Requests for Directed Blood Donations

Abstract

This Ethics Rounds presents a request for directed blood donation. Two parents feel helpless in the setting of their child’s new leukemia diagnosis and want to directly help their child by providing their own blood for a transfusion. They express hesitancy about trusting the safety of a stranger’s blood. Commentators assess this case from the perspective of public health ethics in the setting of blood as a scarce community resource during a national blood shortage. Commentators review the child’s best interest, right to an open future, and harm-benefit considerations. Commentators recognize the professional integrity, humility, and courage of the physician to admit his own lack of knowledge on the subject and to seek help rather than claim directed donation is not possible without further investigation into options. Shared ideals such as altruism, trust, equity, volunteerism, and solidarity are recognized as values relevant to sustainment of a community blood supply. Pediatric hematologists, a blood bank director, transfusion medicine specialists, and an ethicist provide a range of perspectives to inform the case.

Directed Blood Donation (DBD) poses a values tension between sense of fiduciary responsibility to one’s own child versus blood as a common good gift to benefit the larger community.

Of the over 2 million blood donors collected annually in the United States by the American Red Cross, approximately 1,000 donors each year were through directed blood donations (personal communication),¹ with noted increase in directed donation requests during the coronavirus pandemic.² Directed donations occur when a family member or friend donates blood for an individual anticipated to need a blood transfusion in a non-urgent setting. The blood product (whether red blood cells (RBC), platelets, or less often plasma) is collected, processed, distributed, and stored within hospital blood banks, and then transfused to the intended recipient if needed. Directed donors are required to meet the same eligibility criteria as community (non-directed) volunteer donors. As a result, blood components derived from directed donors can be used for other patients if not used by the intended recipient. Autologous donations (for the patient to later use his or her own blood, e.g., post-operatively) are a type of directed donation, while allogenic directed donation are given from a known related or unrelated donor acquintenace.

In some instances, it may be medically necessary to perform DBD for hematologic or immunologic indications, such as transfusion of maternal platelets in neonatal alloimmune thrombocytopenia or providing blood from donors with rare blood types to recipients with alloimmunization to common antigens. For a child who may require multiple donor units, there may be benefit to directed donation by decreasing donor exposure. In other scenarios, the medical burden or benefit to the child may be equal between receiving directed donation versus community donor blood and then the family’s values and public health ethics warrant additional thoughtful consideration.

The Case

A 5-year-old girl presented to her primary care provider with fatigue. She was found to be tachycardic and markedly pale, and her primary care provider referred her to the emergency department. At presentation, her white blood cell count, hemoglobin, and platelet count were low, and her lactate dehydrogenase and uric acid were high, raising the concern for leukemia. Jane’s parents were shocked and saddened by the news. When the treating physician explained the need for an emergent blood transfusion, both parents asked about whether they could donate blood for her. They wanted to do something to help their daughter and were worried about her contracting an infectious disease from a transfused unit from an unknown donor. The physician would generally tell parents that directed donation is not possible but also recalled receiving emails and seeing newspaper articles about a national blood shortage. He tells the parent “I don’t know” when asked whether direct donation would be an option for their child’s first transfusion. He asks the hematologist/oncologist on call, who is coincidentally a member of the hospital’s ethics committee, for help.

Dr Courtney Lawrence, Community Blood Bank Director, Transfusion Specialist, and Pediatric Hematologist, Comments

Both the necessity and feasibility of directed donor requests should be contextual to the multifactorial decline in global blood collection³ and the national blood shortage occurring in the United States at the time of the child’s diagnosis which was notably the worst shortage in over a decade.⁴ The collection, processing, and storage of blood for a specific recipient requires additional logistic, financial, and personnel considerations. Cost-effectiveness studies have indicated that directed donation assumes higher staff time investment for product preparation and higher processing cost.^5–7 During contingency and near crisis measures such as during the pandemic, blood collection organizations and healthcare facilities face not only supply chain challenges but also staffing shortages which can substantially impact the ability to accommodate additional workflow processes required in directed donation product collection and tracking. As blood remain a finite resource with its temporal availability susceptible to multifactorial trends influencing demand, donor recruitment, and blood collection, careful consideration must be given to personal preference for blood source and public health efforts to augment supply.⁸

To uphold blood stewardship, directed donations require additional attention to minimize product waste. Directed donors are required to meet the same eligibility criteria as volunteer community donors, and consequently units from directed donors can be used for other patients if not used by the intended recipient. Potential product reallocation requires ongoing clear communication between laboratory staff and clinical providers for the intended blood recipient, as well as awareness of the expiration date of the product. If the recipient is a small child who does not require transfusion of the full volume of the donor unit, staff must also determine how to best utilize the remaining product. Out of fidelity to the intended recipient who may be anticipating future availability of the donated product, its limited shelf life (e.g. 5 days for platelets and up to 42 days for RBCs) requires transparent communication of expectations to the donor, recipient, and clinical teams.

Trustworthiness represents a core tenet of transfusion medicine, as families need to be able to trust the safety and fairness of the blood donation process. The U.S. Food and Drug Administration is responsible for ensuring the safety of donated blood. According to current surveillance, every donation is screened for Hepatitis B and C (HBV and HCV), Human Immunodeficiency (HIV), Human T-Lymphotrophic, and West Nile viruses as well as Trepenoma pallidum (syphilis), with Trypansoma cruzi (Chagas disease) at first time donation.⁹ Cytomegalovirus (CMV) serologic testing occurs when needed for certain recipients, and additional infectious disease screening may be instituted for donors living in endemic areas (e.g. babesia testing for donor collections in the Northeastern and upper Midwestern U.S. states) or during outbreak periods (e.g. Zika virus screening from 2016–2021). Due to storage conditions that make platelet products more susceptible to significant bacterial contamination, platelets either undergo pathogen inactivation at collection or additional screening methodologies post-collection.^{10, 11}

In the United States, the “estimated residual risk”¹² of transfusion-transmitted infections are very low; generally reported at 1 in 2 million transfusions for HIV, HBV, and HBC.¹³ Notably, the last US reported case of transfusion-transmitted HIV infection was from a 2008 transfusion depite well over 10 million products transfused per year,⁹ thus these numbers may be considered conservative risk estimates. The family should be informed that there is no evidence that directed donor blood is safer than volunteer donor blood supply for children.^{7, 14} From an infectious disease and patient safety perspective, directed donation does not represent a superior form of donation for the child. The risk of transfusion from the community blood supply does not in itself justify directed donation for the child although the values or beliefs of the family may justify pursuing directed donation when additional time to procure a direct donation does not place the child at increased risk of medical harm. Family requests must also be contextualized to the ability of the blood supply chain to feasibly meet public health needs in times of national shortage.

Dr Marianne Yee and Dr Ross Fasano, Pediatric Hematologists and Transfusion Specialists, Comment

The harm and benefit ratio specific to the child in the case should take decisional priority. Directed donations are mainly used in non-urgent settings because the time required to ensure donor/intended recipient ABO compatibility and donor infectious disease testing is complete prior to blood component release prohibits DBD use in more emergent situations.

Because of an increased risk of transfusion-associated graft-versus-host disease due to human leukocyte antigen similarities in family members, all cellular blood products (i.e. RBC, platelets) from related donors undergo pre-transfusion gamma irradiation. In Jane’s case, blood products from any donor should be irradiatd due to her presumed leukemia and immunocompromised state. Due to potassium and free hemoglobin leakage 24 hours following irradiation, RBC units should optimally be irradiated as close to administration as possible rather than stored for prolonged periods following irradiation, especially for neonates or other patients who may not be able to safely tolerate a large potassium load.^{15, 16} If the hospital’s blood bank has an irradiator on site, this poses minimal logistical challenges for directed donor RBC units. However, as part of the ethical duty to plan, optimal coordination between the hospital’s clinical service, transfusion service, and blood supplier is required in cases where units are irradiated off-site at the blood collection center. Logistically, it would be easier to get any available ABO-compatible red cell product froma blood supplier that could be irradiated prior to shipping over at a time of need than coordinating irradiation of a specific direct donor product off-site. Whether the child’s clinical condition would be harmed by waiting comes into consideration in order to foster the best interest and better clinical outcome for the child.

Beyond the biologic, the psychosocial experience of the family warrants consideration. The family is seeking to help their child in what must feel like an overwhelming and helpless moment. In the event that the child experiences an adverse reaction during or as a result of the transfusion, there may be an unintended imposition of parental guilt when the parent is the donor, which would not occur following a transfusion from an anonymous donor due to lack of personal familiarity with the donor. Directed donations are not free from transfusion reactions, particularly in situations of directed granulocyte donations which are complicated by upward of 10% rate of alloimmunization and other transfusion reactions.¹⁷

For many years, there has existed public perception that blood transfusions from family members or close family friends are safer than allogeneic transfusions from volunteer community donors. However, there is no evidence that directed donor units are safer, and in fact higher rates of positive infectious disease markers have been shown in directed donor units compared to repeat volunteer donor units.^{18, 19} It has also been demonstrated that first-time parental donors have significantly higher rates of positive infectious disease testing results compared to volunteer community donors for their children.²⁰ Truthfulness represents a core tenet in the blood donor screening process and parents (or family friends) who are trying to help their own child (or their friend’s child) may have an additional pressure to answer screening questions in accordance with approval to donate. DBD may pose privacy risks in revealing past bloodborne illnesses or high-risk behaviors to the co-parent (or family friends) as parents may wonder why their co-parent or family friend is not able to donate for their child. For fairness, integrity in donor requirements, and consistency in standards, directed donors should still be selected according to institutional and federal guidelines rather than the creation of special exceptions for directed donor qualifications.

A remote but real risk in directed donation from parent to child is HLA alloantibody development. In the instance where the blood donor may potentially be considered to serve as a donor for a future bone marrow transplant (BMT) for the recipient, exposing the child to DBD may result in HLA antibody formation that would later preclude that parent from serving as a haplo BMT donor or result in graft rejection. Ethically, requests for DBD should be contextualized to the child’s right to an open future with consideration of whether a directed donation would restrict the child’s access to a future familial-donor transplant. While it would be an over-statement to imply that a child who received DBD unequivocally could not later receive a bone marrow or solid organ transplant from the donor, providers should continue to try to minimize risk of HLA alloimmunization against familial donor alloantigens particularly when haploidentical transplant may be considered in the future.

Dr Meaghann Weaver, Palliative Care Physician and Ethicist, Comments

Jane’s physician previously told families that DBD is not possible likely because directed donation was not a familiar process. When a family requests an unfamiliar intervention, the request presents an opportunity to admit a lack of knowledge and to commit to gathering new information to better inform the response. Medical interactions include “meetings between different epistemologies (i.e., lay and expert knowledge)” with asymmetry in power dynamics.²¹ The physician in this case voiced the powerful phrase, “I don’t know”, which linguistically carries both a literal admission of knowledge void and also an important relational role of humility. It takes professional courage and humility to admit lack of expertise on an uncertain topic.^{22, 23} In an era when physicians are expected to offer ready knowledge and encylopedic answers,²⁴ admitting “I don’t know” upholds professional integrity.

Curiosity remains both an ethics competency and a keen clinical commitment. “Let me look into that” offers a more dignified and partnering response than an uninformed “not possible.” The emergency medicine physician upheld professional integrity by asking a knowledgeable colleague about options available for the family. Asking for clarity and seeking additional information requires awareness of personal cognitive bias or blind spots in order to fill in information gaps.

Beyond just the academic or acquisition of new knowledge, curiosity also lends itself to learning more about the beliefs and values held by Jane’s parents. Learning what motivates their request for DBD would offer insight into the values guiding their preference for DBD.

The physician has an opportunity to honor the parents’ role and respect the parental desire to help their child in what feels a helpless moment. The physician can explicitly recognize the parental intention to care for their child directly as a shared intention with medical team’s goal to also care well for the child. This case provides opportunity to expand the parents’ sense of fiduciary responsibility to the child to also recognize altruism as a community value. In settings with a large and primarily volunteer blood donation system such as in the United States, strangers donate blood to sustain one another. This signifies that values such as altruism, trust, equity, volunteerism, and solidarity sustain the community blood supply.

A robust volunteer donation system expands the accessibility of this resource. In many countries, the infrastructure for blood donation systems and community blood banks does not exist and all blood donations are obtained through direct family connection.. In some countries, donors are elicited from within the recipient’s genetic blood line as a practice culturally aligned with family-oriented expectations.^{25, 26} In other countries, principles of altruism and community duty include donation of blood when need arises within a social circle even outside of the immediate family unit.^{27, 28} A potential consequence in settings where donations must be obtained by family recruitment of others includes preferential access for children from larger healthier families of means, and decreased access for children without such advantages or social networks. The collection of blood for a child from voluntary and specifically nonreumunerated community donations helps to avoid confounding motivations of duty, coercion, side payment or bribery, or personal gain that may come from reliance on social networking to obtain blood.²⁹

Justice means avoiding the systematic creation of separate blood access routes based on privilege while still attending to the relational or safety values motivating DBD requests. The physician is uniquely positioned to honor his professional integrity in admitting lack of knowledge and willingness to obtain knowledge, to explore the family’s values, and to consider the larger community and public health values.

Outcome of the Case

Jane begins to desaturate when sleeping and needs supplemental oxygen. Now that she is symptomatic from her anemia, there is increased risk if transfusion is delayed which shifts the harm-benefit ratio. The provider meets with the family to recommend transfusing available blood from the community supply as the timeframe required for directed donor blood processes would delay care. The physician shares education materials with the family regarding the safety of the community blood supply. He also provides initial information about the process for DBD for the family to further discuss together with the hematology and oncology team. The child’s father asks how he can donate to the community blood bank tomorrow to “give back” for the unit of blood his daughter will receive tonight.

Abbreviations:

BMT

Bone Marrow Transplant

DBD

Directed Blood Donation

HBV

Hepatitis B Virus

HCV

Hepatitis C Virus

HIV

Human Immunodeficiency Virus

RBC

Red Blood Cells