By Ryan Pferdehirt, D.Bioethics, HEC-C

February 2022

Bioethics case study on blood shortages and scarce resource allocation.

A 75-year-old, female identifying patient is admitted to the ICU for abdominal distress. Her name is Graciela.

Graciela’s family members tell hospital staff that she has not been feeling “herself” as of late. She’s been drowsy, visibly jaundiced, and in a constant state of pain. One morning, her sons found her hunched over and gasping for breath. They immediately called 911.

After a series of tests, Graciela’s medical team determines that she is showing signs of seemingly irreversible multi-system organ failure with one or more probable causes, but none of them curable given the current state of medical knowledge and treatments. Her hemoglobin is notably low, requiring transfusions to make the patient feel better, but without any hemorrhaging site noted. With proper care, inclusive of additional blood transfusions, Graciela’s prognosis is estimated to be a life expectancy of 3 to 6 months.

An attending physician informs Graciela and her family about what has been learned, what her care team knows, what they still don’t know, and what is anticipated as a likely outcome. Understandably, both patient and family are distraught by this bad news. While consoling his mother, Graciela’s son Roberto asks her doctor if there isn’t something that might be done to help his mother. He insists that she wants to be healed and return to her previous happy existence as a doting grandmother and gardener. If neither doctors nor God produces the miracle all are praying for, Graciela wishes to be kept as comfortable and pain-free as possible, at home and surrounded by family. Graciela nods her agreement to what the son has stated.

Given these stated goals of care, the primary team requests a palliative care consult. After evaluating the patient, Palliative recommends various comfort measures including pain medications and routine blood transfusions as needed. Their chart note indicates hope that by following this course of palliative care, the patient might remain alert and comfortable for the remaining months of her life.

The attending physician, although in agreement with palliative recommendations, is worried about the proposal to continue transfusing his terminally ill patient. A national blood shortage significantly impacts not only this health system but all others and their patients. An executive memo to physicians in this hospital recently called upon everyone to utilize blood products judiciously and conservatively on account of a critical shortage everywhere.

But what would “judicious” use of blood mean in Graciela’s situation? Indeed, there is a 22-year-old patient in the hospital named Julian who also needs routine blood transfusions (in combination with other therapies) for sickle cell anemia. He is otherwise not dying, or not anytime soon, if given access to sufficient resources of donated blood. Then too there are the multiple trauma victims arriving at the Emergency Room daily in this busy urban hospital. What happens to those hemorrhaging patients if we run out of blood for having used up our supply on dying patients like Graciela?

Graciela’s care team, discussing this dilemma, feels morally distressed. If these were normal times with blood products well stocked, then all patients who stand to benefit from transfusions—Graciela, Julian and those in trauma bays—could be treated equally and equitably without allocation concerns. However, when blood is a scarce resource, when there are patients who need the resource for long-term survival and not mostly for palliation, what then should be done? On the other hand, excellent palliative care at the end of life is also significant. There is value to helping someone live out the remaining months of their lives with optimal quality of life. This seems a worthy goal, even if the anticipated outcome is not long-term survival.

What should be done? Graciela’s attending physician requests an ethics consultation.