A blood banker who works at a regional medical center in Southern USA wonders if it is appropriate to impose a policy to limit the amount of blood that an individual patient receives, if the transfusion of that patient is likely to exhaust the local blood stocks to the extent that other patients could be jeopardized by an acute local blood shortage.

The inquiring blood banker reports that her hospital does not currently have such a policy, but is considering adopting one. The possible need for such a policy recently came up with treatment of a patient who suffered 3rd degree burns over 92% of their skin surface. According to the inquiring blood banker, surgical treatment of the burns was estimated to require over 70 units of RBCs plus many units of platelets, which would have exceeded local blood stocks. The inquiring blood banker's hospital is a level one trauma center, has a burn unit and a sickle cell anemia treatment center, so they try to always maintain a fair amount of blood on hand for these other patients.

The following replies were submitted in response to the above question.

1. The Editor reminds the e-network that an earlier discussion on the e-Network Forum is germane to this question.

2. A Texas blood banker is of the opinion that this is a problem that needs the input of an ethics committee, and cannot see how there could be a simple policy. At her hospital, occasionally a similar problem develops with CABG re-do's. The responding blood banker is concerned when she is told by several nurses working in the OR that the patient is moribund and will not recover, yet the attending physician keeps using blood products. However, she is reluctant to say "You've used more that you're allotted, so do without." She believes it is common sense to cancel elective surgeries, to convert 4-unit crossmatches to 2, and to release units that have been set up for people with a hemoglobin level above 8 gm/dL who are not bleeding, while waiting for the blood supplier to find more units. She believes a policy could only say this much: "When X amount of packed cells, FFP, Platelets, etc. have been used for one patient, a dialog should take place among the primary physician, the blood bank director and the ethics committee director to ascertain how to continue treatment." This is too complicated to just say "You've had your 2 cookies today, no more."

ADDENDA May 9, 2004

3. A colleague in the state of Washington reports that a question about the ethics of rationing blood products has been raised for discussion at his hospital's Ethics Committee. For example, what if there were three hypothetical patients who were all in need of blood transfusion, but the local supply was inadequate to meet the defined medical needs of each patient? For example, of three hypothetical patients, assume the first patient has severe trauma and is actively bleeding, assume the second patient is in the operating room undergoing open heart surgery and bleeding, and assume the third patient is severely anemic and receiving chemotherapy. The inquiring colleague comments that their Ethics Committee has made no decision yet as to a general policy to approach the 'rationing' of blood products when supply is inadequate to meet real time patient needs. However, if such a scenario actually came up, the inquiring Washington colleague is certain that the situation would most likely be 'resolved' on a 'first come first served' basis, or the physicians caring for the patients would advocate for their individual patients in order to decide which patient needs the blood the most.

ADDENDA May 12, 2004

4. A transfusion service physician in Maryland believes that the situation described in comment #3 above illustrates the importance of the role of a medical director of a blood bank. She says that a "First come, first serve" system is not necessarily in the best interests of patient care. In her opinion, while it is the responsibility of a patient's physician to advocate for a particular patient's need for blood, only another physician (such as an engaged blood bank director) who is actively involved in transfusion medicine is qualified to question a physician's demands for blood products, when such demands may compromise transfusion care for the rest of the hospital's patients. Every situation in a hospital is different and decisions sometimes need to be made quickly, so a case-by-case ethics committee consultation is also not a complete solution.

The Maryland physician wishes to pose a different ethical dilemma which she already posed recently to a prominent ethicist during his presentation of the baby "K" case (PDF), which centered on whether physicians should be compelled to provide care for a case they felt was futile. Disappointingly, he answered with a typical discussion of rationing of blood products. This baby "K" case did not involve blood transfusion and the end result was that the physicians were compelled to provide care. She questioned whether it was ethical to provide blood transfusions to futile cases when the blood came from voluntary donors who were recruited by pleas that the blood would be used for beneficial care. Futile care cases have typically centered on conflicts between physician autonomy and patient autonomy. In cases involving blood transfusions from voluntary donors, she argues that the motivation of the blood donor is a relevant consideration.

ADDENDA May 13, 2004

5. A Medical Director of a Regional Blood Center reports that she is troubled that the e-Network Forum appears to be spending so much time discussing rationing blood when a more fruitful discussion might be how to increase blood donations, so that situations requiring rationing of blood products would arise very rarely.  She points out that with only 5% of the population donating blood, blood bankers have an obligation to continue to work to increase blood supplies.  She is of the opinion that many people can and will donate if it can determined how to make blood donation convenient and attractive.  She adds that (in her opinion) that "We must distinguish true national blood shortages (which occur fairly rarely, only a couple of times a year) with local shortages which can occur when hospitals and local blood providers are unwilling to acquire blood supplies from other centers that have excess.  This is sometimes an economic issue.  Blood is much less expensive than many drugs and other treatment modalities that are used, and we have to keep this in perspective.  None of this is of course an argument for wasting blood, but we certainly have had many patients who used multiple units who have done very well eventually.  Of course, extremely local shortages can arise.  However, if a hospital has this situation arising more than rarely, especially if it is a trauma center, perhaps it needs to increase its inventory levels or look at more rapid resupply from its blood center.  With modern transport and communication, we should be able to resolve most of these shortages, and should spend more energy in that direction."

6. The physician from Maryland who submitted response #4 disagrees with the opinion expressed by the Regional Blood Center Physician (response 5). According to the Maryland physician, we must be sensitive to the risks to which blood donors expose themselves with each donation, since donors can experience harm such as hematomas, nerve damage, fatigue, and every year there are donor fatalities reported to the FDA . Blood donors take these risks with the expectation that their donations will be doing a great good for patients. In the opinion of the Maryland physician, we must make certain that every transfusion is intended to do a great good, which raises the ethical question of using donated blood for futile cases. For the sake of discussion, the e-Network Forum is referred to the Montreal 1980 Code of Ethics for Blood Transfusion, statement II - 22 - "Owing to the human origin of blood and to the limited quantities available, it is important to safeguard the interests of both recipient and donor by avoiding abuse or waste." (Vox Sang 40: 303-305 (1981). The Maryland physician suggests that we should delete the phrase "and to the limited quantities available."

She believes that this is not an issue of supply, but rather, an ethical issue.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator