Dealing with Competing Patient Demands for Blood

Below are replies (some have been paraphrased) to the query about how to deal with a liver transplant surgeon who requests that the hospital blood bank pull units of blood that have already been crossmatched for another patient, so that there can be enough blood for a liver transplant patient who is bleeding out, even during a severe blood shortage. For example, a facility recently used over 200 components for a liver transplant patient. The question stirred quite a bit of controversy. One individual suggested that the topic of "Setting Priorities Among Patients During Blood Shortages" as an urgent one for a national consensus conference.

Editor's Note: This issue was the subject of a forum discussion at the CBBS Annual Meeting in May 2001 on the Queen Mary in Long Beach, California. Also see another visit to this issue on Aug. 29, 2002.

1. It is a frequent argument given by physicians regarding their own patient's needs that their ONE job is to be that patient's advocate. We in the lab and in the blood bank are charged with being the hospital's advocate and we need to facilitate the treatment of ALL the patients.First of all, if a patient required over 200 components, the surgeon must have underestimated what the patient needed, so everyone was undoubtedly unprepared. This is part of the risk that the patient and the surgeon take by undergoing this type of procedure. If the patient bleeds to death that is part of the risk of the procedure, and the patient and their family must understand this point. Secondly, this should be brought to the blood utilization committee and then to the medical staff for their input. If the entire hospital and the medical staff concurs with this doctor that every other patient should be put at risk and all other surgeries cancelled during these heroics then that would be the consensus. I really doubt you could find a hospital of surgeons willing to put their careers and patient's lives at risk for the high profile hero and the dubious outcome of one high-risk surgery.
   
   
2. My philosophy is that I need a certain minimum inventory for the other patients in the hospital, and for the next emergency that comes in.
   
   
3. In the case described, the medical director of the blood bank needs to be an active participant in the decision-making process. The procedure should require immediate, active participation in this effort. A Scylla and Charybdis situation for sure. The important thing is information. Are there any other known emergencies? In the Emergency Dept; in surgery; on the floors? What is the availability of additional units from the supplier? Can the supplier scarf some units already issued to other hospitals? What is the status of patients who have units crossmatched on the shelf? Emergency? Surgery completed? Can surgery be postponed hours or days? I do not think it is acceptable to deny or delay additional units to a patient undergoing liver transplant, units which may mean the difference between survival and non-survival, in favor of a patient who hasn't yet appeared at the hospital, or who is scheduled for elective surgery - just to have an inventory. Yes, it is nice to have an inventory and to be prepared, but if you have a current urgent need, the inventory must be abandoned in favor of the immediate need. The inventory can be built up later after the crisis with, hopefully, no emergency need arising in the interim. I agree with the liver transplant surgeons.
   
   
4. Making special priorities or rules for certain patients is always a risky business. One widely accepted exception is special requirements and priority for newborns. We have special rules and priorities for newborns in our hospital, in part, because their low-volume requirements do not complete with or adversely affect the welfare of other patients. Liver transplant patients' needs often compete with the immediate needs of one or more other patients. We will "pull" crossmatched blood designated for another patient, if we have assurance from our community blood center that replacement supplies are on the way and in time to prevent harming another person. I believe that the ongoing national blood shortage, in the face of increased blood collections, is driven to a considerable extent by liver transplants and pretransplant preparations. I see the topic of "Setting Priorities Among Patients During Blood Shortages" as an urgent one for a national consensus conference.
   
   
5. This is a great question for an ethics class. I think that the guiding principle is the one that is basic to all medical practice: "First, do no harm." This applies both to the patient receiving the liver transplant as well as to the subsequent patients who may be inconvenienced, suffer or die from insufficient blood stocks in the days following the liver transplant. The obvious answer is that liver transplantation is a community project (run by a community committee), not just a one-on-one between a patient with liver failure and his transplant surgeon. If the community in which you practice is to have a liver transplant program several things must be in place: 1) Blood inventories must be adjusted throughout the entire service area to reflect that enormous amounts of blood may be occasionally necessary, 2) there must be a mechanism to immediately cancel elective surgeries if blood supplies become critically short, and everyone involved must buy into this up front, 3) under no circumstances can a critically ill patient be denied any life-saving measure so long as no other patient is in imminent danger, 4) there must be a mechanism in place to secure large numbers of additional units from another community within a matter of hours if the liver transplant program is to go forward, and finally 5) there must be a mechanism in place whereby blood that has not be completely tested (e.g., nucleic acid testing, etc.) can be transfused if the alternative to not transfusing is death. This may be a hard sell but it follows from guiding principal, "first, do no harm." One final thought: Liver transplants should not be done at centers where the team is inexperienced and morbidity (e.g., excessive blood loss) and mortality is high. In Southern California about a decade ago, one such program was discontinued for just this reason.
   
   
6. This is an interesting question that I have heard raised philosophically many times, i.e., at what point would you consider "sacrificing" the well-being of a patient or a few patients over others? However, I have not heard of someone actually being requested to do this as was posed in the question. Of academic interest, regarding keeping a "minimum" inventory, I refer the network readership to Chapter 3 of the AABB Technical Manual (though this chapter appears a bit outdated in some respects) where it is recommended to have a minimum inventory level. One suggestion I have is to present this information to your transfusion committee and/or risk management staff or whatever pertinent group you have at your facility ASAP. In times of blood emergencies, it would help to have some sort of consistent policy, e.g., when to cancel elective surgeries or "elective" transfusions, when to pull crossmatched blood for other patients, etc. This also would apply to hospitals with Emergency Rooms, and if there were "no blood," at what point would you close your ER (even though likely no one else in the city would have blood either).
   
   
7. I have experienced similar scenarios during my Transfusion Service days. We have taken crossmatched blood off the shelf, but under a specific protocol. The first units to be removed were any that had been crossmatched for greater than 24 hrs (we held blood for up to 48 hr). However if the patient had antibodies and the units were specially screened, it stayed. Next to be removed would be units that were crossmatched for specific procedures, e.g., cardiac caths, where the procedure was completed and the patient stable. Lastly we would reduce the number of units on crossmatch hold. For example, if the order was for 4 units, we'd leave 2 available for the patient and take down two. We always tried to maintain a minimum inventory of "O" cells (approximately 20 Pos/10 Neg) to have something for other emergencies as they might arise.
   
   
8. Sounds like typical surgeon banter about "my patient is more important than yours;" "and if I don't get what I want then it is your fault that the patient died". The only situation, I think, where I would seriously consider reserving specific cross-matched units for a specific patient is in the case of rare or difficult antigen matches. On a more global, ethical standpoint, should blood be distributed on a purely "first come, first served" basis? This can be a difficult question when you have a patient exsanguinating in the OR and surgeons are yelling over the phone. Too bad for the next liver transplant who comes in tomorrow, or the bleeding leukemic that needs blood. And, unfortunately, the blood bank cannot predict when the next demand for blood will come or how it will come. One of the primary roles of the blood bank, or blood center, is stewardship of the blood supply and making sure that the ethical principle of justice is kept in the forefront. Sometimes communication with the surgeons before and during the case helps to ease tensions and get through a particularly difficult case. If there is truly a blood shortage, the whole medical staff should probably be alerted. Should your hospital even be doing liver transplants if there is such a severe shortage of blood because an unknown number of patients might suffer because of lack of blood? You might also want to bring the issue to your hospital ethics committee. I would present it to them with at least a preliminary plan on how you (the blood bank/transfusion service) are going to allocate/prioritize blood during such severe shortages. The surgeons should also be part of the discussion on how they would like to prioritize blood, what alternatives are available during shortage situations (e.g., greater use of volume expanders, transferring the patient, etc). Dealing with this type of problem on a single case, acute situation is one thing, but if you are having a chronic problem then it is a different matter and some sort of policy probably should be formulated. I think it is unfair, and unreasonable, and potentially harmful to other patients, for one group of surgeons to demand that their patients are more important than anyone else's patient and that they have a right to all the blood they want.

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