Note: This document is in the design stage and not recommended for use at this time. We invite the comments of physicians, attorneys and other interested parties regarding the use of this form.

Informed Consent and Statement of Understanding regarding Blood Transfusion Therapy

I have been advised that the transfusion of one or more blood products may be medically necessary. I have received information on the alternatives and the risks associated with them, as well as the risks associated with the use of blood therapies.

As one of Jehovah’s Witnesses I am aware of the following:

1. The Watchtower Society has gradually developed a policy of permitting some blood products but not others.
   
2. The policy is controversial and has changed repeatedly.
   
3. The current policy permits the use of any blood product fractionated from red cells, white cells, platelets and plasma.
4. The Watchtower's classification of major and minor blood components is only one of several possible classifications.
5. If I choose to accept a major blood component, I could potentially face congregational judicial action in the form of disfellowshipping. However, I have the right to do so and I have the right to medical confidentiality.
6. If I reject a blood product deemed absolutely medically necessary and alternatives have been exhausted, I may be injured, disabled or die.
   
7. The blood components deemed major and currently prohibited by the Watchtower Society include red cells, white cells, plasma and platelets.

The following charts summarize the Watchtower Society present blood policy. The policy has changed frequently with more and more blood components, therapies and techniques being added in recent years. Please consult with the local H.L.C. members if there is any question regarding the current policy.

Medical personnel from this facility have requested an explanation of which blood therapies I will accept and which I will not, and what the basis for that decision is. I am making an informed choice is this regard. I understand the Watchtower Society's current explanation of God's law on blood.

I have been given the brochure, "Do Jehovah’s Witnesses Really Abstain from Blood," which is produced by A.J.W.R.B. (The Associated Jehovah's Witnesses for Reform on Blood).

I understand that should I decide to accept a blood therapy not presently approved by the Watchtower Society, every effort will be made to protect my confidentiality.

Patient Statement of Understanding and Advance Directive

I acknowledge that my physician has advised me to have, or that I may need to have a blood transfusion. I have had a chance to ask for additional information about blood transfusions, the risks and alternatives. I am satisfied with the information and have no further questions. I am fully aware of the consequences of my decision.

I understand that there are limitations to "no blood" techniques, and that in some situations no viable alternatives exist, and that serious injury, disability or death may result if a transfusion deemed medically necessary is rejected. I hereby waive any claim for damages against the doctors, nurses and institutions involved in providing medical care to me should harm result due to my refusal of blood therapies deemed medically necessary.

Patient should initial one of the following statements:

_____ I reject the use of all blood therapies, including those the Watchtower Society has approved for use by its members.

_____ I will accept only the following blood therapies: ______________________________________________________________________________________________________________

_____ I will accept any blood therapy approved by the Watchtower Society, but no others.

_____ I elect to reject any blood therapy not approved by the Watchtower Society. However, in the event that all non-blood alternative therapies are exhausted, I direct that blood therapies deemed medically necessary be used to save my life.

_____ I grant permission for the use of blood therapies deemed medically necessary.

Refusals Involving Minors

The above patient is a minor and we are the minor’s parents (if one parent is deceased or not competent, references to "we" should be interpreted to mean the parent signing the form). We do not give permission for the use of blood transfusion therapies for this minor, other than those approved by the Watchtower Society. We understand the risks involved by not permitting transfusions in situations where blood loss may exist. We understand that blood loss can result in injury, disability or death. We assume all responsibility for this decision and will indemnify and defend all physicians, employees, and agents of (Name Facility) against all claims and actions which may result from this refusal. Our initials below reflect our decision in regards to (Name Facility) policy which requires the appointment of a legal guardian and a petition to a local court for authorization of blood transfusions or blood products.

This form is available for use by the entire health care industry. The form is being developed for use by AJWRB. If you choose to use this form, you specifically waive any right to claim damages against AJWRB, its members or directors. We recommend that you submit the form to your legal counsel for review and adaptation prior to use.