View
2
Download
0
Category
Preview:
Citation preview
Blood Donation
Ethics & Law
Case 7 ILOs
To discuss the ethical complexities of blood donation
We will be covering
Blood donation – Gift or commodity?
Safety of supply and transfusion – When things go wrong
Blood refusal
Blood donation – Gift or commodity?
Blood donation – Gift or commodity
Who might need blood?
Any of us and not only that there is an expectation that it is there
when we need it.
Is it fair that if we are not prepared to donate we should have the
unreasonable expectation that we are entitled to receive?
Blood donation in the UK
UK NHS blood services
NHS Blood and Transplant
Scottish National Blood Transfusion Service
Welsh Blood Service
Northern Ireland Blood Transfusion Service
Altruistic, voluntary non-reimbursed blood donation
Approximately 5% of eligible people are regular donors
Barriers to donation
Donor & rarer types shortage
Black, Asian and minority ethnic donors and recipients
Blood donation – Gift or commodity
A gift of life?
-As a society we strongly encourage donation i.e giving.
-To donate blood is a morally good thing to do-help another
human.
Scenario 1
Mrs X is a 35 year old lady, she has 2 children aged 5 and 7.
She presents to A&E with abdominal pain and internal bleeding.
Mrs X has a ruptured ectopic pregnancy.
She requires an emergency blood transfusion. There is a
shortage of her blood type and stocks have been low. She does
not survive.
Blood donation – Gift or commodity
Given there have been shortages in blood supplies, should we
pay people?
Sales of blood
Against
Society should encourage people to be altruistic.
Moral personhood; people should not be treated as things
that can be bought/sold.
There is the risk of vulnerable/poor being exploited.
People are less likely to disclose health problems when
donating if there is a financial incentive.
Compromise own health by donating too often.
Blood should be given on basis of medical need not to
whoever can pay the most.
Sales of blood
For
False dichotomy presented-gift/sales.
Duty to rescue.
Life saving necessity-avoid the harm of human suffering.
Supply/demand issues are determining price.
Altruism is not necessarily moral.
WHO
“The safest blood donors are voluntary, non-remunerated donors
from low-risk populations.”
http://www.who.int/bloodsafety/voluntary_donation/en/
Safety of supply and transfusion –
When things go wrong
Blood transfusion – safety and risks
Relative safety of blood transfusion in the UK
Donor selection, screening, testing…
Haemovigilance - Serious Hazards of Transfusion
Better Blood Transfusion
Wrong blood
Nearly 2 million red cell units issued across UK in 2014
10 ABO incompatible transfusions, 1 major morbidity
‘Never events’
Acute transfusion reactions
Transfusion transmitted infections
Transfusion Transmitted Infections
Transfusion Transmitted Infections
Bacterial sepsis
CMV
vCJD
Serious blood-borne viruses inc Hepatitis B, Hepatitis C, HIV
Rare
Measures to avoid
Donor selection, screening, testing, deferral, exclusion
Treatment and appropriate handling of blood products
Importing blood products
NHS contaminated blood scandal
‘The worst treatment disaster in the history of the NHS’ - Lord
Robert Winston
1970s-1980s
Blood products imported from USA and some domestically sourced
Blood donations were sought from high risk populations
Contaminated with Hepatitis B, C and HIV
Pooled products to produce clotting factors were very high risk
Around 5000 people with haemophilia and others were and are affected
Scenario 2
Mr X had a laparoscopic cholecystectomy. The procedure was
surgically quite challenging and he lost a significant amount of blood.
The surgeon felt that he couldn't continue the laparoscopic procedure
and so converted to an open cholecystectomy.
In total Mr X was transfused 5 units of blood. He makes a good
recovery and is discharged home.
A year later Mr X presents to his GP with a 9 month history of general
malaise, arthritis, myalgia and abdominal pains. He is found to have a
virus contracted when he received the blood transfusion.
Scenario 2
His virus could have been picked up by a screening test. The
screening test is known to be very expensive but detects the virus.
If you were to test 10000 units of blood you would only pick up the
virus in 2 units.
Safe blood/transfusion
We have an ethical/legal responsibility to ensure that blood is safe.
Is it better to have more blood available or maintain a pool with higher
purity?
Consent
-Explain why a blood transfusion is indicated.
-What the associated risks are.
-Outline if there are alternative options available.
http://www.transfusionguidelines.org/transfusion-practice/consent-for-
blood-transfusion-1
Blood Refusal
Who might refuse blood?
Anyone
Jehovah’s Witnesses
Beliefs about blood transfusion
Talk to your patient
Scenario 3
Mrs Z was involved in a RTA. She is brought to A&E with multiple
serious injuries. She requires emergency surgery.
She is unconscious and is haemodynamically unstable as she
has lost a significant amount of blood.
Scenario 3
In an emergency situation, if a patient lacks capacity then we act
in their “best interests” and deliver “life saving treatment” if we
have no reason to believe they have registered a valid “advanced
refusal of treatment”.
Case 4
Newcastle Upon Tyne Hospitals FT v LM [2014] EWHC 454 (COP)
LM is a Jehovah's witness. She was found to have a bleeding
duodenal ulcer. She was profoundly anaemic but despite this was
adamant that she didn't want blood products and understood that she
may die without transfusion. Her discussion with the
gastroenterologist was documented in her medical records. She was
felt to have capacity.
A few days later she deteriorated and required intubation/ventilation.
She had no formal advanced refusal of treatment or lasting power of
attorney.
Case 4
Newcastle Upon Tyne Hospitals FT v LM [2014] EWHC 454 (COP)
Would it be lawful to withold transfusion?
Case went before the court of protection.
-Prior to losing capacity she had clearly indicated her wishes.
-Must respect her autonomy.
-Competent adult is permitted to make decisions even if we consider
them unwise.
-Would not have been in her best interests to be transfused against
her will.
Scenario 5
A 16 year old undergoes a tonsillectomy. Overnight post-operatively
they have a haemorrhage necessitating a blood transfusion. He
refuses a transfusion. His parents are telephoned and they also
refuse to give consent.
It's 2am and you are alone on the ward. You have called your
Consultant who is making their way into hospital.
What should you do?
Scenario 5
Re R (A Minor)(Blood transfusion) [1993]
Court ordered that child be given a blood transfusion, despite parents
refusal (jehovah's witnesses).
If parental consent cannot be obtained, further legal advice must be
sought.
Who might refuse blood?
The usual rules about consent and refusal of treatment apply
A competent adult (an adult with capacity) has a right to refuse
even life-saving treatment
Valid, applicable, Advanced Decisions to Refuse Treatment,
where there is no good reason to believe the incapacitated adult
has changed their mind, must be respected
Providing emergency treatment, that which is immediately
necessary to preserve life, taking account of the above, is the
right thing to do
Who might refuse blood?
Who can consent for a minor? A parent
A minor aged 16-18 can consent for themselves
A competent minor can consent for themselves
The courts
Case Law Re S (a minor: medical treatment)
Re E & Re L (a minor)
Blood refusal situations – Who and what might
help
Elective procedures – Planning
Seniors
Medical optimisation
Iron, B12, folate
EPO
Crystalloids & Colloids
Cell salvage
Hospital liaison committee
Hospital legal department
On call judge – specific issue orders
Defence body
Any questions?
Recommended