The Case
As part of the therapy for rheumatoid arthritis, you decide to prescribe rituximab to one of your patients. Since your office is not offering this infusion on site and she lives several miles away from the infusion center that you usually use, you agree to prescribe the medication and coordinate the rituximab infusion with a colleague in hematology who has been following her for anemia. After your conversation with the hematology colleague, he agrees to infuse rituximab for the patient under your orders. You fax your colleague an order for rituximab 1,000 mg IV on Day 1 and Day 15, and methylprednisolone 100 mg IV with each rituximab infusion, as per rheumatoid arthritis protocol.1 The plan is to repeat rituximab infusions every six months, if effective, after this induction phase. As part of the orders, you request copies of the infusion notes and obtain safety labs, with the results to be sent to you for review and charting. The patient calls your office stating that she is confused, because the hematologist has been infusing her rituximab every three months, which was not indicated by the instructions that you initially gave her. When your office calls the hematologist, they encounter a difficult situation in which the visit notes and lab information are not provided. You call the hematologist to clarify the situation; he becomes upset and decides to refuse infusing your patient anymore. The patient has been doing much better on rituximab, and she does not want to go to the hospital for the infusions. She has already failed infliximab, adalimumab, etanercept, and abatacept. She cannot afford the self-injectable medications and Medicare only covers the infusions.
Ethical Questions
- Is it ethical for the hematologist to change your rituximab prescription? What recourses are available for the continuity of care of the patient?
- Is it ethical for you, as the ordering physician (rheumatologist), to give the patient limited options in terms of how to obtain her treatment, especially in this situation?
- What is the ethical method of action to continue caring for this patient without jeopardizing her safety, if you cannot obtain records for review at the facility where she receives the rituximab infusion you ordered?
- Who is responsible for the safety lab review, the rheumatologist as the ordering physician or the oncologist as the infusion clinic supervisor?
What do you think? see below for the answers.
Infusion Ethics: Answers and Discussion
1. Is it ethical for the hematologist to change your rituximab prescription? What resources are available for the continuity of care of the patient?
