Blood sampling from dying patients: an ethical dilemma

Introduction

A version of this article has been published previously in a Norwegian-language journal. ¹ At Norwegian hospitals blood sampling from inpatients is performed by biomedical laboratory scientists (BLSs), whereas in many other countries nurses do this. The Clinical Ethics Committee (CEC) at Lovisenberg Diakonale Hospital received the following case for deliberation from one of the hospital's BLSs:

BLSs frequently experience the following dilemma: blood tests have been ordered on a patient who, when we arrive, turns out to be in terminal phase. Often deeply distressed relatives are present. We are very reluctant to intrude in such situations, and often the relatives will ask if blood tests are really necessary. We then turn to the ward nurses, who may reply that blood sampling must be performed because ‘the doctor has ordered it’; or that ‘when the doctor has ordered tests it is probably important’. We can see that it is not easy for the nurses to decide; and often the doctor will say (if we even get hold of him or her) that blood tests must be performed anyway. This feels both unpleasant and disrespectful towards the patient and the relatives, and for these reasons we would like a discussion of the ethical aspects of the case.

In what follows we discuss the moral aspects of the BLS's dilemma. The case was originally discussed in the CEC and structured around the model for case deliberation developed by the Centre for Medical Ethics at the University of Oslo. ² This model involves the identification of the ethical problem and the facts of the case; identification of the parties involved and their interests; the relevant norms, values and legal regulations; and the identification and evaluation of available lines of action. Our discussion builds on and expands the original deliberation at the CEC, while retaining the structure of the discussion as outlined.

We conclude that the BLS ought not to take blood samples in this situation without having attempted to clarify the justification for the procedure. The dilemma is an example of how health-care workers could come to experience moral distress and have their moral integrity challenged.

What are the facts of the case and the ethical problem?

As we shall see the case raises issues for several categories of health-care workers, but we choose the BLS's dilemma as our focus: How should a biomedical laboratory scientist act in cases of possibly purposeless blood sampling from dying patients? What should the BLS do when he or she thinks it medically wrong to take blood samples but the doctor/nurse disagrees?

A purportedly typical situation from clinical practice in a Norwegian hospital is described above. Many blood samples are taken in the morning. These have often been ordered by the doctor at the ward rounds the previous day. The patient's condition can have changed substantially since the last time the doctor examined the patient. Often the blood sampling is performed just after the nurses’ morning shift has begun, and so the nurse in charge is perhaps not always fully updated on the patient's situation. This sometimes has unfortunate consequences and to our knowledge several instances have occurred where the patient had died as the BLS, unaware of this, entered the room for blood sampling.

The BLS's role involves a brief contact with the patient, where one gets only a brief impression of the patient's current status. The nurses, on the other hand, spend more time with the patient, and have often followed the patient throughout the hospital stay. This gives them a better basis for assessing the patient's condition. However, even though BLSs do not have the same training in clinical assessment as nurses, at the time they visit the patient they get the most current impression of the patient's status. Therefore the BLS will sometimes wonder why certain tests have been ordered, or why tests have been ordered at all, considering the patient's condition. However, whether the patient is really dying within a short amount of time is often difficult to establish.

Blood samples usually have no place in the care of patients who are in a terminal phase and are expected to die within days. In this phase good medical practice involves giving priority to symptom relief, and not to diagnostic procedures. ³

Who are the parties involved, and what are their views and interests?

Five parties are involved: the patient, any relatives present, the BLS and the nurse and the doctor in charge of the patient. A dying patient needs high-quality palliative care, and to be spared for medical procedures that do not have positive consequences; that is, purposeless treatment and diagnostics. The relatives are concerned with the patient getting a good and dignified death, and for the health-care team to act with care and respect. The BLS will perform blood tests for the sake of the patient's interests, but will not wish to burden the patient unnecessarily, as purposeless sampling can. The BLS in our case experiences that he or she suddenly and without the opportunity for preparation becomes a respectless intruder into a situation of vulnerability where a patient is dying. The nurse effects the treatment ordered by the doctor, in addition to providing quality nursing care while also being aware of the needs of the relatives. The doctor will order treatment to relieve the patient's suffering. Before the doctor judges that the patient is very close to death he or she will also attempt to identify and treat reversible conditions such as infections, dehydration and electrolyte disturbances. The doctor should only order tests that potentially lead to a benefit for the patient. All these categories of health-care workers can experience time pressure, which would make it harder both to acquire an up-to-date impression of the patient's condition and to provide quality health care.

We would also mention that BLSs and doctors could view blood testing in different ways. BLSs could experience at close hand a hospital's overuse of laboratory tests, and may focus on the need for the reduction of unnecessary testing. Doctors focus on diagnostics, curing and prolonging lives, and may realize later than would be ideal that the patient is in a terminal phase where the focus must change. Different approaches like these could contribute to BLSs and doctors interpreting the need for blood tests differently.

Relevant ethical values and principles, and legal regulations

Seven potential problems with performing blood tests of questionable benefit for a terminal-phase patient were identified.

The testing itself involves discomfort for the patient (the principle of non-maleficence). ⁴ The discomfort can vary from minimal to very pronounced. The pain from the needlestick can become psychologically straining when repeated daily. It is often technically difficult and time-consuming to draw blood from dying patients, because they can have damaged veins and haematomas, oedemas and reduced circulation;

The burdens to the patient and relatives described in 1–4 involve moving away from the ideal of a dignified death.

In Norwegian health law a BLS, like members of other health professions, has a duty to provide health care that is caring and medically sound (Health Personnel Act [HPA] §4). As all health care presupposes a valid consent (Patient rights act §4–1), the patient's and the relatives’ treatment preferences are relevant. The doctor is responsible for the health care (HPA §4), and the BLS has a duty to act according to the doctor's decisions. However, if the BLS views blood sampling as medically wrong and as an action that would go against his/her conscience, the BLS has a moral duty to consider the situation thoroughly. A commonly accepted principle is that one ought not to act against one's conscience. ⁵ A duty to reflect morally is also highlighted in the Norwegian BLSs professional code of ethics. ⁶

Two meanings of moral integrity

In our view ‘moral integrity’ and ‘moral distress’ are key concepts that can contribute to better understanding of the dilemma experienced by the BLS. ‘Moral integrity’ has two meanings that are especially relevant here.

A person who has a set of moral convictions or virtues and is able to act in accordance with these has personal moral integrity. ^7,8 Some moral principles are especially important to us, and are deeply rooted in our character. One example could be the moral norm against killing. Other moral principles might be true and good as well, but not fundamental by way of constituting us as the persons we are. One example could be the principle of the health-care worker's responsibility for limiting expenditure through minimizing superfluous diagnostic testing. Being forced to act against one's deepest principles or virtues would harm one's moral integrity. In the most serious case such an act could be experienced as a kind of denial of the person one is: ‘I could not live with myself if I did that … ’

How is personal moral integrity at stake in the BLS's dilemma? A virtue that is challenged is the BLS's practical wisdom as a professional. If the BLS feels pressured to perform blood sampling despite their conviction that this would constitute poor medical practice, blood sampling would feel unpleasant because it goes against the BLS's self-image as a conscientious and skilled professional with good judgement and a respectful conduct towards others.

Social moral integrity is a social virtue that can be developed through interaction with others. ^9–11 By sending the case to the CEC the BLS shows that she has values that she wants to reflect on critically. She does this by asking how she (and other health-care workers) ought to handle a concrete problem that is part of the complexity encountered in everyday clinical practice. One could also say that she is seeking alternative perspectives so that other more morally adequate lines of action can replace an obviously problematic practice. In this way integrity becomes something that is developed and achieved in conjunction with others: the BLS's integrity matures, and the same goes for the professional fellowship constituted by her colleagues. Having the will and ability to reflect critically on one's values and principles, including being able to evaluate alternative perspectives, is to show social moral integrity.

Moral distress

Moral distress can be viewed as a particular kind of moral problem: ‘I know what is morally good and right, but I am unable to do it’, or ‘I am doing something I know is wrong’. ¹² Pendry defines moral distress as ‘the physical or emotional suffering that is experienced when constraints (internal or external) prevent one from following the course of action that one believes is right’. ¹³ In health care this phenomenon has especially been studied in nursing, ¹² but it has also been shown to occur in other health-care professions. ¹⁴ Moral distress can be experienced when one's professional values are violated. Zuzelo's ¹⁵ study identified the execution of unnecessary examinations and treatment as particularly distressing. This is just what the BLS and her colleagues experience. They could themselves feel violated because they know what is right to do, but experience that routines have been developed that place them in situations where they violate patients and relatives. This could lead to moral distress. Stress, burnout, withdrawal from patients and a feeling of being abandoned by one's employer are common symptoms of moral distress that can appear when the violation is sufficiently powerful. ^12,13,16

It is vital that the BLS's report to the CEC is handled constructively and with respect, as this will matter to her and possibly to other health-care workers’ professional self-image. This is likely to be useful (morally, medically and economically) for the hospital.

Assessment of possible lines of action

In a situation in which the BLS judges the patient to be terminally ill, and therefore considers it bad practice to perform blood tests, it would be wrong to follow the doctor's orders without clarifying the situation further. The reason for this is that the potential negative consequences of poorly justified blood sampling, discussed above, can be significant both for the patient and the BLS. The BLS ought therefore to discuss the situation with the nurse in charge. Sometimes such a conversation will bring clarity and agreement on the proper line of action. If not then the BLS should speak with the doctor in charge of the patient. Due to the organization of the ward this could be another doctor than the one who ordered the tests. The BLS should communicate his or her judgement. National and local customs influence whether a BLS would have access to the doctor and whether the doctor would consider a subordinate's inquiry appropriate. In countries where the health-care service is strongly hierarchical, such an inquiry could be seen as an unacceptable challenge to the doctor's authority. In Norwegian hospitals it would most likely be seen as acceptable. Because something important is at stake in this situation, in our opinion it is right and proper for the doctor to take time to explain the rationale for the tests. Perhaps the BLS's observation leads to the doctor and the nurse re-evaluating their assessment of the patient, the treatment plan and the need for diagnostic tests. Alternatively the BLS could have a satisfactory explanation of why tests ought to be performed anyway. Such a conversation with the doctor should resolve most of these cases, and this illustrates how good communication often resolves or prevents moral dilemmas.

In some cases where the doctor in charge is subordinate to the doctor who ordered the tests he or she could be reluctant to go against their colleague's decision by cancelling the tests. However, a subordinate doctor has both a duty and a right to make independent decisions. In addition, circumstances can have changed. Therefore a re-evaluation of the superior's decision is called for in this situation.

In cases where the BLS's worry persists after speaking with the doctor, he or she has two alternatives: either act against one's conscience by taking the tests, or refuse to take the tests. The last line of action would be to claim a kind of conscientious objection, a moral right to refuse to partake in health care that goes against one's conviction. This should be a well-contemplated decision reserved for very special cases where the negative consequences of following the doctor's decision are deemed very significant. In our view the BLS should promptly report such a refusal to their superior.

This case and our discussion have pointed to reasons for considering the BLS as a member of the treatment team, one who makes independent observations and sometimes can have valuable information to convey when decisions should be re-evaluated. The nurse and/or the doctor should ensure that electronic orders of blood test are changed or deleted, or the BLS is informed directly, when dictated by changes in the patient's condition. In that way some of these situations can be avoided.

When at first the dilemma arises, in our view it should be exploited as an occasion of learning for others, for instance by making the CEC's written report available for involved categories of health-care workers, or for the administration in conjunction with the CEC arranging discussions of this kind of dilemma across professions. Another issue raised by this case is when it is appropriate to perform blood tests on patients with a short life-expectancy. The answer to this will have both medical and ethical premises, and will be particularly relevant for discussion among the doctors.

Conclusion

As a rule health-care workers must follow the decisions of the doctor in charge. However it is important that in special cases there is room to act against these decisions, if there are sufficiently strong reasons. A judgement that blood sampling from a patient in the terminal phase would be inappropriate, unhelpful and injurious could constitute such a reason. It is vital for the health-care service to have professionals with a strong moral sense and the capacity for independent judgement. Each health-care worker is responsible for cultivating and employing one's own judgement, as well as alerting co-workers and superiors when morally problematic practices are uncovered. ¹⁶ The management has a special responsibility for cultivating a moral climate in which there is room for asking questions and challenging decisions. Health-care workers’ judgement that moral integrity is at stake – and that moral distress follows – can constitute important moral correctives for health-care institutions.

In many other countries nurses already involved in the daily care of the patient perform the blood sampling. The special role of the BLS as a professional external to the ward who is called on to perform what is often regarded as a quick and simple technical procedure, is partly responsible for the dilemma we have discussed. Dilemmas of a similar shape might arise for professionals occupying similar roles; we have spoken with radiographers who report experiencing similar dilemmas in the context of imaging studies of uncertain justification for terminal phase patients.

In closing we ask whether hospital management ought to produce a procedure for the sake of securing that such difficult situations do not become irresolvable or unnecessarily heated. What counts in favour is that a written procedure could help for the resolution of such cases without unnecessary conflict. What counts against is that such cases ought to be open to resolution through good communication and moral reflection, and this concern should be decisive in our view. Another written document in the health services, in which the number of such documents is rapidly increasing, does not remove the need for the good judgement of each health-care worker.

Conflicts of interest: All authors declare that there are no conflicts of interest.

Funding: The work was funded by Lovisenberg Diakonale Hospital.

Contributorship: MM is the guarantor. MM wrote the first draft. All authors contributed substantially to the analysis and the revision of the article, and all authors approved of the version to be published.