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Case

Dr. J, a second-year resident on the palliative care service, has become quite close to his patient, Emma, a 5-year-old girl with acute lymphoblastic leukemia. Two years ago, Emma completed successful chemotherapy and achieved remission, but a recent bone marrow biopsy showed lymphoblastic infiltration. She was started on a rescue therapy program with little response and underwent a bone marrow transplant. During this relapse, she has been hospitalized on multiple occasions for infections and bleeding, which required blood and platelet transfusions, and is now receiving palliative care for tumor lysis syndrome. It is Emma’s medical team’s opinion that there is no more that can be done to cure her leukemia, which prompted her transfer to the palliative care service. Shortly after transfer, Emma developed bright red blood per rectum, and Dr. J requested human leukocyte antigen (HLA)-matched platelet transfusion for her to help stop the bleeding.

Dr. S, a third-year pathology resident, received Dr. J’s request for HLA-matched platelets. Typically, pathologists oversee platelet distribution, since they are the physicians responsible for administering transfusion services in a hospital—maintaining an adequate blood supply, monitoring blood donor and patient-recipient safety, ensuring appropriate blood utilization, and directing the preparation and safe use of blood components according to a hospital’s platelet distribution protocol. Since Dr. S oversees a busy transfusion service with many sick patients requiring blood and platelets, one of her duties is to carefully assess each request for these limited resources. She contacts Dr. J and asks for more information about his request. Dr. S explains that HLA-matched platelets are in short supply and most often used for patients who are still being aggressively treated to try to cure their illness.

Dr. J responds, “Hmmm. . . . Why would the fact that a patient is no longer receiving aggressive acute care prompt us to reconsider her use of this resource? We still have an obligation to treat her, even when the goal is palliative rather than curative.” Both physicians wonder about how to proceed.

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AMA Journal of Ethics

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