Rationalising red blood cell transfusions in advanced haematological malignancies: a patient-centred approach
Authors: Bingwen Eugene Fan, Dheepa Christopher, Christian Aledia Gallardo, Venkata Sreekanth Sampath
Journal: The Lancet Healthy Longevity (2021)

We read the Series paper by Ulrich Wedding with interest.1Wedding U Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated care.Lancet Healthy Longev. 2021; 2: e746-e753Summary Full Text Full Text PDF Scopus (2) Google Scholar We agree that achieving better palliative outcomes involves overcoming the barriers to obtaining transfusions in hospices; however, this point would benefit from additional discussion. First, a substantial organisational barrier to patients obtaining access to hospice care is the limited availability of blood transfusions in hospice programmes, which is due to existing hospice protocols or insurance policies that do not support hospice-based transfusions.2Odejide OO Steensma DP Patients with haematological malignancies should not have to choose between transfusions and hospice care.Lancet Haematol. 2020; 7: e418-e424Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar Second, due to a scarcity of high-quality evidence for end-of-life transfusions, inherent biases on what constitutes a so-called good death has led to some hospices not providing palliative transfusions. However, emerging support for the benefits of palliative transfusion in some groups of patients with haematological disorders includes the 2020 American Society of Hematology guidelines recommending that red blood cell transfusions be made available for patients aged 55 years and older with acute myeloid leukaemia who are receiving end-of-life care or hospice care,3Sekeres MA Guyatt G Abel G et al.American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults.Blood Adv. 2020; 4: 3528-3549Crossref PubMed Scopus (47) Google Scholar and a 2018 systematic review proposing the benefit of transfusions in adult palliative care in reducing symptoms of fatigue, weakness, and dyspnoea.4Chin-Yee N Taylor J Rourke K et al.Red blood cell transfusion in adult palliative care: a systematic review.Transfusion. 2018; 58: 233-241Crossref PubMed Scopus (21) Google Scholar Third, there are underlying patient and physician barriers, including a reluctance to discontinue regular transfusions at the end of life by patients themselves or by their physicians,5Mannis GN McNey LM Gupta NK Gross DM The transfusion tether: bridging the gap between end-stage hematologic malignancies and optimal end-of-life care.Am J Hematol. 2016; 91: 364-365Crossref PubMed Scopus (21) Google Scholar which contribute to decreased hospice enrolment due to the absence of transfusion support. Early advanced care planning and engagement with palliative medicine are pivotal in helping patients with advanced haematological malignancies in transitioning from active treatment to best supportive care. Clear strategies in communicating with patients on their transfusion requirements are needed. Managing physicians need to balance this communication with proper stewardship of blood products, including mitigating transfusion risks and adopting a restrictive transfusion strategy. Thus, we propose this patient-centred approach to aid physicians grappling with the complexity of red blood cell transfusions in advanced haematological malignancies (figure), recognising that transfusions in the palliative setting should be patient-centred, respecting patients' goals and values, with the focus on providing symptomatic relief while balancing risks. More high-quality studies and randomised controlled trials are required to evaluate the cost-effectiveness of palliative transfusions, measuring both observer-reported and patient-reported outcomes in quality of life, symptoms, and physical activity level. These data will enable stakeholders to advocate for policy change to promote optimal transfusion support at the correct site and setting. In summary, an evidence-based and patient-centred approach will enable better identification of patients with advanced haematological malignancies who would benefit from transfusions that would improve their quality of life. We declare no conflict of interests. Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated carePalliative care, hospice care, and end of life care have been the focus of increased attention over the past two decades; palliative care has shifted from being introduced only at the end of life to becoming an integrated part of routine care for patients. Currently, the timing and extent of the integration of palliative care into standard medical care practice depends on the underlying disease. Patients with haematological malignancies receive less palliative care initiated at a later disease stage compared with patients with other types of cancer. Full-Text PDF Open Access