“End-of-life blood transfusion can improve quality of life”—a narrative review of debate on scope and consideration

Introduction

Background

In medical literature, the term end-of-life has not been well defined and there is no consensus to define exactly the term “end-of-life” (1). The European Society for Medical Oncology has defined the term “end-of-life” in their clinical practice guideline as care for people with advanced disease once they have reached a point of rapid physical decline, typically the last few weeks or months before and inevitable death as a natural result of a disease (2). As per the National Hospice and Palliative Care Organization (NHPCO), end-of-life care or hospice care starts when a person has a diagnosis of terminal illness and less than 6 months to live and curative treatments are no longer available (3). Whenever end-of-life has been declared by healthcare professionals for a patient who is approaching towards death, the goal of care remains focused towards managing comfort and offering a specialized, tailored, and individualized management of quality of life. At this stage of life, care for patient focusing on ‘comfort’ is usually holistic in nature and person-centered, focusing on the interrelationship between physical, psychosocial, and spiritual issues. Whenever the decision for end-of-life is agreed active intervention or curative intent treatments are stopped and direction of treatment shifts to comprehensive physical symptom management (4). Depending on the circumstances like wishes of the patient, clinical condition, family support etc., this end-of-life care may take place at the hospital, home, care home, or hospice.

An important function of red blood cells in normal human body is to carry oxygen and supply to the living cells and organs for meeting their metabolic demands. The symptoms commonly faced by patients at end-of-life care are pain, fatigue, nausea, vomiting, breathlessness, noisy breathing, delirium, psychological issues etc. (2). Symptoms like breathlessness and fatigue are usually multifactorial. At the same time, this can be attributed to inadequate oxygen supply to the cells and may be related to inadequate red blood cells in the body (i.e., anemia), from where the relevance of the transfusion in end-of-life starts.

The appropriate use of blood and blood components for end-of-life care patients is a subject of unique, complicated, and sometimes contentious issues. The subjects of end-of-life transfusions encompass oncological and non-oncological patients, frail and elderly patients with concurrent illnesses, decompensated complex chronic patients, patients with acute infections, and patients with complete postoperative and transitional care, among others. A patient-centric decision-making procedure is required, considering the patient’s general health, life expectancy and prognosis, potential benefits vs. risks, and most importantly, the patient’s choices, which may involve the patient, family members, and multidisciplinary care team (5). While transfusion is not an exceptional circumstance in end-of-life care patients, blood transfusion aims to improve oxygen carrying capacity of blood and alleviates patient symptoms like dyspnoea, fatigue, etc. as well as maintains their quality of life (6).

Rationale and knowledge gap

End-of-life blood transfusion can occur in various clinical settings, like inpatient palliative care units, medical oncology units, hospices, and patients’ homes as per norms in different countries. Patients with certain chronic illnesses (hematological diseases, cancer, or advanced chronic diseases) may need intermediate or long-term transfusion therapy, which can be financially and physically burdensome for patients if it involves hospital care (7). Despite growing knowledge about managing acute conditions, there is no international agreement on transfusion thresholds, and varying practices have been reported (7). Concerning the healthcare system and an increasingly aged population worldwide, an efficient end-of-life blood transfusion policy can enable resources to be used sustainably, by cost-cutting, avoiding unnecessary patient transfers, and promising better patient and caregiver satisfaction (8).

Another concern is the ethical obligation of healthcare providers to provide quality end-of-life care. As per Beauchamp and Childress’s paradigm, the conflicting principle of social justice suggests that clinical resources should be rationally distributed (9). Blood is a scarce resource and utilizing the scarce resources for patients who are designated “comfort/palliative care only” cannot be fully justified. Some schools of thought believe that blood transfusion is a disease-modifying treatment and that patients seeking that aren’t ready for hospice. However, this concept needs to be examined from the perspective of patients, whose preferences need to be duly considered (10).

Transfusion of blood components outside hospital care settings is rarely implemented due to safety concerns (7). Yet, in a national survey, more than one-half of hematologists agreed that more patients could be referred to hospice care if transfusion support were available (11). Some hospice providers avoid blood transfusions because they view it as a disease-modifying option which is not aligned with end-of-life care or due to economic and logistics issues. An Association for the Advancement of Blood & Biotherapies (AABB) initiative recognized certain areas of facility improvement to overcome these challenges for patient benefit and operational sustainability (12).

Currently, the scientific literature on blood transfusion in the end-of-life care population is sparse, leaving several unanswered questions about transfusion practices. Specifically, factors influencing the decision to transfuse RBCs, the effect of transfusion on symptoms, quality of life, survival, and the risk of adverse events from this intervention in this population, site for transfusion remain poorly characterized. We conducted a narrative review to assess the potential benefits of transfusion in end-of-life care patients in comparison to adverse outcomes, associated guidelines for end-of-life transfusion, potential barriers to this service and to resolve myths associated in this service pathway. So that, patients receive this benefit at terminal stage of their illness.

Aim and objectives

By this narrative review, we aim to address the following questions which are relevant for accessibility of end-of-life transfusion facility to all patients.

• What is the global picture of availability of blood transfusion services for end-of-life care patients?
• Does end-of-life transfusion promise better quality of life and if there is any available alternative?
• What are the transfusion guidelines for patients undergoing end-of-life care?
• Should we consider home-based transfusion for end-of-life care patients?
• What are the special considerations for leukemia and cancer patients for end-of-life blood transfusion?
• What are the policy issues and barriers for transfusion in end-of-life patients?

We present this article in accordance with the Narrative Review reporting checklist (available at https://aob.amegroups.com/article/view/10.21037/aob-24-28/rc).

Methodology

We looked for articles on this issue on PubMed and Google Scholar using the search terms like “end-of-life”, “terminal illness”, “palliative care for advanced diseases”, “hospice care”, “terminal care”, and “actively dying” (Table 1). We read abstracts of all the articles and according to their relevance to blood transfusion and transfusion services and our research questions. If those abstracts were found relevant to us, we read the manuscript in detail and used those research concepts, data, and conclusions for generating this manuscript. Since end-of-life transfusion is not practiced in many countries, there is paucity of literature. We included original studies, narrative reviews, systematic reviews, guidelines, editorials, commentaries, letters, and case reports—a series that mentioned blood transfusion issues in end-of-life care and to some extent patients with hospice care or terminal illness.

Discussion: narrative

Hospice vs. palliative care: a comparison and considerations for blood transfusions

Hospice and palliative care both aim to provide comfort and support to individuals with serious illnesses, but they differ in key aspects. Hospice care focuses on end-of-life care for terminal patients, offering comfort in the final stages of life when curative treatments are no longer effective, and life expectancy is limited to 6 months or less. In contrast, palliative care can be provided at any stage of a serious illness, aiming to enhance quality of life by addressing physical, emotional, and spiritual needs, starting from diagnosis through treatment and survivorship (10).

Hospice care blood transfusion is delivered at home or in hospice facilities, while palliative care transfusions can be provided in hospital or palliative care settings. In the United States Medicare, Medicaid, and most private insurance plans cover hospice care; however, coverage for palliative care varies widely (13). In hospice transfusion, the goal is quality of life enhancement and high emphasis on shared decision-making in family. Contrast to it, palliative care transfusion is aimed at crisis symptom management and the role of family decision-making is also limited.

Are blood transfusion services accessible globally for patients in hospice care?

In hospice care, blood transfusions are generally not part of the treatment plan in some countries such as the United States, as the focus is on comfort rather than aggressive medical interventions. Moreover, transfusions may not be readily available due to reimbursement policies and costs. A study from the United States on end-of-life hematopoietic stem cell transplant recipients mentions that usage of blood transfusion may act as a barrier to prevent those patients to access hospice care (14). Whereas in the United Kingdom (UK), there is no restriction related to reimbursement and access to blood transfusion services in hospice care are too liberal when it is judged against international evidence-based guidelines for blood transfusion (15,16). End-of-life or terminal cancer patients prefer to attend day transfusion services at day hospice than attending hospital (17). Restriction to the blood transfusion services for end-of-life and terminally ill patients are not uncommon due to remote geographic location and unavailable round the clock facility of blood bank (18). An interesting study from Germany evaluated medical care situation and availability of supportive oncological therapies for terminal ill cancer patients in all hospices. The study mentions blood transfusion practices and supportive oncological therapies like transfusing erythrocyte concentrates and platelet concentrates that are never or rarely used. A variety of obstacles has been mentioned like assumption of cost, training of physicians, and the limited involvement of hematologists and oncologists for this group of patients (19).

Does end-of-life transfusion promise better quality of life and if there is any available alternative?

A recurring question in discussions about blood transfusions is whether they are used appropriately and if they offer real benefit. The UK literature has noted that other treatments, like oral or intravenous iron, are sometimes overlooked before transfusions are initiated (16). This national audit also mentions that evidence that benefits of red blood cell transfusion appear to be very limited in the population of patients who are undergoing hospice care with advanced disease; at 30 days following blood transfusion, only 18% appeared to have sustained benefit, while 32% had died indicating poor patient selection or increased mortality from blood transfusion (16). A Cochrane systemic review including generally low-quality before and after studies showed 31% to 70% of patients with advanced cancer respond to blood transfusion by improvement in their fatigue, breathlessness, or general well-being. Unfortunately, duration of this response was limited to 14 days or less (20). Studies conducted by Brown et al. (21) and Mercadante et al. (22) also mentioned resolution of fatigue and dyspnoea in advanced cancer patients were very limited and short-term after blood transfusion. A study from Nepal on terminally ill advanced cancer care patients mentions that there was improvement in fatigue and breastlessness in post-transfusion phase for 37% and 56.5% patients respectively in comparison to 14.5% had resolution of fatigue without transfusion (23). Research by Saito et al. on using palliative radiotherapy for bleeding tumors suggests it may reduce the need for red blood cell transfusions, potentially benefiting patients with months of life remaining (24). Similarly, Chow et al. found that using erythropoiesis-stimulating agents in chronic kidney disease (CKD) patients on dialysis reduced the need for transfusions and hospitalizations (25).

Chin-Yee et al. indicated that doctors’ attitudes toward transfusions might be a more significant barrier to hospice enrollment than the views of patients or their families (5). Despite the risks associated with transfusions, timely use in appropriate patients can improve the quality of life, particularly for those who are still active. Several ongoing clinical trials are exploring related issues, including the impact of palliative transfusions on quality of life in patients with blood cancers (PalliaQOL), removing transfusion dependence as a barrier to hospice enrollment (BRUOG-407), and the use of platelet transfusions in patients with palliative hematologic malignancies at the University Hospital of Besançon (26).

Transfusion guidelines for end-of-life care patients

These guidelines aim to ensure that transfusions are used appropriately to enhance the quality of life for patients nearing the end of life. If a time-limited trial of continued transfusions is pursued, be specific about the signs which would signify an appropriate time to discontinue transfusions. Examples of reasonable “end-points” include: (I) an anticipated prognosis of weeks or less; (II) platelet values that no longer respond to transfusions; and (III) a terminally-ill, homebound patient who develops a moribund functional status, as the burden of transport to an infusion clinic may supersede any clinical benefit (27).

• Symptom management: transfusions should be considered to alleviate symptoms such as severe anemia, breathlessness, and fatigue. They can help improve the patient’s comfort and overall quality of life (10).
• Patient-centered care: decisions about transfusions should be made by clinicians in collaboration with the patient and their family, considering the patient’s goals, preferences, and spiritual needs as benefits may be limited and patients may have two or more factors that make them at high risk of transfusion-associated circulatory overload (TACO) (28).
• Palliative care integration: transfusion should be integrated into a broader palliative care plan that addresses the patient’s physical, emotional, and spiritual needs (27).
• Hospice considerations: for patients in hospice care, transfusions may be provided to manage symptoms and improve comfort. However, the availability of transfusions in hospice settings and vary, and discussions with hospice providers are essential (28).
• Ethical considerations: the benefits and burdens of transfusion should be carefully weighed, especially in the context of the patient’s overall health and end-of-life goals (27).
• Determine transfusion requirements: patients should be weighed before red cell transfusion planning and transfusion volume of 4 mL/kg will typically provide a hemoglobin (Hb) increment of 10 g/L (16).
• Review of clinical outcomes: if the transfusion was given to treat symptoms of fatigue or breathlessness, an assessment of the symptom pre- and post-transfusion to guide further management and determine subsequent transfusion decisions is needed. At the same time, if feasible, there should be repeat Hb level check after transfusion and performance status check (16).

Should we consider home-based blood transfusion at end of life?

Patients suffering from advanced stage of chronic disease or cancer, hematological diseases might require frequent blood transfusions. Home-based transfusions under monitoring of trained physician and nurse could be a better alternative approach than hospital transfusions in this category of patients. Several reasons support this approach, the main rationale being patient convenience and comfort (12,29,30). It is cumbersome for patients with terminal disease and undergoing end-of-life care to travel for hospitalization and go through admission procedures for blood transfusions at regular basis. Home-based transfusion will not only avoid the stress of hospital visits, but also reduce the risk of hospital-acquired infections as this patient population is already immuno-compromized.

Home transfusions can be tailored to more personalized approach for individual patients with the help of experienced healthcare professionals. This will help in gaining greater satisfaction for both patient and caregivers along with better outcomes. The family and social support will improve patients’ sense of wellbeing and positively boost their moral security. Home transfusion can overcome logistical barriers in some patients having transportation issues or mobility restrictions. For safety measures as reported by some studies (31,32), the maximum distance between patient’s residence to reference hospital must be within 15 km. Although the concept of home care started with the aim of preventing the overcrowding of hospital grounds in New York around 1947, the concept expanded to a broader aspect of more humane approach to patient care. Home care is cost-effective depending on local healthcare facility, governance, and insurance coverages, etc., as it can reduce extra-finances associated with outpatient visits or hospital stays. Chronically transfused patients will better adhere to home-based transfusion routine in their daily lives and this will drastically improve patient outcomes. It is vital that home transfusion is carefully planned and co-ordinated by healthcare team to ensure its effectiveness and safety.

Pros and cons of home-based blood transfusion

The Cures Act in the United States was enacted into law in December 2016 and established a new Medicare home infusion therapy benefit for the administration of intravenous or subcutaneous drugs or biological (33). The legislation defined home infusion drugs as parenteral drugs and biologicals administered intravenously or subcutaneously for an administration period of 15 minutes or more, in the home of an individual through a pump that is an item of durable medical equipment (DME) covered under the Medicare Part B DME benefit. Many types of prescription drugs, including intravenous immunoglobulins, antibiotics, chemotherapeutic agents, pain management medications, and parenteral nutrition, among others, are covered under this home benefit; yet, blood transfusions may not be fully covered, depending on the cost of the blood to the provider (34,35).

Home therapy is known to be safe and effective in shortening or avoiding stays in hospital and nursing home facilities, which are more costly and less convenient and comfortable for the patient and their family. Despite this, there is a general lack of knowledge and experience when it comes to home transfusion therapy. A recent systematic review from Spain found that home blood transfusions appear to be safe, noting that the overall incidence of severe adverse events was 0.05%, and that many patients are accepting of transfusions at home (7). The review was limited by the fact that only few low-quality studies (14 studies meeting predefined criteria in all) were included and that no studies evaluated the effectiveness of home vs. hospital transfusions. A study from the United States also supported the concept that home blood transfusions would be well received by transfusion-dependent patients with hematologic malignancies based upon interviews (36).

Yet, another preliminary report from Italy evaluated home transfusion therapy in pediatric patients from 2014 to 2020 (37). This study reported on transfusions of RBCs and/or platelets in 101 pediatric patients, ages 0 to 18 years, diagnosed with advanced malignancy or with incurable chronic conditions. No adverse events occurred, including acute hemolytic reactions, febrile reactions, anaphylactic reactions, TACO, transfusion-related acute lung injury (TRALI), equipment failure, and issues with blood product transport or storage or with patient identification. The study concluded that home transfusions were feasible and safe, with families reporting satisfaction with less disruption in everyday life. Furthermore, a cost analysis resulted in a consistent cost saving for the regional health system.

Myths related to home-transfusion

Myth 1: there is higher risk of transfusion reaction and related complications in home transfusion

In most centers associated with home transfusions, the physician in charge of the patient evaluates the medical condition of the patient before discussing the possibility of home-based transfusion with caregivers. The patient must be vitally stable and able to withstand transfusion without any serious adverse reaction (38). Home-based transfusions are carried out in the presence of physician and experienced nurse along with trained patient caregivers. Some studies have quoted the use pre-transfusion medications like hydrocortisone, acetaminophen, diphenhydramine, or furosemide in patients having history of transfusion reactions (39,40). However, in some centers, home transfusions are not practized in patients having past history of transfusion reaction (31). Most of the transfusion reactions reported in previous studies have shown that patients were managed conservatively at home by existing protocols, in very few cases, it was required to admit the patient in hospital.

Myth 2: higher risk of infection in home-based transfusion

In home-based transfusions, the nursing officer in charge of patient sends blood sample of the patient along with transfusion request to transfusion lab. After obtaining results of pre-transfusion compatibility tests, the screened components are properly labeled and documentation of cold chain is maintained. Before transfusion, the healthcare professional verifies the documentation and checks patient vitals at regular interval. A qualified health care team carries out the transfusion procedure using strict aseptic techniques in a controlled environment with proper monitoring.

Myth 3: home transfusions are more expensive than hospital transfusions

Substantial reduction of transport costs and admission charges have been reported in home-based transfusions (7). Traveling to nearby hospital is difficult, especially for terminally ill patients, thus home transfusions are known to have greater satisfaction and comfort to patient and their caregivers.

Myth 4: home transfusions are less effective than hospital transfusions

According to the available literature, packed red blood cells are the most common transfused blood component in home transfusions followed by platelet components (41). Martinsson et al. studied that among patients receiving home-transfusions, 68% had post-transfusion improvement in terms of lab values and patient outcome (41).

Myth 5: home transfusions are unsafe

As a safety measure, the reference hospital for home-transfusion is chosen nearby patient’s home with easy accessibility. This ensures easy patient transfer to hospital at time of emergencies without causing harm to patient health. The protocols for home-based transfusions are designed in such a way that the mild reactions could be managed at home under guidance of physician and trained nurse (7).

Myth 6: regulatory compliance regarding home-transfusions

Since every country has stringent regulatory norms regarding blood transfusions, administration of blood components outside hospital premises may not comply with existing standards. Incorporation of home transfusions requires multi-disciplinary approach and has been supported by well-known organizations since the past few decades (7). The AABB provides clinical guidelines to ensure safe transfusion practices and better patient outcomes (12).

It is important to follow regulatory guidelines and help patients and patient caregivers for making informed decisions regarding possible home-transfusions for better patient care and clinical wellbeing.

End-of-life transfusion management among leukemia and oncology patients

End-of-life is a common medical intervention for oncology and, by extension, leukemia patients with advanced disease where the goal of treatment is to relief symptoms and not the use of chemotherapeutic or any other targeted cancer-modifying agents. It has been found in literature that patients with solid tumors are more likely to enroll for hospice care than blood malignancies which can be due to early recognition of solid tumors (42).

Although oncology patients are particularly prone to cytopenia and coagulation disorders, anemia and thrombocytopenia are the most prevalent in patients with hematologic malignancies, where up to 70% of them could be in the advanced stage (43). The anemia and thrombocytopenia are as a result of multiple factors such as bleeding, nutritional deficiencies, toxic effects of chemotherapeutic agents on the bone marrow, cytokines-induced anemia of chronic disorder, myelophthisic anemia due to bone marrow metastasis, or secondary renal involvement. The main goal of blood component transfusion is to alleviate short-term symptoms and signs associated with anemia and thrombocytopenia (44).

From prospective observational studies, the most common indications for blood transfusion in a palliative setting, including for oncology patients and those with hematological malignancies, were weakness, dyspnoea, and bleeding. After red blood cell transfusion, using a visual analogue scale with scores from 0 to 10 (for well-being, strength, and breathing), significant improvements were reported in all three domains from days 2 to 14 (22). With regards to platelet transfusions, the goal is to arrest active bleeding or prevent bleeding in patients whose counts are less than 10,000/µL (22). Relieving patient symptoms like fatigue, dyspnoea or bothersome bleeding by transfusion is arguably a goal similar to care of pain, obstructive symptoms, or constipation to solid tumors (45). There is great variability in platelet usage at end-of-life ranging from zero platelet transfusion in palliative care units to a median of 11.5 platelet units per patient in intensive care or hematology patients (46,47). It has been observed that platelet transfusion can increase in the last 2 weeks of life, with the increasing burden of hemorrhage and platelet refractoriness in hematological patients (48).

Identifying blood transfusion risks in end-of-life patients requires close monitoring during and an immediate period after the procedure to identify fatal events such as hemolytic transfusion reactions and severe anaphylaxis. Additionally, TACO has been shown to be a main cause of transfusion-related deaths, including in end-of-life patients who have multiple co-morbid risks, such as advanced age and poor cardiac and renal function (49). This underscores the need, although difficult to carry out, to weigh these subsets of patients so that the right volume of blood component is prescribed and administered to reduce the risk of TACO. It is therefore pertinent to investigate and, correct anemia early, using erythrocyte-stimulating agents such as erythropoietin, iron therapy, and other haematinics as alternatives to red cell transfusion in palliative care patients (44).

As endorsed by the National Quality Forum, United States one of the standard indicators of end-of-life care is place of death, and most cancer patients prefer to die at home. In a study over 21,000 Medicare beneficiaries of leukemia, it has been concluded that although quality of end-of-life remains poor in these patients, but patients receiving hospice care have lower costs of medical care or receiving futile chemo-treatments including lower risk of dying at hospital (3% vs. 75%) (42).

Reimbursements issues

In hospice care, blood transfusions are often not part of the treatment plan as the focus is on providing comfort and support rather than aggressive medical interventions. Additionally, blood transfusions are not always available in hospice care due to reimbursement policies and prohibitive costs. Hospice facilities are responsible for covering the cost of blood transfusions, but the reimbursement rate is often inadequate (10). While the Centres for Medicare & Medicaid Services (CMS) has explicitly recognized the ability of hospice providers to cover palliative blood transfusions, the reimbursement rate is inadequate to cover the cost. On average, patients with hematologic malignancies receive two units of blood per week, with a reimbursement rate of only about 50% (50).

Some hospice providers also consider blood transfusions to be disease-modifying treatments and do not include them in their end-of-life services. However, transfusions can help address palliative care needs like fatigue, bleeding, and breathlessness (10). For example, patients with acute leukemia often receive frequent transfusions to prevent bleeding and control symptoms. The reimbursement for blood transfusions in hospice and palliative care settings can be complex due to several issues.

• Medicare, Medicaid, and private insurance plans may have specific guidelines and limitations on reimbursing blood transfusions in hospice and palliative care some payers may not cover blood transfusions as they are considered aggressive interventions that do not align with the palliative care philosophy.
• Proper documentation of the medical necessity and rationale for blood transfusions is essential for reimbursement in hospice and palliative care period inadequate documentation or lack of clear guidelines on reimbursement criteria can result in denial of claims.
• Compliance with regulatory requirements and billing codes is crucial for ensuring reimbursement for transfusions in hospice and palliative care failure to adhere to coding and billing guidelines can lead to reimbursement issues and potential audits.
• Communication gaps between health care providers payers and patients and families can impede the reimbursement processes for blood transfusions. Clear and effective communication is essential to ensure that reimbursement issues are proper and accurate.
• Ethical dilemmas arise when considering the use of blood transfusion in hospice and palliative care as they may conflict with the goal of providing comfort and quality of life balancing the ethical considerations with reimbursement concerns can complicate decision-making.
• Limited resources in hospice and palliative care settings may impact the availability and reimbursement of blood transfusions. Prioritizing resource allocation and ensuring cost-effectiveness are key factors in determining the feasibility of reimbursing for blood transfusions.

Policy and legislative efforts

In the United States, the CMS (12) has recommended ways to increase access to blood transfusions for hospice patients, including:

• Clarifying that palliative transfusions are a covered benefit;
• Creating reimbursement models to promote transfusions;
• Exploring new ways to access transfusions, like at-home transfusions.

Financially, performing transfusions during hospice care is often impractical. Legislation has been proposed to test a model where blood transfusions are billed separately, based on the theory that combining hospice per diem with a la carte blood transfusions might still be more cost-effective than non-hospice care. America’s Blood Centers is advocating for Congress to pass S.2186, a bill directing the CMS Innovation Centre to create a demonstration program for (51) reimbursing palliative blood transfusions outside the hospice benefit. This bill, along with S.1845 (52), the Expanding Access to Palliative Care Act, is currently under consideration in the Senate (53).

In China, end-of-life policy is in early-stage of development and out-of-pocket expenditures are common (54). However, reimbursement rate for hospitalization expenses exceeded 55% with China’s medical insurance schemes (55). In Germany, end-of-life care is governed by the German Hospice and Palliative Care Act 2015, and reimbursement is covered under statutory health insurance system [Gesetzliche Krankenversicherung (GKV)] (56). In Japan, hospice and palliative care are addressed by the Japan Hospice and Palliative Care Foundation and expenses are covered under Japan’s National Health Insurance (NHI) (57). Patients might have to bear some additional charges in case availing of private insurance systems. In middle-income countries (Africa, India) there is a lot of policy gaps regarding this aspect with reliance on out-of-pocket expenses.

Conclusions

Overall interpretation

With an increasing number of old-age population worldwide, it is important to consider new models of transfusion, including end-of-life transfusion at hospice care and palliative care facilities. Our findings suggest that both patients and caregivers might benefit from transfusion at home if it is appropriately delivered. Blood transfusion at home could serve not only to relieve overcrowding of health services but also to improve the care and quality of life of a significant portion of transfusion-dependent patients. While blood transfusion may not be included in the hospice facilities, as they are viewed as disease-modifying treatment modality, yet they may address different palliative medicine needs. We tried to explore the complex and dynamic perspectives of a blood transfusion program in end-of-life care facilities, from the perspective of patient, caregiver, and physician involved, which may involve a careful analysis of salient medical and ethical issues involving responsible use of blood resources. With reasoned consideration of the ethical issues, it is not possible to ignore the certain benefits of end-of-life transfusions which include financial benefits, benefits of a home assistance program. The reported rate of adverse transfusion reactions is not significantly higher than that in hospital-based transfusions. There are scopes of improvement in the current scenario that may include the presence of a physician or nurse, considering possible different medical regulations and resources for the whole duration of the transfusion procedure as a safety add-on, as seen in limited evidence available from the literature.

It is equally important to evaluate real-world cost variability in specific countries, as healthcare practices vary across countries of different socioeconomic strata. It is vital that the legislations of respective countries address the concerns, needs, and challenges faced by our patients and develop a patient-centered initiative of home blood transfusion program that can promote end-of-life transfusions. However, further research is needed to establish the effectiveness of end-of-life transfusion, resolve certain ethical queries like appropriate usage of blood products, as well as organizational and economic issues. The review was limited by the fact that only few low-quality studies meeting predefined criteria were included and that no studies evaluated the effectiveness or cost-benefit analysis of home vs. hospital transfusions.

Future directions

Recent studies conducted in 2022 from the United States mention that data suggest hospice providers are supportive of increasing access to the transfusion services for end-of-life patients and there is a critical need for innovative hospice payment models (58). On the other hand, another ray of hope in developing countries is introduction of electronic crossmatch and remote blood releasing system, which will enable round the clock service of blood transfusion for end-of-life care patients in difficult geographic regions (59).

This narrative also highlights a few avenues for further research. More robust data on the attitudes of palliative care physicians and hematologists toward transfusions should be assessed. There is an unmet need for research data of which patient populations or specific symptoms are likely to improve with transfusions, may start to provide a framework for developing guidelines. At the same time, it also important to develop and train manpower such as nurses and other health care professionals at the community level around the globe who will provide this home-based transfusion services for terminally ill patients locally at the home level in addition to their current clinical role. This will reduce the overcrowding at the hospital and day care services and it will be comfortable for the patients to receive these services.

We also recognize that there should be provisions for non-invasive Hb measurement for patients who are prone to develop anemia because of their underlying diagnosis like leukemia and solid tumor patients, end-stage renal disease patients. This will prompt the diagnosis and offer a better care. This narrative review also directs that there is a necessity of multi-institutional audit which will address difference in end-of-life blood transfusion practices indications and challenges faced by the patients and the clinicians. This will also help to develop a guideline to address indications for end-of-life transfusion, monitoring using clinical parameters.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Richard Gammon) for the series “Patient Blood Management’s Role in Current Healthcare Environment” published in Annals of Blood. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aob.amegroups.com/article/view/10.21037/aob-24-28/rc

Peer Review File: Available at https://aob.amegroups.com/article/view/10.21037/aob-24-28/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aob.amegroups.com/article/view/10.21037/aob-24-28/coif). The series “Patient Blood Management’s Role in Current Healthcare Environment” was commissioned by the editorial office without any funding or sponsorship. R.G. served as the unpaid Guest Editor of the series. M.T.F. serves as an unpaid editorial board member of Annals of Blood from November 2024 to October 2026. S.M. was funded by the National Institute of Health Research, UK for a recent job role academic clinical fellow and funded by UK Research and Innovation for a current job role clinical research fellow at the University of Nottingham; he reports support for attending meetings from the British Society of Haematology. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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