Practical Management of Directed Donations for Patients with Cancer
A transfusion medicine colleague at a major hospital in Texas asks for assistance in solving a nagging problem, namely, how to responsibly handle directed donations. Some of their patients are very insistent about choosing 'their own donors' and are creating an ongoing demand for that treatment option. The inquiring physician says that they are struggling with devising a workable uniform policy for directed donations for their cancer patients. They have tried using "reasonable" time limits (e.g., 7 days to 14 days) for reserving donated RBC units, and then releasing these units for general use, with variable success. A few years ago they were 'persuaded' to keep directed units solely for the use of the designated recipient, resulting in about a 50% outdate rate currently. The Texan requests colleagues share their policies, practices, and advice about how to address this issue for cancer patients.
The following responses have been received.
ADDENDA Feb. 21, 2003
- A colleague in Kentucky reports that they have a policy that directed donations are released and returned to the general inventory on the day the designated recipient is discharged from the hospital. This release information is in the Informed Consent for Blood Component Transfusion. A call to the Transfusion Services by the ordering physician to request that the unit(s) not be released (surgery was postponed, etc) is required to prevent the product from being placed into the general inventory.
- A colleague in Washington state reports that at her institution they strongly discourage the use of any directed donor units and this works, probably for the most part because the physicians strongly discourage such requests by their patients. She thinks this works better than anything else. Patients are informed that it may take up to 5 days from the order to the time the unit is available for use. They have set up a system of checks whereby if the patient has directed donor units they are issued a different colored bracelet (blue) that signifies that these units exist so that nursing staff will check specifically for directed donor unit availability. This bracelet is removed when there are no more directed donor units available. Patients with directed donor units have flags on the computer that alert the technician that they should be used before other blood components and the directed donor units are kept in front of any other units that may have been assigned to the patient. They do not release unused directed donor units into the general inventory.
- A transfusion medicine physician in Detroit reports having similar issues with directed donations for non-surgical patients a few years ago. When there is no set "date of use", the question is how long is a 'fair' amount of time to keep these units prior to release to the general inventory? According to the responding colleague, a key factor is having the patient or representative understand that, since they are essentially taking on the job of the blood center in recruiting donors, it is strictly their responsibility to keep track of the number of units available, dates units will no longer be available, maintaining a flow of donors to cover possible transfusion dates, etc. After blood bank policy has been presented in the form of a fact sheet, with contact phone numbers, the blood bank simply serves to process and/or store the units for transfusion to that patient for a set period of time, which is clearly stated up-front. No "warnings" from the blood bank about impending non-availability of units will be issued! That being said, it is totally up to the blood bank how long to allow units to remain directed prior to releasing them to the general inventory. When we drew these units in our facility, we kept units 'directed' for medical patients until 10 days prior to expiration. Depending on how busy the transfusion service is, this is usually enough time to utilize these units in the general inventory. Facilities can make this time longer if needed. For surgical patients, the units remained directed for 10 days following surgery, or until hospital discharge, whichever came first.
ADDENDA Feb. 24, 2003
- A colleague from Saudi Arabia believes that there are several reasons for discouraging directed donations. One of them being the risk of some kind of group pressure or from the patient's relatives and friends. For this sole reason, directed units should never be moved to the general inventory, in his opinion. He reports that the 2001 AABB annual meeting had an abstract (SP277) by Wong et al, George Washington Univ. Transfusion-Transmitted Viral Disease and Deferral Rates in Parental Directed and Community Donors for Pediatric Patients. This study reported a 2-3 fold higher seroprevalence of HIV, HCV, HBsAg in donors of directed units compared to community donor units.
Editor's question: If it is true that directed donations are so much more dangerous that they should not be moved to the general inventory, why would we use directed units for the directed recipient unless these units had a clear-cut medical advantage (such as an HLA-matched plateletpheresis unit for a patient refractory to platelet transfusions) without giving informed consent to the patient that explains the increased risk of directed units?
ADDENDA Mar. 3, 2003
- A transfusion medicine physician colleague in the Netherlands reports that at their center, directed donations are only carried out when there are medical reasons for them. They are often asked whether it would be possible to donate for a spouse or child. The reasons given for not approving such a directed donation at their center are: (i) increased risks of the transfusion (eg GVHD; necessitating irradiation); and (ii) greater risks associated with any procedure which is not routine.
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Ira A. Shulman, MD
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