Abstract
Introduction
A
Potential Benefits of Continuing Transfusions
Patients may receive significant improvement in fatigue and dyspnea within hours from RBC transfusions when hemoglobin levels are <7. These benefits likely dissipate after 13 days. 3
Platelets transfusions can stop or prevent bleeding caused by severe thrombocytopenia within hours but usually have a life span of only four to eight days. 4 Although the usual threshold at which prophylactic platelet transfusions considered is 10,000, 5 that threshold and the role of prophylactic platelet transfusions in seriously ill TD patients remain controversial and unstudied.
A retrospective analysis of dying cancer patients suggested that RBC transfusions were associated with a longer survival (15 days) than anemic patients who were not transfused (7 days), and platelet transfusions increased the interval between hospitalizations from 10 to 16 days. 6
Regular transfusions based on threshold laboratory values often become a familiar component of the care plan recommended by the cancer team. Transitioning to a care plan in which transfusions are based on how they feel, not laboratory values, can, therefore, be unsettling to patients.
Potential Harms of Continuing Transfusions
Not only is TD a marker of disease severity, organ damage from iron overload can also result from multiple transfusions. Thus, there is a 2.2-fold increase in one-year mortality risk and a four-year survival of only 47% among TD patients.7–10
Although transfusions often can be coordinated for hospice patients with a specific symptom need, logistical complexities do not allow transfusions to be done in a patient's home.
For patients who desire to continue regular laboratory draws and blood transfusions, frequent visits to infusion clinics ensue and are associated with a diminished quality of life.8,11 Furthermore, hospice involvement is often delayed, thereby increasing the chances of death in a hospital.11,12
Counseling Patients and Families
A hospitalization due to a major medical crisis often prompts a discussion about discontinuing transfusions in the context of a larger discussion about transitioning to comfort-focused care. This can be a challenging time to discuss transfusion discontinuation, as patients can be overwhelmed by their overall medical situation. The following pearls may assist clinicians:
Once TD is realized and eventual clinical deterioration is anticipated, discuss the expectations of transfusions along with clinical signs that would suggest an appropriate timing to discontinue them. This would pre-empt initiating such discussions during a time of medical crisis. Patient and families may worry about inciting imminent death or demise from discontinuing transfusions. For example, they may have been told that discontinuation of platelet transfusions can trigger massive bleeding. Fortunately, most dying patients who stop platelet transfusions do not suffer significant bleeding and most TD patients live more than a week after transfusions are discontinued.
6
Transparent disclosure of these prognostic implications may alleviate, not exacerbate, concerns. Inquire about ethical, legal, cultural, and/or religious concerns that may lead patients to associate transfusion discontinuation with “giving up” or euthanasia. Involve a chaplain or spiritual leader if concerns are identified. If a time-limited trial of continued transfusions is pursued, be specific about signs that would signify an appropriate time to discontinue transfusions. Examples of reasonable “end-points” include (a) an anticipated prognosis of weeks or less, (b) platelet values that no longer respond to transfusions, and (c) a terminally ill home-bound patient who develops a moribund functional status, as the burden of transport to an infusion clinic will likely supersede any clinical benefit. Involve the patient's oncologist or hematologist. Patients may need to hear from a trusted clinician that it is okay to stop transfusions.
Novel Programs
Open access or concurrent care is offered by select hospice agencies in coordination with some insurers. Through models such as these, patients who are willing to come into clinics for ongoing blood product transfusions may be able to also have access to an interdisciplinary hospice team. Coordination with clinical social workers can help patients and families explore these possibilities.