Introduction The decision to deliver transfusions to patients who are receiving palliative care is complex, where they may be of variable benefit especially towards the end of life. We describe a case of a gentleman with metastatic castrate resistant prostate cancer presenting with non-resolving active bleeding gastrointestinal tract, and discuss the ethical considerations attached to the issue of continued blood transfusions in the palliative setting.

Case Report Mr W is a 67-year-old Chinese male with CRPC that progressed despite anti-androgen therapy, bilateral orchidectomy and radiotherapy. He presented with melena and a haemoglobin level of 3.9g/dL. He was started on proton-pump inhibitors and red blood cells transfusions. He remained comfortable throughout his admission. His condition was complicated by a NSTEMI, urinary tract infection and acute kidney injury. He was reviewed by Cardiology who deemed him not a suitable candidate for cardiac interventions nor anti platelet therapy in view of his active BGIT.

His echocardiography revealed a reduced ejection fraction of 37%; he developed fluid overload and required intravenous diuresis. He was assessed to be a high risk for esophagogastroduodenoscopy considering his NSTEMI. He remained ambivalent when broached about continuation of blood transfusions, while his family felt that withholding transfusions was akin to ‘giving up’. Mr W continued to have daily melena and was supported with blood transfusions every other day, to pace with family members to come to acceptance. Eventually they were agreeable with the medical recommendation to discontinue further blood transfusions and he was discharged back home with home hospice support.

Discussion This case raises the ethical dilemma of blood transfusions despite medical futility, while balancing the family’s maintenance of hope. The Jonsen’s Four Box Method (figure 1)¹ enables physicians to navigate a holistic approach.

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Abstract P-51 Figure 1

In Mr W’s case, it was recommended that repeated blood transfusions be withheld. There were no alternative curative interventions for his active bleeding that could be taken upon safely, and the low chances of a spontaneous recovery weighed significantly less against the increasing harm of worsening fluid overload. He remained comfortable and symptom-derived benefits from transfusions were negligible; fatigue and reduced activity are nonspecific symptoms and are often considered insufficient reasons for transfusion. In addition, the presence of his life-limiting metastatic CRPC, ongoing functional decline, and infective complications already portends a poor prognosis. Further prolongation of hospitalisation with repeated intravenous cannulation was not in keeping with quality of life to him. Offering a trial of therapy, with clearly defined end-points, to demonstrate medical futility facilitates acceptance of the circumstance and aligns eventual goals of care. It is imperative that physicians provide families with accurate, current, and frequent prognostic estimates throughout the course of the illness. There is a need to address the emotional needs of the family to understand the problems from the family’s perspective by being available, approachable, and compassionate.

Reference

1. Albert R Jonsen, Mark Siegler, William J Winslade. Clinical ethics a practical approach to ethical decisions in clinical medicine.