Health Team

Duke physicians come up with a plan for 'tragic choices'

Posted September 24, 2012

Duke physicians have developed a plan for "tragic choices" in medicine.

— Imagine there are two patients, both needing what could be a life-saving pill – but there's only one pill available. That's what's called a "tragic choice," and it's what hospitals hope to avoid as they continue to deal with drug shortages.

Duke University Medical Center Pharmacies is one of the few in-hospital compounding pharmacies in the country. It gives Duke Hospital an advantage in dealing with drug shortages, but even the raw ingredients they need to formulate medications can become scarce.

Duke compounding pharmacist Ken Latta says they've been out of morphine and other narcotic pain killers commonly prescribed for patients. They have been short on anesthesia drugs used in surgery and commonly used IV solutions.

"A lot of these drugs have been short at one time or another," Latta said.

But why? Often there's a temporary shortage of raw materials, or drug manufacturers stop producing a drug when it's no longer profitable.

It can all boil down to a "tragic choice," having to decide who gets a potentially life-saving drug and who is denied.

"We've gotten very close to it, but fortunately we haven't gotten to that point where we haven't had a treatment option available for the patients," said Duke pharmacist Dr. Kuldip Patel.

Duke physicians come up with a plan for 'tragic choices' Duke physicians come up with a plan for 'tragic choices'

"You're not supposed to use the word 'rationing,' because that is a dirty word, but that is indeed actually what it is," said Duke bioethicist Dr. Philip Rosoff.

Rosoff says there is no uniform system in place in the country to decide how to ration scarce drugs. So he and a panel of physicians and pharmacists set out to create one.

"That would obey certain principles of fairness, to benefit the most people that we possibly could," Rosoff said.

The system suggests these decisions need to be free of favoritism.

"Meaning there are no special people," Rosoff said. "Patients are patients, if they are similarly medically situated."

Rosoff hopes hospitals will adopt the system, and then even adapt it to their own needs. He stressed that it must be a plan that is clearly communicated to patients and their families, and there must be an appeals process for patients who might be denied a medication.

There is a move in Congress to expand the powers of the FDA to intervene more with these shortages. But they don't have the power to prevent a manufacturer from making the decision to stop production. Rosoff says this is a public health issue that requires serious action.


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  • djfuente Oct 1, 2012

    actually, it's when drugs lose their patent that they become less profitable for drug manufacturers. The drugs we're talking about here are morphine and other anesthesia meds that have been around for much longer than we've been alive...even simple IV medications like calcium gluconate...all generic stuff.
    I'm not saying that I have a solution, some level of government intervention is probably going to be necessary, but decreasing exclusive marketability patents is not the solution for this.

  • brentf777 Sep 26, 2012

    The easiest way to end these drug shortages is to decrease the amount of time before a patented drug can be produced generically and to end bans on the import of drugs from foreign countries. No rationing plans necessary. Problem solved.

  • claygriffith01 Sep 26, 2012

    Hey TriangleMommy, I need someone to take care of my lawn, but I can only afford to pay 60% of the operating costs for you to do the job. But if you refuse to work at an expense to yourself, you'll be responsible for creating a habitat for dangerous animals in my yard and compromising my safety.

    --Think that sounds wrong and unfair to you? Now think about what you just said about forcing companies to produce a product at a loss.

  • storchheim Sep 25, 2012

    TriangleMommy, I agree in spirit. But if you start forcing certain sectors to forego profitability (continuing drugs that result in operating losses), they'll lose the best minds in the field.

    As a society today, we can also take better care of ourselves (if we're able to, of course) and not take a pill for every mood, ache, or unnecessary purpose (weight loss).

  • Student Nurse Sep 25, 2012

    From what I understand, it isn't a drug shortage, but the fact that there are a lot of users that should be winning Oscars for their fine performances in the ER for their "back pain" and "migraines" that can only be treated with narcotics because they are allergic to Tylenol, aspirin, ibuprofen, etc. etc.

  • TriangleMommy Sep 25, 2012

    Maybe if the drug companies started caring about the people again and not ONLY their bottom dollar this wouldn't be such a big issue. Let them see the face of the life or death consequences of them not making some of these medications that are not profitable for them.