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A medical oncologist is faced with an ethical dilemma that he presents to the Figure 1 community:


“A 71 year-old man with dementia presented 6 months ago with slowly evolving pancytopenia x 1 year. Ten months ago his WBC was 2.25 x 10^9/L, ANC 1.04 x 10^9/L, hemoglobin 11.0 g/dL, hematocrit 34%, MCV 103 fL, and platelets 172 x 10^9/L. Two months ago his hemoglobin had fallen to 7.8 g/dL, ANC to 0.46 x 10^9/L, and platelets 110 x 10^9/L. Non-neoplastic causes for cytopenias such as medication effect or nutritional deficiency were ruled out. Peripheral blood mutation testing showed DNMT3A R882C in 22% of sequencing reads and U2AF1 S34F in 21% of sequencing reads.

The patient’s wife is his health care proxy; the patient himself lacks decision-making capacity. He knows own name and his wife’s name, but does not know the date, the President, or the name of the medical facility; he frequently makes nonsensical and off-topic statements during office visits.

The patient’s wife declined a diagnostic bone marrow biopsy on his behalf. The patient was treated with darbepoetin once his Hb fell below 10 g/dL since his endogenous EPO level was only 60 U/L but he is now transfusion dependent. Today he was found to have 10% circulating myeloblasts.

Last week the patient’s wife was diagnosed with advanced breast cancer. She still does not want the patient to have a bone marrow biopsy nor to have any treatment beyond transfusions. How would you approach this patient?”

The oncology specialist includes some more context in the comment section:

“She says it is not a scenario they had discussed, but she clearly cares deeply for him and has his best interests in mind. It is difficult for us to watch a treatable malignancy evolve before our eyes but autonomy is a core value so we respect her wishes. Since he seems to get benefit from transfusions, we’ll continue that, which unfortunately makes him ineligible for the local hospice. This is actually a difficult problem for hematological malignancy patients: a large proportion of hospices do not allow transfusions, but for our patients transfusions can be part of palliative care.”

What would you do? Join the discussion and see what other healthcare professionals are saying about this ethical dilemma.


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