66. Case: Blood Transfusions

Joyce Skinner is a 38 year old woman with non-curative leukemia. She is the single mother of two children, ages 11 and 8, and her ex-husband is ‘out of the (parental) picture’. Since her leukemia diagnosis, Joyce has approached her progressive hematological cancer in an assertive manner, seeing it as her responsibility to fight to stay alive and look after her children for as long as possible. Over the past few years, her attending hemato-oncologist, Dr. Jones, has arranged for her to be a research participant in a variety of experimental chemotherapy trials, which have extended her life beyond what was initially anticipated. However, about 6 months ago, Joyce’s leukemia moved into a treatment-resistant phase and her medical regime is currently palliative in nature and intent. Joyce is now residing in a hematology clinical unit of a tertiary care hospital where she is followed regularly by a palliative care consultant, Dr. Miller. In the last 3 weeks, the frequency of blood transfusions required to keep Joyce’s hemoglobin at a low functional level has progressively increased such that she is now receiving transfusions every second day. Joyce is not eligible for transfer to the hospital’s Palliative Care Unit while blood transfusions are a component of her care plan. She is very weak and is confined to her hospital bed. Her children visit her regularly with their aunt, Cathy, who has assumed parental responsibility for them. They have missed a considerable amount of school time in the last few months.

Despite the honest information provided by Dr. Jones, Joyce is in some denial about her grim prognosis and strongly believes that she can continue to ‘beat the odds’. She remains reasonably clear-headed and is capable of making health care and treatment decisions on her own. She insists that Dr. Jones continue the blood transfusions indefinitely. Her sister and Drs. Jones and Miller are of the shared opinion that the transfusions should be discontinued and that Joyce should be transferred to the Palliative Care Unit.

Dr. Jones, who sits on the provincial blood management committee, is aware that there has been an exceptional demand on existing provincial blood resources in the last few weeks due to a number of major highway accidents. The hospital is chronically under-resourced. There are typically one or more patients waiting in the emergency department for admission to the hematology clinical unit.

 

 

1. What do you think is important to Joyce (in terms of her personal values)? What do you suspect about her personality structure?

 

2. On what basis, if any, could Joyce claim a right to continue receiving blood transfusions? What other ethics principles and values are at play in these circumstances?

 

3. What weight in the decision making should be given to the clinical judgments of Drs. Jones and Miller?

 

4. Should Cathy (as an engaged family member) participate and have some authority in the decision making? Would the nature of this authority change if Joyce loses capacity?

 

5. Is ‘bedside rationing’ of limited health resources an appropriate form of health resource allocation?

 

6. With their mandates to manage limited health resources prudently, should the Nova Scotia Health Authority and/or the provincial Department of Health & Wellness have a role(s) in such end-of-life decision making?

 

7. Under what circumstances, if any, would it be ethical to deny Joyce’s request for further blood transfusions?

 

 

65. Case: Conflict in an Ethics Consultation

The next three cases are from our Advanced Clinical Consultation Workshop facilitated by Paul Hutchinson, Imagined Spaces. These cases were submitted to us from Paul.

I find it is often team conflict that can lead to an ethics consult and this will find its way into the consultation space. This can present in a couple of ways:

• Staff will become quiet and hesitant to speak and it can become difficult to deal with the real issues.

OR

• Conversation will become heated and emotion laden.

One case I remember was in dealing with a young mom whose child had been hospitalized since birth. Part of the reason for this long hospitalization was due to an error in care. This was a very young mom with two other children.  She had very few community or family resources and so proper housing and resources for care of her children were issues.

Staff had very differing views of this mom and her care of her child as well as her behaviors in hospital (she would sometimes stay out late at night with friends and on return could be quite noisy). Some staff felt she avoided caring for her child and was leaving all the responsibility to staff. There was clearly a divisiveness with some staff feeling she was simply not a good mom and would never be able to care for her child and in some cases disempowered her by taking over care. Other staff felt this mom was doing the best she could given her age, education, and socioeconomic status and were very protective of her. Staff were being directed to document and be vigilant re anything that might bring doubt on her ability as a parent and perhaps have her children taken from her.

It was a very difficult situation, and it was ongoing when the consult occurred. It was clear values were being challenged and staff felt very strongly. Many staff felt that were being bullied and pressured by other professions and each other and this was a difficult consult to facilitate.