Neurocritical Care (2018) 28:296–301

https://doi.org/10.1007/s12028-017-0478-4 (0123456789().,-volV)(0123456789().,-volV)

ETHICAL MATTERS

Transfusion of Blood Products in the Neurocritical Care Unit:

An Exploration of Rationing and Futility
Deepa P. Malaiyandi1 • Galen V. Henderson2 • Michael A. Rubin3

Published online: 29 December 2017

Ó Springer Science+Business Media, LLC 2017

Abstract
Rationing is the allocation of scarce resources, which in healthcare necessarily requires withholding potentially beneficial
treatments from some individuals. While it often entails a negative connotation, rationing is unavoidable because need is
limitless and resources are not. How rationing occurs is important, because it not only affects individual lives, but also
reflects society’s most important values. At the core of any rationing, decision is how much a limited resource may benefit
a patient, which can be particularly difficult to determine in the practice of neurocritical care, as prognosis is often
uncertain. We present a case for the consideration of futility and blood product rationing in neurocritical care.

Keywords Blood transfusion
Neurological prognostication
Rationing
Futility
Ethics
Conflict resolution

Introduction In [ 10,000 ICU bed triage decisions across North

The current cost of health care threatens the sustainability
of resource-poor and rich nations’ health systems alike.
The World Bank database estimates that health care
accounts for * 17% of the American gross domestic
product. This is the highest of anywhere in the world and
has also seen the greatest increase in the past decade from
13% in 1995. The Center for Medicare and Medicaid
Services is projecting a further increase to 20% by 2025. In
response, US governing bodies have charged all healthcare
professionals with providing cost-effect, quality-based
care. This challenge cannot be overcome without rationing.
Empiric data from multiple countries document the
rationing of medical services in intensive care units (ICUs).
This case analysis is work product of the Neurocritical Care Society
Ethics Committee and will become part of a recurring series on ethics
published in Neurocritical Care.
& Deepa P. Malaiyandi
malaiyandidp@upmc.edu
1
Department of Critical Care Medicine, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
2
Department of Neurology, Brigham and Women’s Hospital,
Harvard Medical Center, Boston, MA, USA
3
Department of Neurology, University of Texas Southwestern
Medical Center, Dallas, TX, USA
America, Europe, Israel, and Hong Kong, at least 15% of
patients were refused ICU admission, of which approxi-
mately 15% were attributed to lack of beds. Additionally,
during times of ICU bed shortages, admitted patients were
more ill at both ICU admission and discharge, average
lengths of stay were shorter, and fewer patients were
admitted for monitoring, which suggests that some patients
are denied potentially beneficial treatment in times of ICU
bed shortages [1–3].
Despite these being daily, sometimes subconscious acts,
the concept of bedside rationing remains controversial.
Stewards of health care are ever aware that our resources
are limited, with critical shortages of medicines, finite
beds, the need to re-allocate electroencephalogram ma-
chines, and at the most basic level, the time spent at a given
bedside can vary based on a number of factors. However,
withholding or withdrawing even scarce resources in the
absence of medical futility continues to generate angst
among providers. In this case, the resource in question is
blood products. While regulated by the Food and Drug
Administration (FDA) as a biological medicine, blood
must first be donated from an individual as a living tissue.
Since blood products are donated rather than manufactured,
there is an even higher level of concern for their appro-
priate use. Here in arises a sense of duty to protect and use
that gift judiciously. The prognostic uncertainty associated

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with neurocritical care poses unique challenges in trans-
fusion-related rationing decisions.
Medical futility, as defined by the American Thoracic
Society (ATS), refers only to interventions that simply
cannot accomplish the intended physiological goal [4].
This definition of futility does not include interventions
that could provide some benefit, but the likelihood is
unreasonably low compared to the probability that they
will only prolong suffering or will constitute unjust uti-
lization of a scarce resource. Such interventions are refer-
red to as potentially inappropriate according to the ATS
review. When considered in this context, futile care should
never be provided and withholding such care is not con-
sidered to be rationing but rather is necessary in order to
prevent doing harm. Thus, rationing is distinct from futility
and describes specifically the just distribution of limited
resources among society.
The concept that more care may be inappropriate is
rooted in the economic theory of marginal utility. As it
applies to health care, there is a limit to the benefit a person
can gain from being provided additional resources. For
those at the extremes of the spectrum, the margin is small.
Particularly for the chronic or critically ill to whom
immense resources may be allocated, yet they may be too
sick to benefit from them.
Currently, the Society of Critical Care Medicine
(SCCM) suggests that in general, ICU interventions should
be considered ‘‘inappropriate when there is no reasonable
expectation that the patient will improve sufficiently to
survive outside the acute care setting, or when there is no
reasonable expectation that the patient’s neurologic func-
tion will improve sufficiently to allow the patient to per-
ceive the benefits of treatment.’’ Though it also
acknowledges that our ability to accurately predict neuro-
logical outcome for many patients remains suboptimal [5].
An additional layer of complexity is introduced when
considering how one defines benefit, and yet another when
assessing the perceptive ability of the neurocritically ill. At
present, one’s ability to perceive benefit is determined
indirectly by their ability to express, even subtly that per-
ception has occurred.
There are few instances in which blood products would
be withheld based solely on neurological prognosis. When
this occurs, it is likely because transfusion may cause more
harm than good for either the patient or society with respect
to preserving scarce and vital resources. The act of either
giving or withholding transfusion in this situation consti-
tutes rationing depending on whether you have determined
the best use to be for the current patient or the many sta-
tistical patients in society. In such cases, counseling fam-
ilies on interventions that are potentially inappropriate or
necessitate rationing can generate conflicts among provider
teams and surrogates that further complicate care.
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In 2015, the ATS, American Association of Critical-
Care Nurses, American College of Chest Physicians,
European Society of Intensive Care Medicine, and SCCM
published an official policy statement on responding to
requests for potentially inappropriate treatments in ICUs.
Their recommended 7-step process is as follows: enlist
expert consultation; give notice to the surrogates; obtain a
second medical opinion; obtain review by an interdisci-
plinary hospital committee; offer surrogate to transfer the
patient to an alternate institution; inform surrogates of the
opportunity to pursue extramural appeal; and implement
the decision of the resolution process. When the emergent
nature of ICU care denies this structured approach, an
emergent ethics consult may be obtained. When this
resource is not available, it is recommended that the
physician determines the appropriateness of treatment and
uses as many of the 7 steps as possible to implement the
decision. Subsequently, the case can be submitted for ret-
rospective review to a multidisciplinary committee when
indicated. Ideally, these reviews would be used to create
hospital policies to guide practice in future similar sce-
narios [4]. Unfortunately, these recommendations remain
difficult to implement in neurocritical care as some soci-
eties continue to view neuroprognostication as a basis for
withdrawing, withholding, or rationing care as controver-
sial. The following case explores these issues.
Case
Dr. J and her neurocritical care fellow Dr. M were dis-
cussing contingency plans for high census on New Year’s
Eve when they received report on yet another admission. A
22-year-old man, unrestrained driver, was ejected when his
car was thought to have veered off a rural highway into a
ditch. He was last seen normal 8 hours prior to being
found. His best examination was documented as a Glasgow
Coma Scale (GCS) of 4 (extensor posturing) prior to
intubation in the field by emergency medical services.
While his non-neurological injuries were survivable, his
neurological injury was devastating and consisted of a
multi-compartmental closed traumatic brain injury (TBI)
as well as a dominant, holoterritory middle cerebral artery
(MCA) infarct. He was not a candidate for endovascular
therapy. He underwent emergent operative management of
his abdominal injuries as well as decompressive hemi-
craniectomy for evacuation of a large left temporoparietal
subdural hematoma and cerebral edema. Despite these
interventions, he continued to have episodes clinically
consistent with herniation, though these were short and
would respond to therapy. There were a number of family
members present with whom both Dr. J and Dr. M met that
evening. The severity of the neurological injury and poor
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prognosis were explained including concerns that their
loved one was unlikely to survive the night. The family
continued to request full intervention without limitations.
Ultimately, the patient died after developing disseminated
intravascular coagulation (DIC) complicated by gastroin-
testinal hemorrhage (GIB) early the next morning. From
the time of presentation to time of death, he had received a
total of 40 units of balanced transfusion of blood products
in addition to albumin and cryoprecipitate. Approximately,
one quarter of the products were prescribed throughout the
Neurointensive Care Unit admission. Dr. M later inquired
if it would have been appropriate to withhold blood
transfusion up on discovering new onset hemorrhagic
shock secondary to DIC, given poor prognosis and
expected high utilization of blood products on New Year’s
Eve.
Discussion
The Dual Definition of Blood-Based Therapies
The withholding of blood products at the end of life has
been addressed in both ethics and palliative care literature.
Approaches to transfusion limitation in the oncological,
non-transplant candidate, and non-survivable trauma pop-
ulations have been reported. To date, this has not
been addressed for the neurocritically ill [5]. In this case,
several resources were allocated to the patient, but it was
the massive transfusion that raised concern regarding
appropriate utilization of resources. This dilemma stems
from the biological definition of blood as a living tissue.
Medically, blood and blood products are therapies derived
from human donors. Like solid organs, blood products are
precious, life saving, and carry risk of infection as well as
immunogenicity. However, unlike solid organs, there are
no set criteria of eligibility or organized systems for their
rationing. This distinction is largely because donation is
noninvasive and involves minimal risk, and donors
replenish their circulating volume and blood bank stores.
Interestingly, despite their indispensible life-saving
properties, blood therapies were not added to the World
Health Organization model list of essential medicines until
2013. This was in part due to lack of an industry stake-
holder to undertake the effort of submission, but also
because it continues to be perceived as more than a med-
icine. The fact that blood products are consistently one of
the earliest interventions to be withdrawn across patient
populations lends credence to this widely held sentiment
[6]. Despite the reverence it garners, blood products pro-
cessed for the purpose of transfusion are only considered
tissues with respect to their biological origin, safety, han-
dling, and administration. Conversely, blood has been
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Neurocritical Care (2018) 28:296–301
included in the United States Pharmacopeia since 1930 and
has been regulated as a biological medicine under the
jurisdiction of the FDA since the Public Health Service Act
in 1973. The FDA oversight has led to standardization of
blood centers and improved quality and safety of transfu-
sion medicine [7]. However, this dual definition of blood
products as both donated tissues and regulated medicines
has also created an ethical dilemma for physicians on how
and when to ration their use.
The Ethics of Rationing and Resource Allocation
Surprisingly, a survey of US intensivists suggests that
many believe they do not ration [10]. These results may
reflect a lack of understanding of what rationing is or may
reflect a symbolic belief that physicians’ should not be
involved in bedside rationing of care. In either case, the
lack of insight about the inevitability of rationing in ICUs
is problematic, because it suggests that many neurointen-
sivists are not well positioned to be informed participants
in the social conversation about how best to make these
difficult decisions. Daily decisions about who to round on
first, how much time to spend on them, how to prioritize
completion of procedures, and who to give ICU beds to are
all rationing decisions, even if they are not labeled as such.
The main ethical objection to rationing is that physicians
owe an absolute duty of fidelity to each individual patient,
regardless of cost. As we develop a relationship with our
patients and their families, we inherently become biased in
advocating for their well-being over patients for whom we
may not have any connection or interaction. Consider how
often we waver from standard of care when we become
invested in a patient and are tempted to lose our object
professionalism. Likewise, there is a much smaller chal-
lenge to our integrity to protect limited resources when we
have no connection to a patient and they are a reality
removed from our immediate experience. This objection
fails when resources are exhausted or are very limited and
the statistical people who are deprived of care become real
patients. Physicians collectively owe loyalty to them as
well. The ethical argument about rationing then shifts to
questioning the fairest means for allocating scarce resour-
ces through the use of a quasi-objective measure or to start
considering futility of care.
A prior misconception was that futility arose only when
physicians, in keeping with their professional integrity,
refused to offer useless treatments even when patients or
families demanded it. It is now understood that futile
interventions may be administered not solely because of
patients’/families demands but also by physicians acting
out of habit or on the basis of flawed evidence. The ethics
of wasting resources is in part a component of the ethics of
professionalism.
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There are two principal ethical arguments for possible
wasting of resources. The first is that we should not deprive
any patient of useful medical services so long as there
continues to be waste within the system. The second is that
over-aggressive or defensive medical decisions cause
harm. Treatments that will not help patients can cause
complications. Diagnostic tests that will not help patients
produce false-positive results that in turn lead to more tests
and further complications. Primum non nocere becomes
the strongest argument for eliminating non-beneficial
medicine.
Case Analysis
This patients’ presenting neurological prognosis is poor
based on his conditions of a dominant malignant MCA
infarction and severe multi-compartmental TBI associated
with low presenting GCS and hypotension. Ongoing epi-
sodes of intracranial pressure (ICP) crisis despite maximal
therapy further support extremely poor outcome. Here
there is insufficient time to engage in a multidisciplinary
committee process. How should the individual neuroin-
tensivist arrive at an acceptable unilateral decision without
knowing for certain if it is ‘‘reasonable’’ to expect that
neurological recovery will be sufficient to ‘‘perceive’’ the
benefit of treatment? Will there be others in need of mas-
sive transfusions as it is New Year’s Eve? Once significant
resources have been allocated toward an outcome that had
been acceptable to that point for a given individual, is it
more or less wasteful to ration a comparatively lesser
amount of the same resource? Here, the initial thirty units
of balanced transfusion prescribed from the emergency
department presentation to ICU admission, and the addi-
tional four units during ICU admission were able to
achieve stabilization from shock until the onset of DIC and
GIB early the next morning. Even for highly experienced
clinicians, it is difficult to discern the inflection point at
which the diminishing marginal utility of treatment tran-
sitions to being an unjust utilization of a scare resource.
Also, these decisions are being made in real time while
physically and cognitively engaged in the act of bedside
resuscitation and in providing family support. In this
intense environment with a complex interplay of unknown
variables, it can be tempting to pursue the path of least
resistance. Transfuse now and contemplate the difficult
questions later. This also avoids conflict with distraught
family who may find some comfort in believing that no one
‘‘gave up’’ on their loved one.
However, among the care team there can be negative
reactions beyond the potentially unjust use of blood
including feelings of guilt from inflicting harm by pro-
longing suffering and being distracted from providing care
299
to other patients. Ultimately, these sentiments contribute to
moral distress. In one study of nearly 2500 ICU nurses, the
number per week of conflicts with patients, dying patients
cared for, and withdrawals of life-sustaining treatment
were independent factors associated with burnout. A
number of studies have suggested burnout rates among ICU
providers as high as 50% in physicians and 33% of nurses.
Burnout is associated with increased turnover, loss of
productivity, poor patient care, substance abuse and even
suicide [8]. Thus, it is imperative for all healthcare provi-
ders to have avenues through which difficult cases can be
discussed, and through which, the use of ethical principles
to guide such decisions becomes increasingly familiar.
There are two ways to approach the decision to re-ini-
tiate blood transfusion. Both begin with an understanding
that futility does not apply at the onset of DIC because
blood products can treat hemodynamic instability form
hemorrhagic shock caused by DIC. The debate is weather
or not futility must be met in order to justify withholding
treatment. One argument is to give a trial of empiric
transfusion because the patient is young and neurological
recovery is less predictable in these individuals. If the
intervention does not produce the intended physiological
goal, then further transfusion is futile and only comfort
care should be offered. An alternative argument is that
while re-initiating transfusion is not futile, to do so could
be inappropriate because DIC is a complication that has
been estimated to increase the mortality of isolated TBI by
17–50% [9]. In this case, the likelihood of a transfusion
effectively treating this grave complication, restoring
hemodynamic stability, and supporting an overall recovery,
when the preexisting likelihood of sufficient neurological
recovery was so low, is unreasonably small when com-
pared to the likelihood of only prolonging suffering.
In this alternative analysis, blood transfusion is seen as
inappropriate and inadvisable. The gravity of withholding
transfusion in this case is that it also necessitates a transi-
tion to comfort measures. Attempting cardiopulmonary
resuscitation for hemorrhagic shock when DIC is unre-
sponsive to transfusion violates the primary tenet to do no
harm. Therefore, a unilateral decision by the healthcare
team to withhold further transfusion and change the goals
of care to comfort measures would be required. Unilateral
decision making is both undesirable and uncomfortable.
The threat of legal action against the physician and the
hospital is real, as is increasing controversy regarding
limitations of care decisions being based on neuroprog-
nostication. However, the ethical ramification for individ-
ual providers is equally, if not more concerning.
Innovations in neurorehabilitation have produced good
outcomes, particularly in the young, that previously were
not achievable. The thought of withholding treatment from
someone who could potentially have a recovery consistent
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with his or her goals adds to the moral weight of the
decision. Despite these concerns, unilateral decision mak-
ing is a rare but necessary reality in order to advocate to
ease suffering and to preserve the dignity of the dying.
Even this seemingly intuitive argument may not be appli-
cable for those who believe that life must be prolonged at
all costs despite any amount of suffering. In some religious
traditions, suffering is a sign of faith and spiritual renewal,
but physicians have an obligation to attempt to amend
physical and, some would say, existential suffering.
When careful consideration of the above analysis is yet
unyielding of an acceptable decision, it is appropriate to
consider the principle of justice. Is the initiation of trans-
fusion to treat DIC in an individual with devastating neu-
rological injury and ICPs refractory to maximum therapy
consistent with fair and equitable allocation of resources?
Also, age is a strong predictor of neurological outcome.
Often in medicine, and neurocritical care in particular,
aggressive interventions are extended in the young in
whom long-term outcomes are less predictable. Was it just
to have continued transfusion based on age? Would the
same decision have been made if the patient were elderly?
These answers must also consider the potential for strain on
hospital and regional blood blank stores during periods of
known increased demand, such as New Year’s Eve. Some
believe rationing of blood should only occur in the event
that there is another patient, with a better likelihood of
survival, in need and the stores are insufficient to treat both.
The obvious limitation is our inability to predict if or when
a competing need might arise. It then follows that bedside
rationing of blood products in anticipation of potential
patients who are more likely to have a better outcome
would be the appropriate action.
Case Summary
Arguments for Transfusion
1. Only treatment for hemorrhagic shock resuscitation.
2. Only definitive treatment for DIC.
3. Despite severity of neurological prognosis, young age
may afford a small chance for an outcome consistent
with patient and family goals.
4. Respect patient/surrogate autonomy.
5. Avoid unilateral decision to withdraw care and poten-
tial for associated legal and ethical consequences.
6. The team is not aware of an immediate shortage in
blood products that would directly affect another
patient.
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Arguments Against Transfusion
1. Chance of ‘‘good’’ outcome is unreasonably small
compared to chance of prolonged death and suffering.
2. Unjust allocation of resources during a period known
for high utilization of blood products.
Conclusion
This case illustrates the complexity of ethical decision
making in the practice of neurocritical care. It highlights a
number of reasons why, for many, the natural tendency is
to avoid rationing. It is an idealistic perspective that in
high-stakes environments such as the ICU, resources that
are not in immediate critical shortage should continue to be
distributed as though they exist in endless supply and that
there are limitless financial resources to replenish them. For
the purposes of resource allocation, the nature of blood
being a donated tissue forces even the strongest opponents
to have to accept that we indeed must ration. Consequently,
neurointensivists need to understand the nomenclature and
systems that allow for a just distribution of such resources
in order to be better-informed participants in making dif-
ficult decisions regarding competing social goods.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
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