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*2CNTT* 2CNTT 08/19/2019
In connec
tion with my medical condition (low
blood count, decreased ability for blood to clot or other
blood related disorder) and/or the treatment that I wish to
have, Dr. ___________________ has talked with me about
the possible consequences of refusing blood and/or blood
products. Bleeding and/or severe anemia could put my life in danger. It could cause permanent brain damage or
other great danger to my health. I understand that in such a situation, substitutes for blood or plasma might not
work well enough. Blood and/or blood products might offer the only chance to preserve my life.
I refuse to allow any doctor to administer blood and/or blood products to me. I am aware that:
1) Bleedi
ng or problems in my blood could cause my death, permanent brain damage, or other injury;
2) UPMC does
make blood and/or blood products available as a treatment;
3) My condition may require blood and/or blood products to prevent or reduce the risk of death,
permanent brain damage, or other injury;
4) Blood subs
titutes do not have the same properties as blood and/or blood products. Blood substitutes
may not be sufficient to prevent death, permanent brain damage, or other injury;
5) I may
not be conscious and able to respond when my doctors become aware that it is necessary or
advisable for me to receive blood and/or blood products;
6) My doctor
s cannot tell for sure right now if I will need blood and/or blood products during any part of
my treatment;
7) As with o
ther forms of medical treatment, receiving blood and/or blood products may have certain
risks. Not receiving blood and/or blood products could result in much greater risks to my life and well
being; and
8) Neith
er UPMC nor its doctors can guarantee my survival, state of health, or the availability of a cure --
whether or not I receive blood and/or blood products.
I fully accept responsibility for my decision. I hereby release the attending physician, Dr. ______________,
UPMC, its affiliates and their directors, officers, employees, agents, nurses, and all physicians and health care
providers in any way connected with my treatment from all claims or liability including claims resulting from
death or disability which may result from their following
Facility: _____________________________
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my express directions not to administer blood and/or
blood products transfusions in connection with my
I understand that a consult service is available at
877.674.7111 to assist with any questions I or my
clinical providers may have regarding blood and/or blood products transfusion
The following are my wishes and directions regarding blood and blood products.
Please Circle
Whole Blood Components
Accept Refuse Red blood cells/White blood cells
Accept Refuse Platelets
Accept Refuse Plasma/FFP
Conscience Matters: Fractions
Accept Refuse Albumin
Accept Refuse Immune Globulins
Accept Refuse Clotting Factors (i.e. fibrinogen, cryoprecipitate)
Conscience Matters: Medical procedures that use the patient’s own blood
Accept Refuse Apheresis
Accept Refuse Auto-transfusion (Cell Saver, cell salvage)
Accept Refuse Dialysis (i.e. renal dialysis, hemodialysis)
Accept Refuse Epidural Blood Patch
Accept Refuse Heart and Lung Machine
Accept Refuse Hemodilution
Accept Refuse Platelet Gel
Conscience Matters: Medications given to help the patient’s body make more red blood cells
Accept Refuse Erythropoietin (with albumin)
Accept Refuse Erythropoietin (without albumin)
Intending t
o be legally bound, hereby I do execute the aforesaid release this _____ day of
_________________________, ________.
Signed: ______________________________
Signature of Witness
__________ ____________
Date Time
Facility: _____________________________
click to sign
click to edit
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Execute if a
n interpreter is provided to assist the individual in understanding this informed consent form:
I have translated the information and advice presented orally to the individual to be treated by the person obtaining this
consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
Cyracom ID (if applicable)
Print Name
Signature (Not required if a Cyracom Interpreter Was Used)
Facility: _______________________________
click to sign
click to edit
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Glossary of Terms: Personal Choice of Blood Products and Procedures
Whole B
lood- Whole blood is made up of four main components: Plasma (FFP), Red Blood Cells, White
Blood Cells, and Platelets. Blood carries oxygen and nutrients to the lungs and body tissues.
Albumin- Albumin is a protein made by the liver and flows in the plasma. Albumin is sometimes used to
replace liquid when bleeding occurs, as in severe injuries or burns.
Immune Globulins- Immune Globulins, also called antibodies, are proteins that flow in the plasma. These
proteins are important because they fight viruses and bacteria in the body. Sometimes these antibodies are used
in medicines that fight disease, examples of immune globulins are, IgG, IgA, IgM.
Clotting Factors- Clotting factors are proteins that flow in the plasma and help blood to make clots that stop
bleeding. Some patients who tend to bleed more easily are given special clotting factors.
Examples of Clotting Factors: Cryoprecipitate, Fibrinogen.
Apheresis- Apheresis is a treatment for certain diseases when a patients antibodies are attacking his or her
own immune system. A machine removes the bad plasma and replaces it with a good plasma substitute.
Also called: Plasma exchange, plasmapheresis
Question to Ask Your Doctor: Can albumin be used as the substitute?
Auto-Transfusion- Blood is drawn from the surgical site into a continuous flow system and is then washed and
filtered and returned into the patient.
Other names: Cell Saver, Cell Salvage, Salvaged autologous blood
Dialysis- Dialysis uses a machine to act as an organ. Blood flows through the machine in a closed system and
filters and cleans it before returning it to the patient.
Other names: renal dialysis, hemodialysis
Epidural Blood Patch- An epidural blood patch stops spinal fluid leakage. A small amount of a patient’s own
blood is injected into the tissue around the spinal cord. The clotting factors in the blood will help to seal the
ropoietin- Erythropoietin is an injected medicine to help a patient’s own bone marrow produce more red
blood cells. Some brands of erythropoietin contain small amounts of albumin. Other names: recombinant
erythropoietin, EPO, hematopoietin, erythropoietin-stimulating agent, ESA.
t and Lung Machine- The heart and lung machine keeps the patient’s blood moving during certain
surgeries. Blood is directed into a machine where it picks up oxygen and is sent back into the patient. The flow
of blood is in a closed system and is primed with a non-blood fluid.
ilution- Hemodilution is a process that helps to reduce blood loss during surgery. The patient’s blood is
collected into a closed system bag and is replaced with a non-blood fluid. After surgery, the patient’s own blood
is returned to his or her body.
elet Gel- Platelet gel is made from a patients own blood and is used to seal wounds and lessen bleeding. A
small amount of blood is collected and spun down to remove the platelets and white cells. This concentrate of
platelets and white cells is then put on surgical sites to stop bleeding.
Also called: Autologous Platelet Gel or Platelet Rich Plasma.
Facility: ______________________________