Counselling · Intermediate · Haematology

Post-Operative Anaemia in a Jehovah's Witness Patient

Practise this PLAB 2 counselling station on Post-Operative Anaemia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on the surgical ward. Mrs Hannah Pearson, a 45-year-old Jehovah's Witness, had elective hysterectomy three days ago. She developed significant post-operative bleeding and is now anaemic with haemoglobin of 6.8 g/dL. She is refusing blood transfusion on religious grounds. Please discuss alternative management options and address her concerns while respecting her beliefs.

Background notes: PMH: Heavy menstrual bleeding, Appendicectomy (age 18), Mild asthma

What this station tests

  • Respecting patient autonomy: not challenging or attempting to persuade, while ensuring the refusal is informed
  • Exploring which blood fractions may be acceptable: Jehovah's Witnesses vary individually on albumin, clotting factors, EPO, and cell salvage
  • Alternative anaemia management without transfusion: IV iron, erythropoietin, folate, B12, oxygen, minimising blood draws
  • Honest risk communication: the alternative treatments take longer and the period of severe anaemia carries risk
  • Hospital Jehovah's Witness liaison committee: a support resource for both patient and clinical team

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Managing significant anaemia in a patient who refuses blood transfusion on religious grounds tests the candidate's ability to respect autonomy while maximising alternative treatments. The candidate must not try to persuade the patient to accept blood, but must ensure the refusal is informed and explore all acceptable alternatives. Mrs Pearson is 45, Jehovah's Witness, 3 days post-hysterectomy with Hb 6.8 g/dL, refusing transfusion. Open with: 'Mrs Pearson, I understand you have been through a lot. I want to discuss your situation and make sure we are doing everything we can to help you recover.'

Core approach

Respect her decision first. 'I understand that accepting blood products is not something you are able to do because of your faith, and I respect that completely. I want to work with you to find the best alternative treatment plan.' Do not challenge, persuade, or express frustration. Her capacity is intact and her decision is legally binding.

Explore what she will and will not accept. Jehovah's Witnesses vary in which blood fractions they accept. Whole blood and packed red cells are always refused. But some accept albumin, immunoglobulins, clotting factors, or erythropoietin. Cell salvage (collecting and returning her own blood during surgery) may be acceptable to some. Ask her specifically: 'Different Jehovah's Witnesses have different positions on specific blood components. Can I go through some options with you?'

Alternative management for severe anaemia without transfusion. IV iron (ferric carboxymaltose, rapid infusion) to maximise endogenous red cell production. Erythropoietin (EPO) to stimulate bone marrow. Folate and B12 supplementation. Minimise further blood loss: avoid unnecessary blood tests, use paediatric tubes when blood is needed. Supplemental oxygen to maximise oxygen delivery. IV fluids to maintain circulating volume. Bed rest to reduce oxygen demand.

Assess her current clinical status. Is she symptomatic (tachycardia, dyspnoea, dizziness)? At Hb 6.8, she is likely symptomatic. Monitor closely for deterioration. She was terrified last night and thought she might not survive.

Closing and safety netting

Present the plan: 'We are going to give you IV iron today to help your body make new red blood cells as quickly as possible, along with erythropoietin to boost your bone marrow. We will minimise blood tests, give you extra oxygen, and monitor you closely. Your haemoglobin should start to rise over the next few days to weeks.'

Be honest about the risk: 'At your current haemoglobin level, there is a period where you will feel very tired and may feel breathless. The alternative treatments take longer to work than a transfusion would. But many patients in your situation recover well.' Address her guilt about the surgery: she did not anticipate this complication. Reassure that the surgical team is supporting her decision.

Confirm her advance directive is documented. Ensure the healthcare team all understand her wishes. Contact the hospital liaison committee for Jehovah's Witnesses if available (they provide support to both patient and medical team). Safety net: 'We are monitoring you very closely. If your symptoms worsen, we will intensify the supportive treatments.' Follow-up: daily Hb checks, clinical review twice daily.

How examiners mark this station

Examiners will assess your ability to explain post-operative anaemia and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Current clinical status assessed (symptoms, haemodynamic stability). Specific blood product preferences explored. Surgical complication reviewed. Advance directive confirmed. Current medications and allergies checked.

Costs marks: Not assessing clinical status. Not exploring specific product preferences. Not checking advance directive.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: IV iron and EPO prescribed. Blood conservation measures implemented. Oxygen supplementation. Monitoring plan (daily Hb, twice-daily review). Honest risk communication. JW liaison committee contacted.

Costs marks: No alternative treatment plan. Not knowing IV iron or EPO. Not minimising blood draws. No monitoring plan.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Respecting autonomy without judgment. Exploring preferences respectfully. Honest about risk without being coercive. Addressing her guilt about the surgery. Supporting her emotionally through a frightening situation.

Costs marks: Attempting to persuade. Being judgmental about her faith. Being coercive. Not addressing her fear. Expressing frustration.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Attempting to persuade the patient to accept transfusion. Her capacity is intact, her decision is informed, and challenging it is disrespectful and unethical. Candidates who argue that 'your life is at risk' to try to change her mind demonstrate a failure of autonomy respect.
  2. Not exploring which blood fractions she accepts. Assuming all blood products are refused may deny her treatments she would consent to. EPO, albumin, and cell salvage may be acceptable. Candidates who do not ask miss treatment options.
  3. Not knowing the alternative treatments. IV iron, erythropoietin, and blood conservation strategies are the management of severe anaemia without transfusion. Candidates who say 'there is nothing else we can do' are incorrect and unhelpful.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this post-Operative anaemia counselling consultation?

Managing significant anaemia in a patient who refuses blood transfusion on religious grounds tests the candidate's ability to respect autonomy while maximising alternative treatments. The candidate must not try to persuade the patient to accept blood, but must ensure the refusal is informed and explore all acceptable alternatives. Mrs Pearson is 45, Jehovah's Witness, 3 days post-hysterectomy with Hb 6.8 g/dL, refusing transfusion.

Where are marks won and lost in this post-Operative anaemia station?

Examiners reward: Current clinical status assessed (symptoms, haemodynamic stability). Specific blood product preferences explored. Surgical complication reviewed. Advance directive confirmed. Candidates are penalised for: Not assessing clinical status. Not exploring specific product preferences. Not checking advance directive.

Where do candidates most often go wrong in this station?

Attempting to persuade the patient to accept transfusion. Her capacity is intact, her decision is informed, and challenging it is disrespectful and unethical. Candidates who argue that 'your life is at risk' to try to change her mind demonstrate a failure of autonomy respect.

Can I do well in this station without real-world experience of post-Operative anaemia?

This station rewards process over personal experience. The skill being assessed: Exploring which blood fractions may be acceptable: Jehovah's Witnesses vary individually on albumin, clotting factors, EPO, and cell salvage. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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