood product transfusion as part of a procedure should be documented in form 10-0431a.

10-0431b

VA FORM APR 2008

Practitioner obtaining consent:

§ All relevant aspects of the treatment and its alternatives (including no treatment) have been discussed with the patient (or surrogate) in language that s/he could understand. This discussion included the nature, indications, benefits, risks, side effects, and likelihood of success of each alternative.

§ The patient (or surrogate) demonstrated comprehension of the discussion.

§ I have given the patient (or surrogate) an opportunity to ask questions.

§ I did not use threats, inducements, misleading information, or make any attempt to coerce the patient/surrogate to consent to this treatment.

§ I have offered the patient (or surrogate) the opportunity to review a printed copy of the consent form.

C. SIGNATURES

Patient or surrogate:

§ Someone has explained this treatment/procedure and what it is for.

§ Someone has explained how this treatment could help me and things that could go wrong.

§ Someone has told me about other treatments/procedures that might be done instead, and what would happen if I have no treatment.

§ Someone has answered all my questions.

§ I know that I may refuse or change my mind about having this treatment/procedure. If I do refuse or change my mind, I will not lose my health care or any other VA benefits.

§ I have been offered the opportunity to read the consent form.

§ I choose to have this treatment.

Witnesses: No witness is required if the patient or surrogate signs their name. Two witnesses are required only when the patient's signature is indicated with an “X” or some other identifying mark.

10-0431b

VA FORM APR 2008

8.0.1291.1.339988.308172 Consent for Transfusion of Blood Products 10-0431b