Commentary — June 2017
Tex Med. 2017;113(6):11-12.
By Angela Nguyen, DO
I walked toward room 942 expecting the morning's encounter to be no different than previous encounters. My patient was sitting upright eating her breakfast. She told me she was dizzy and still had abdominal pain. The nurse noted, "2 bloody stools per the night nurse, nothing new." I sighed internally, thinking the patient will probably get transfused again today during hemodialysis. We were constantly playing "catch-up" with her hemoglobin status; over 20 days, she had received 11 units of packed red blood cells (RBCs).
Sadly, having bloody stools was this patient's "new normal." When I first admitted her three weeks earlier, she was in the emergency department with shortness of breath, chest tightness, and a hemoglobin of 3.6 g/dL. She had multiple recent hospitalizations for symptomatic anemia from chronic gastrointestinal bleeding due to inoperable colorectal cancer and end-stage renal disease (ESRD) on hemodialysis. Gastroenterology, interventional radiology, hematology/oncology, renal, and palliative consults were obtained as in prior admissions. Embolization or cauterization was not an option due to the risk for tissue necrosis; surgery was not an option due to her congestive heart failure; and she was not a chemotherapy candidate due to her ESRD. She declined hospice services because dialysis and transfusions "made her feel better."
It was not surprising that my patient felt better after transfusions. The incidence of fatigue is higher in anemic cancer patients than in non-anemic cancer patients.1 Fifteen percent of anemic cancer patients are treated with RBC transfusions.1 Although one unit of packed RBCs should increase levels of hemoglobin by 1 g/dL, my patient had received a total of 12 units during her hospital stay without a sustained rise in her hemoglobin count. It felt medically futile and costly for the patient to receive automatic blood transfusions three times a week during dialysis for a hemoglobin lower than 7 g/dL.
Medical futility is a "clinical action that is not performed for achieving a clear goal, and hence, is not useful for the intended patient."2 Popular reasons behind providing futile medical treatments include patient/family desire; health care professionals' personal beliefs; organizational factors and fear of medical litigation; and social, cultural, and religious factors. However, futile medical treatments yield consequences: patient suffering; decreased quality of care due to suffering, moral distress, job burnout, job dissatisfaction, and increased turnover by nurses and physicians; and heavy financial burdens on families, health care systems, and societies.
During the course of my patient's hospital stay, my team met with her and her family twice regarding transitioning to hospice. We reviewed the risks of multiple blood transfusions, including acute hemolytic reaction, allergic reaction, anaphylactic reaction, delayed hemolytic reaction, iron overload, over-transfusion, and transfusion-related lung injury. In the face of medical futility, their refusal of hospice care was hard to hear. But, I also could not imagine what it would be like to face one's own death. Even though the patient reported that she had some good days mixed in with her bad days, having daily bloody stools and weakness seemed overall to be a miserable experience.
Yet, the temporary spurts of "feeling better" after dialysis and a blood transfusion were enough for the patient to believe that the interventions made her quality of life better and, furthermore, that she had a "better" quality of life in the hospital because she would be "too much of a burden for her family at home."
From our perspective, there was nothing much we could offer her other than transfusions, even though it seemed to everyone involved in her care that she was draining the blood bank. At a point during her stay, we discussed the ethics of refusing to continue transfusions. But who is to say that her life isn't as valuable as anyone else's or that she is less deserving of blood transfusions than anyone else who exhibits a hemoglobin lower than 7 g/dL?
As medical residents, we are placed in challenging situations that will make us better physicians. Medical futility is especially difficult within the context of terminally ill cancer patients. Treating this patient allowed me to learn that medical futility presents itself as something that is complex, subjective, and situation-specific, and it cannot be determined based solely on objective parameters. In turn, as physicians, it is important that we not become preoccupied with the "lab values," but rather view and treat the patient as a whole.
Angela Nguyen, DO, is a family medicine resident at The University of Texas at Austin Dell Medical School. Swati Avashia, MD, assistant professor of medicine in the family medicine residency program at Dell Medical School, contributed to this article.
- Schrijvers D. Management of anemia in cancer patients: transfusions. Oncologist. 2011;16 Suppl 3:12-18.
- Aghabarary M, Dehghan Nayeri N. Medical futility and its challenges: a review study. J Med Ethics Hist Med. 2016;9:11.
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