A middle-aged female with advanced cancer admitted for long-term care with poor functional status and lack of a peripheral venous access, who denies any physiological symptoms arising from anaemia, does not receive a transfusion for three months while asymptomatic. The decision to transfuse is made later when she develops signs of breathlessness and swelling in the legs, and implores the physician to do so.
The clinician chooses to question himself over this delay and attempts to understand its ethical ramifications.

The extrapolation of restrictive thresholds used in the intensive care setting to advanced cancer, in the absence of a definitive palliative medicine specific guidance is inherently problematic. It could be argued that the delayed decision to transfuse might represent moral distress arising as an offshoot of the paternalistic restraint exercised previously.

The use of the term “implore” also needs to be subjected to further scrutiny. While on one hand it might represent the meaningful exercise of patient autonomy and the outcome of a psychological need for therapeutic action, on the other it underlines the epistemic injustice wherein the actual intent of the appeal, the individual’s attempt at ensuring dignity remains largely unaddressed. It becomes difficult for the physician to ignore that such an impassioned plea generates substantive empathic pressure and presents a case for a shift in the decision making threshold once suffering assumes centrestage.

An analysis of the clinician’s reasoning delineates an absence of clear symptoms attributable to anaemia as the primary reason to withhold transfusion. The delayed decision represents a respect for autonomy (transfusion given upon patient demand) and the culmination of the insistence on evaluating symptoms regularly represents a noteworthy allegiance to iterative reassessment (which prevented overtreatment and led to the identification of symptoms as they developed). While, the absence of symptoms at first also has the effect of shifting the balance towards clinical proportionality, the poor functional status, where fatigue could not have assessed accurately points at the existence of a physiological smokescreen.

In his defence, could the transfusion now have been labelled as a time-limited trial of intervention? In this fickle undefined space overpopulated by uncertainty, can this decision be expected to stand the test of time? And despite the rhetorical flourish, when has time been my friend?

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press.

Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. Oxford University Press.

Leadership Alliance for the Care of Dying People. (2014). One chance to get it right: Improving people’s experience of care in the last few days and hours of life. NHS England. https://www.england.nhs.uk/wp-content/uploads/2014/06/ltc-onchr.pdf

National Institute for Health and Care Excellence. (2015, updated 2023). Blood transfusion (NICE guideline NG24). https://www.nice.org.uk/guidance/ng24

National Institute for Health and Care Excellence. (2015). Care of dying adults in the last days of life (NICE guideline NG31). https://www.nice.org.uk/guidance/ng31

Preston, N. J., Hurlow, A., Brine, J., & Bennett, M. I. (2012). Blood transfusions for anaemia in patients with advanced cancer. Cochrane Database of Systematic Reviews, 2, CD009007. https://doi.org/10.1002/14651858.CD009007.pub2

Quill, T. E., & Holloway, R. (2011). Time-limited trials near the end of life. JAMA, 306(13), 1483–1484. https://doi.org/10.1001/jama.2011.1413

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