Next step in blood use program: end-of-life transfusion

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Advocate Health Care recommendations

The following recommendations are intended to provide assistance to physicians in managing blood transfusions for patients who have a poor prognosis for recovery or have chosen to seek limited care. Additional assistance regarding individual patient scenarios should be reviewed with Advocate Health Care’s ethics committee.

1. Blood product transfusions should be limited to red blood cells and platelets in order to ameliorate a patient’s symptoms. Limited transfusions for comfort purposes can be made available, in addition to other palliative symptom management.
2. RBC units should be transfused as single units and limited to no more than twice a week.
3. Platelet units can be transfused up to two units per week.
4. Rare blood transfusions should be avoided (granulocytes, rare blood types, and HLA matched platelets).
5. Standing orders should not apply during a blood shortage.
6. Rh-negative blood should be transitioned to Rh-positive blood.
7. Transfusions for eligible organ donors will be managed per the organ procurement coordinator.

The results of the physician survey pointed to a need to advance the discussion within Advocate about patients with poor prognoses for recovery and ethical issues related to the transfusion of blood. Our approach is multi-pronged; it includes clear institutional guidelines, physician education, and additional resources related to questions of ethics and palliative and spiritual care for those physicians who treat patients in medically futile situations. One of the authors (SK) wrote a set of recommendations and presented them to the Advocate Health Care transfusion safety steering committee. With full support from our leadership, we developed seven transfusion recommendations for patients at end of life (see box). The Advocate ethics committee approved them in fall 2014, and a pilot project is being designed under the supervision of Advocate Palliative Care physicians. The aim of the pilot is to educate intensivists, primary care physicians, and nurses about the role of blood transfusions at end of life and assist them as needed.

Physicians’ primary ethical obligation is to promote the well-being of individual patients. Physicians also have a long recognized obligation to patients in general to promote public health and access to care. This obligation requires physicians to be prudent stewards of the shared societal resources with which they are entrusted. It is our hope that in the near future blood will not be considered an elixir that heals all maladies.

1. Kriebardis A, Antonelou M, Stamoulis K, Papassideri I. Cell-derived microparticles in stored blood products: innocent-bystanders or effective mediators of post-transfusion reactions? Blood Transfus. 2012;10(suppl 2):S25–38.
2. Nester T, AuBuchon JP. Hemotherapy decisions and their outcomes. In: Roback JD, et al., eds. AABB: Technical Manual. 17th ed. Bethesda, Md.: American Association of Blood Banks; 2011:573–574.

Dr. Khan is medical director of transfusion services, Midwest Diagnostic Pathology; Beth Halperin is transfusion safety manager; and Maria A. Niedos is ISO and accreditation consultant—all at Advocate Health Care, Chicago.