39. CASE: Setting Priorities

In the wake of a mass casualty event, a hurricane that devastated much of Nova Scotia, blood resources within the province are extremely scarce. There is not enough blood to meet all the legitimate blood-related health needs of Nova Scotians, and the blood supply is not expected to increase significantly in the next two months. Tough choices have to be made. The following three patients have been admitted to a rural general hospital and are in need of blood transfusion:

Jim is a relatively healthy, 87-year old man who requires a colectomy for a benign hemorrhagic bowel disorder. He is scheduled for surgery along with many urgent others, and it is anticipated that he will not rise to the top of the waiting list for at least two months. To bridge the gap between now and then, he requires regular (e.g., q 3 weeks) transfusions. Jim lives independently in the community and is very engaged with two of his children and six grandchildren who live in the local area.

Sue is a 42-year old woman admitted to the palliative care service whose progressive leukemia is causing her to be significantly fatigued and short of breath. The attending hematologist estimates that regular blood transfusions would allow her to remain functional at home for about another eight months. She has three children ages 4, 7 and 11. The family is dependent on the single income of her husband who is a plumber.

Kevin is a six-year old boy with a poor prognosis cancer diagnosis. His present quality of life is poor – he is confined to bed and spends most of his time asleep. He is not experiencing any pain. Kevin is able to communicate with his parents for an hour or two a day. His medical oncologist estimates that regular blood transfusions would extend his life for about another five months. It is anticipated that Kevin’s quality of life will remain essentially unchanged during this period of time. Kevin’s parents are demanding that their son receive these blood transfusions.

Dr. Fairchance, as the hematologist on-call, is asked to make a decision about which of these three patients should be started on blood transfusions. She recognizes that there is currently enough available blood to meet the needs of only one of these patients. Dr. Fairchance is also asked to prioritize the other two patients in the unlikely event that more blood becomes available in the next week or two. As the medical resident on-call, you have been requested to assess Jim, Sue and Kevin and to report back to Dr. Fairchance regarding their present health status. She would also like you to assist her with the rationing decision.

  • What factors should be considered in micro-allocation decisions? How do you prioritize them?
  • What principles and values would inform your decision-making?
  • What decision-making process would you use to work through this decision?
  • Is there a better way than ‘bedside rationing’ to allocate scarce health resources?
  • What are the implications – organizational or otherwise – of your decision?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting
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