Wasting a precious gift

This week my toughest case involved futile care.  We admitted a patient with very advanced cancer, dying naturally at home on hospice. Because of last minute family intervention, the patient ended up spending 48 hours on super-max support, dying quite horribly with tubes and lines in every natural and unnatural orifice.  Liver failure, lung failure, kidney failure, bleeding, blood clots and overwhelming sepsis guaranteed, without any hope, that the body distorted by brutal medical care, four rounds of CPR, 23 doctors and $3000 per hour, ended in death.

As I relived this disaster, and tried to clear my head by running a few miles further on the treadmill, my focus fell on the concept of waste. The waste in the pain of the patient and family.  Waste of dollars and cents. The waste of valuable intensive care unit space, while the emergency room overflows with patients who could be saved. The waste in the time, expertise and energy, which burns out highly trained, passionate, medical personnel.

Moreover, my interest focused on a type of waste I have missed in prior similar cases. The loss and waste of a precious, special resource. The waste of blood.

I do not mean the patient’s blood, which spilled across gowns, bed and floor. Rather I mean the plasma, cryoprecipitate, platelets and red cells which where poured into and through the dying body.  Blood products, which, especially with the lull in summer donations, are so difficult to replace.

I have donated blood without being particularly introspective.  It is simply “the right thing” to do. However, if I am honest, I have this ideal fantasy of my gift making a difference.  Somewhere, there is a man, woman, maybe even a small child, who, in their moment of desperation, are given the opportunity, by me, to heal.   Perhaps, I am being naïve, but there seems to be a social contract that says that my donation will be used with respect and care.  I feel violated by the idea that someone may callously dispose of this given part of me, in a futile battle, or even worse use my blood to amplify suffering.

I know it is time for me to grow up and realize that I live in a complex society and understand that others will use my contributions according to their definition of need.  I buy into an insurance pool, some of which is used for poor quality care.  I pay taxes, which are not always used as I might wish.  I accept sending my kids to schools, which may teach somewhat differently than I might choose. We all lose some element of personal freedom each day, in order to guarantee the safety of the whole.  I should relinquish any emotional attachment to that which is donated, realizing for it to be truly be a gift, it must be without bond.  However, somehow, the personal nature of wasting blood donations sticks in my craw.

I do not have a real solution for this problem. It is not practical to require a family in crisis to replace the donation, and I am not certain that would address the squander of a magical resource, nor the societal harm that comes from breaking a contact based on healing.  Nonetheless, perhaps this dilemma opens up another way of measuring futility. Not in money, nor in the willingness to suffer or cause suffering, but might we measure whether care is reasonable or necessary, by our willingness to consume such a perfect resource?

As an extreme example, what if this family had demanded a liver transplant?  How about a kidney? Open-heart surgery?  These would be ridiculous requests. Wasting blood seems less a waste, because it is easier to replace.  Nevertheless, what about if we were all more conscious of the true “cost” of the care we were demanding and the societal obligation we are assuming.  Might we be more cautious of what we request and what we are willing to “spend?”

Societies, like very large families, sacrifice and care for one another. However, we must never forget that in that web of life there is not only a responsibility to provide, but also for what we demand.  This balance, this obligation, creates vitality in our community and provides life to all of us.  We risk the whole when we assume precious gifts are ours to waste.






  • Stephanie
    I think this is a very interesting perspective. As a former blood donor, I took this job seriously. Sometimes I would consider the food I ate or the medication I took. They would call me from the blood bank for MY blood. Now that I have cancer, those days are over and I have missed the fact that I can no longer give back in this manner. Donated blood truly helped save my life when I was very young and almost hemorrhaged to death. A few weeks ago I was at MD Anderson seeking a miracle. At registration I was asked a series of questions I called "the Henrietta Lacks questions." I started to think about my rare cancer cells living long after my death and ultimately being helpful to someone somewhere. It's a funny thing, this need we have to contribute to and promote society's wellness even in our death. You're so right about the waste, but for this scenario to make sense to me I have to think that someone benefitted even if it was a resident or nurse learning a new task or sharpening their skill during some aspect of this unfortunate patient's care. Or maybe this paved the way for one of the family decision-makers to NEVER chose this way again for other loved ones in the future.
    • James Salwitz, MD
      I hope you are right, that this entire episode served to teach young doctors or perhaps some of the family members of the nature and harm in futile care. Thanks, jcs
  • Mary
    Well said again, doctor! But what if it is the Doctor that is trying to continue interventions on an obviously dying DNR patient?? "Just one more attempt" even as the least educated civilian can tell death is near. Then to have that same doctor question my loyalty and love for my mother (in an attempt to shame me into acquiescing) as I argued "not MY will but HERS be done." That inhumane scene played out scant hours before her death and the nurses and hospice were left to clean up the administrative and logistical mess since he would not "allow" her to die on HIS unit. It was an ugly cancer death made needlessly uglier by a hospitalist who had never set eyes on her before and obviously couldn't read the giant DNR on her chart. Must we tattoo it on our foreheads?
    • James Salwitz, MD
      Absolutely right ... it is not just families that cross the line (for whom they can be forgiven as they are under such terrible stress), but doctors, who should know better. Thanks, jcs
  • Liz
    I think the "blood" problem is a symptom of the underlying problem... a problem you have addressed in other blog posts - death, dying, discussions with the patient and family on the topic in a way they can hear it and act on it... as you have noted before, as a society we don't "do death" well.
  • Alyce Kowal
    Everyone needs an advance directive. I think it should be discussed with every cancer patient and their immediate families. It is sad to see so much wasted. We should have the right to die with a modicum of dignity.
  • Bill Wickart
    Given society's current relations with medicine, this point cannot be discussed too often. I forget the actual figures, but I recall seeing in many places that something on the order of 25% of medical costs -- in both resources and dollars -- are spent on the final few weeks of life, in palliative care and desperate delays. My family have been fortunate to have understanding medical support. My parents and my wife's were all listed as "DNR", and all of them died under simple, low-key support at that level: care for discomfort, but no wasteful measures of extension. In casual conversation, I've found that many people, including some of our well-educated friends, simply have not bothered to consider end-of-life care instructions. Mary's story of "not on MY unit" fortunately seems to be the exception, but still happens too often. As you've touched on many times, James, the doctor's victory is often not in returning a patient to stable health, but in treating the family through the patient's death.
  • IBS
    As far as giving blood, my friend needed my type blood for her son. I went to the hospital where they asked me a lot of questions. #1 Did you ever have Mono? I said, "yes" when I was 10 years old. They told me I can't be a donor. (I'm glad he didn't receive my blood because all of my medical problems, and the boy is fine today.) As far as a DNR, it doesn't work so easily. You need more information for the MD's. Look on the web for them.....Sign it and give it to your doctor to put it on your chart. Give your family members copies. Make sure one also has your doctor's name and telehone number of your doctor. I even carry the paper in my pocketbook. I personally feel Hospice should have a Chaplain that could come immediately to help the family accept their loved one is leaving and just talk to him/her for the hearing is the last to go. This way the family has peace. Hospice should also be retrained if they see a patient dying the day before, since she comes once a day. Perhaps the hospice nurse can speak to the doctor, and then she can call the chaplain. Remember, DNR doesn't always mean what you think. What about tubes, and other medical support systems. Perhaps the MD offices should have copies of an original DNR that explicitly states everything. Remember, it's right online.
  • Linda DeLia
    I find your comments are eloquent, very close to my ideas on the subjects and always thought-provoking. This one is no exception.
    • James Salwitz, MD
      Much appreciated...happy to hear from a kindred soul, jcs
  • Oncologist are a very special breed. It hurts my heart knowing all you witness but you have the previlage of very deep relationships. Our society has a hard time of letting death take its natural course. Families are often not prepared to just let go. Know the work you do is extremely important. I wish you a peaceful heart.
    • James Salwitz, MD
      Thank you very much, jcs
  • [...] via Wasting a precious gift – Sunrise Rounds | Sunrise Rounds. [...]
  • D Someya Reed
    I agree that such a futile situation wasted the blood resource. It’s sad that, it appears, the patient did not have an advanced directive or the family chose not to respect it. How do you feel about the practice of requiring a blood transfusion prior to surgery when not truly required (patient in normal range)but just to bump up the numbers so the surgeon is more comfortable (just in case)? There is no futility issue. Is this wise medicine or also wasting a resource?
    • James Salwitz, MD
      Work by Dr.Jeffrey Carson over that last few years has been lowering the trigger number for transfusions for surgery and in the ICU. That is to say, evidence says that we should transfuse less and only for severe anemia (once upon a time we transfused at a hemoglobin of 10, now the trigger for many situations is 7). In addition, research looking at the use of bone marrow stimulating agents, such as Procrit, has also lowered the goal on red counts. In both situations high numbers are not just wasteful or "futile", but possibly dangerous. Most experts would look at preoperative hypertransfusions as not a great idea. On the other hand, "donating" for yourself and having the blood on standby, can be a good idea for complex elective surgery. jcs
      • D Someya Reed
        I thought of mentioning "donating for yourself" but I understand that this (or compatible blood from a family member) is rarely allowed by medical facilities. Maybe this is a West Coast thing or "elective" is the key word?
        • James Salwitz, MD
          A number of major institutions nationally no longer allow directed donations of blood from family members. The open blood donor programs have made blood so safe, that if you push a family member to donate, that blood is potentially more dangerous (because your brother-in-law might not tell you about that wild time in Bogata before he met your sister). Self "donation" is still used widely, but requires signficant planning, therefore is limited to elective surgery. jcs
          • Bill Wickart
            Does the community still have the concept of donating on behalf of a particular person? Not that it's a directed donation, but that it replaces the unit, and somehow counts to the patient's credit. I tried to do this internationally last year, but ARC doesn't trade unit credits with eastern Europe.
          • James Salwitz, MD
            Not as much as in the past. I remember when there seemed to be an understanding that if Dad got blood, the family would give. Perhaps it is a committment we should encourage. jcs
          • The issues of dysfunctional families during traumatic times can impact communication and very often treatment. A friend, PHD Physics, had a similarly credentialed friend on regular dialysis whose healthy mom was a match. Would not donate..my friend was understanding...I could not understand that. When my husband was going into surgery (mitral valve) minimally invasive...a wife of another patient was sitting near me and desperate..her husband stressing her out by not following doctors orders was there for heart surgery as well..and also may have needed one of her kidneys..here..she did not look healthy enough..I suggested she not feel guilty but talk with a doctor about rational choice. The word 'waste' makes me uncomforatable when used in these discussions..but I think I understand..good post.
  • IBS
    Dr. S...When women are donating their life as a gift for others when they pass, is it possible for a person to donate a uterus? There are so many people that want children, yet so many, either through age or illness are unable to. What a beautiful loving gift; one may pass, but a life could still continue. For me, a precious gift is not wasted.
    • James Salwitz, MD
      Fascinating idea. Unfortunately the anatomic complexities and need to suppress the immune system, would make pregnancy unlikely and the risk to fetus very high. jcs
      • IBS
        Thank you for replying. ...perhaps in the future.

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