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Home / Station 26: Refusal of blood transfusion

NAC OSCE preparation

Station 26: Refusal of blood transfusion

Complete the task in 11 minutes. Reveal the full standardized-patient script, examiner prompts and structured debrief only after your attempt.

Station time

11:00

Ready for an 11-minute attempt.

Candidate instructions

Refusal of blood transfusion

11 minutes

Discipline: Communication, Ethics & Professionalism
Station type: Capacity + informed refusal
Setting: Emergency department

Your task

Discuss management with a patient who has gastrointestinal bleeding and refuses blood products.

Information available at entry

HR 112/minBP 98/60 mm HgRR 20/minSpO₂ 98% room airHemoglobin 64 g/L

Coach prompt: Respect a capable refusal while treating hemorrhage and offering acceptable alternatives.

In Exam Mode, coaching cues are hidden. Ask a partner to use the standardized-patient script after you start the timer.

Finished your attempt?Reveal the full station only after completing or stopping the timer.

Complete station package

Standardized-patient script and structured debrief

Station 26 of 30

Standardized-patient profile

NameMs. Grace Okafor

Age42

Pronounsshe/her

RolePatient

Demeanour: Calm, consistent and able to explain her values.

Opening statement: “I understand I am bleeding, but I will not accept blood under any circumstances.”

History and standardized-patient responses

Decision and understanding

Candidate explores	Standardized-patient response
Choice	Refuses red cells, plasma and platelets.
Reason	Long-standing religious conviction; decision predates illness.
Understanding	Can explain risk of worsening shock, myocardial ischemia, permanent harm and death.
Appreciation	Understands those outcomes could happen to her.
Reasoning	Compares consequences and consistently chooses bloodless care.
Communication	Clearly communicates stable choice.

Acceptable options

Candidate explores	Standardized-patient response
Procedures	Accepts endoscopy, surgery and anesthesia.
Medications	Accepts tranexamic acid if indicated, iron, erythropoietin and volume support.
Fractions/cell salvage	Wants each product discussed individually; may accept some fractions but not stored autologous blood.
Advance documents	Carries a signed directive.

Supports

Candidate explores	Standardized-patient response
Family	Wants sister present, but decision is her own.
Privacy	Allows relevant care team to know refusal.

Physical findings

Pale but alert and oriented.
Cool extremities; no current chest pain.
No evidence of intoxication, delirium or coercion.

Examiner prompts

Capacity?

She demonstrates understanding, appreciation, reasoning and communication for this decision.

Can you transfuse anyway?

Not when a capable adult gives an informed, voluntary refusal; follow applicable law/policy and obtain urgent ethics/legal support if uncertainty arises.

Plan?

Resuscitate with acceptable measures, urgent source control, blood-conservation strategy and meticulous documentation.

Differential diagnosis

Acute GI hemorrhage with severe anemia
Potential hemorrhagic shock

Investigations

CBC and serial hemoglobin
Coagulation profile, type and screen for identification even if products refused as locally appropriate
Renal/liver profile, lactate and ECG
Urgent endoscopic evaluation

Management

ABC support and monitored setting
Large-bore access and judicious crystalloid
Urgent source control/endoscopy
Proton-pump inhibitor or condition-specific therapy
Minimize phlebotomy
Iron/erythropoiesis and hemostatic options acceptable to patient
Escalate to surgery/interventional radiology

Communication behaviours

Use neutral language
Separate capacity from agreement with the choice
Confirm product-by-product preferences

Critical safety actions

A capable adult's informed refusal must be respected
Do not delay source control
Document accepted and refused interventions precisely

Model closing summary

Ms. Okafor understands the nature and severity of the hemorrhage, appreciates that refusal may result in permanent harm or death, reasons consistently from her values and communicates a stable choice, so she has capacity for this decision. I would respect her refusal, document it carefully, clarify acceptable products and techniques, provide aggressive blood-conserving resuscitation and arrange urgent endoscopic or surgical source control with anesthesia, ethics and other support as needed.

Common pitfalls

Calling the patient incapable because the choice is risky
Pressuring through family
Assuming all blood fractions are refused
Abandoning treatment because transfusion is declined

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

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