transfusion in palliative cancer patients: a review of the literature
TRANSCRIPT
Palliative Care ReviewFeature Editor: Vyjeyanthi S. Periyakoil
Transfusion in Palliative Cancer Patients:A Review of the Literature
Marıa Elena Uceda Torres, MD,1 Juan Nicolas Rodrıguez Rodrıguez, MD, PhD,2
Jose Luis Sanchez Ramos, MD, PhD,3 and Francisco Alvarado Gomez4
Abstract
Background: Transfusion is not an exceptional circumstance in palliative cancer patients (PCPs). This makes itnecessary to confront not only medical aspects but also those of infrastructure and ethical issues. On someoccasions, literature needs to be consulted to work out the best approach in a patient’s particular case. Our aimwas to review the literature contained in PubMed and EMBASE so as to find out about the information availableon transfusion in PCPs.Methods: A search for literature was carried out in databases PubMed and EMBASE, using ‘‘transfusion,’’‘‘cancer,’’ ‘‘end-of-life care,’’ ‘‘terminal care,’’ and ‘‘palliative care’’ as key words. Publications were classifiedaccording to the main topic discussed (clinical, infrastructure, and ethics) and the information included in eacharticle critically assessed.Results: We found 334 articles but only 43 were considered valuable for the present study. Of these 43 articles, 21deal with clinical topics while 12 deal with infrastructure and 10 with ethical issues. There is an absolute lack ofrandomized controlled trials or clinical guidelines. Trigger parameters for transfusion are not clearly established.Benefits of the procedure are shortly experienced and remain controversial. Home transfusions are encouraged,but this sole procedure has not been demonstrated to be cost effective. Different cultures, cases, and realitiesillustrate the diversity of the ethical management of transfusion in PCPs.Discussion: Although transfusion is certainly a common practice in PCPs, there is a relative lack of literature onthis topic. Publications are unconnected and hardly any prospective studies have been performed. A large partof the little literature available only concerns descriptive and very general aspects of the issue. As transfusionalproducts and financial and human resources are finite, it would be desirable to establish clear research lines onthe different aspects considered (clinical, infrastructure, and ethical) that can help clinicians, nurses, patients, andcarers to make a decision.
Introduction
Transfusion is one of the treatments used to alleviatesymptoms derived from cytopenias and coagulation
disorders observed in cancer patients. Anemia is the mostwidely occurring cytopenia (50% of patients at some pointduring the evolution of their disease,1 more in hematologicmalignancies, and 70% of patients in the advanced period2);but also platelets and coagulative factors can be affected. Inthe transfusion management of palliative cancer patients(PCPs), some particular aspects must be taken into account:the time and place of transfusion, trigger values for transfu-
sion, the patient’s life expectancy, the patient’s and family’swillingness, the degree of improvement of the patient’s per-formance status with the transfusion, and the complicationsderiving from the procedure.
At this moment, transfusion becomes one of the most dif-ficult problems doctors and nurses have to face. Curiously,any literature specifically concerning transfusion in palliativecare is scarce. Moreover, only one previous review, restrictedto red blood cell transfusion (RBC-T), clinical trials, and fo-cusing exclusively on clinical aspects, has been published veryrecently.3 The aim of the present article is therefore to find outthe information available regarding transfusion in PCPs,
1U.G.C. Health Centre ‘‘Molino de la Vega,’’ Huelva, Spain.2U.G.C. Hematology, 4Andalusian Public Health System Virtual Library, Hospital ‘‘Juan Ramon Jimenez,’’ Huelva, Spain.3Nursing Department, University of Huelva, Huelva, Spain.Accepted September 2, 2013.
JOURNAL OF PALLIATIVE MEDICINEVolume 17, Number 1, 2014ª Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2013.0387
88
which not only considers clinical but also infrastructure andethical aspects as well.
Methods
Search strategy
PubMed and EMBASE were chosen to be studied as theyare some of the most powerful and popular search engines formedical consultations. The period of investigation was 1946 to2011. The search in EMBASE was restricted to articles in-cluded exclusively in this database. Table 1 shows the searchstrategy followed and its results in both databases. Referencescontained in the articles finally selected were reviewed for thepossibility of finding additional papers of interest.
Selection criteria and process
A first selection was performed using the title and/or ab-stract idea of the article and using the following items (at leastone) as exclusion criteria:
1) Not in the English language.2) Pathologies other than cancer.3) Transfusion as a part of an active treatment (with or
without palliative intention).4) Nonpalliative patients.5) Others (radiology techniques, cancer evolution, and
miscellanea).
For those articles in which the title and/or abstract ideawere not available or were insufficient to clarify the content ofthe article, the article was read in its entirety to make thedecision regarding its content, following the same exclusioncriteria stated above.
Data extraction
To classify the purpose of the articles, the following aspectswere considered according to the central topic discussed bythe authors.
1) Clinical: product and incidence of transfusion; type ofpatient (pediatric or adult; solid or hematologic ma-lignancies); inpatient or home transfusion (outpa-
tients); parameters and triggers for decidingtransfusion; improvement of symptoms with the pro-cedure; transfusion as a prognostic factor for survival.
2) Infrastructure: possibility of home transfusion, infra-structure to perform it; and cost analysis.
3) Ethical.
Results and discussion have been outlined and carried outrespectively according to these three different aspects.
Results
Initially we found 157 articles in PubMed and 178 in EM-BASE for a final overall count of 334 articles (one redundantpublication was detected). Of these, 291 (87.1%) were ex-cluded, and only 43 (12.9%) were considered valuable for thereview. The main cause of exclusion was the consideration oftransfusion in the article as part of an active treatment. Those43 selected articles were grouped as follows.
Clinical (21 articles)
No clinical guidelines, reviews, or consensus conferenceshave been found. Only a position paper regarding platelettransfusion (Plt-T) in hematologic advanced malignanciescould be considered a certain guide to use. No clinical trialscomparing the efficacy of transfusion to placebo or other al-ternative treatments, e.g., erythropoietic stimulating agents(ESA) could be found either. Minimal or no references to freshfrozen plasma have been found in these articles. (See Table 2.)
RBC-T. The incidence of RBC-T in PCP is variable (5%–17.5%), being higher in hematologic malignancies, bleedingsolid tumors, inpatients, conventional care (general acute carehospitals), and in those admitted to oncology units. A mixtureof hemoglobin (Hb) levels (usually £ 8 g/dl) and clinical pa-rameters should be taken into account when deciding ontransfusion. Most patients are transfused only once during theperiod of study, and the mean of RBC units per patient is < 3.No frequent or important reactions related to these transfu-sions have been described. Six studies report the results ofRBC-T in terms of improving quality of life or feeling better.Approximately 60% of patients feel this benefit. This benefitdoes not seem to be related to age, pretransfusion Hb level,ECOG score, nor severity of pretransfusion symptoms relatedto anemia; and it seems to be higher in discharged patientsnow at home (78.6%). These benefits are observed early on(after two days), but are not sustained for any longer thanthree weeks later. One study focuses on RBC-T as a negativepredictor parameter for survival in solid tumors when per-formed in the last two weeks of life.
Plt-T. Plt-T is an increasingly valuable intervention inthese patients and is most frequently performed in hemato-logic patients. Most authors do not use these transfusions for aprophylactic purpose but rather for when a bleeding episodeoccurs. The frequency of Plt-T is slightly higher (1.6 per pa-tient) than the one for RBC-T. Reactions to these transfusionsare scarce as well.
Infrastructure (12 articles)
For most authors, transfusion at home is feasible andshould be a major objective in palliative care, because it helps
Table 1. Search Strategy and Results
Num. Query PubMed Embasea
#1 cancer 2,657,076 831,223#2 transfusion 119,539 63,384#3 end-of-life care 51,582 6,338#4 terminal care 41,775 6,190#5 palliative care 43,567 17,747#6 #3 OR #4 OR #5 83,893 21,897#7 #1 AND #2 AND #6 160 205#8 PubMed: #7 AND filters:
publication date from1/1/1950 to 12/31/2011Embase: #7 AND[ < 1966–2011]/py
157 178b
aEMBASE results reflect only those articles included exclusively inthis database.
bAfter crossover analysis, only one duplicated paper (both inEmbase) was detected.
py, publication year.
TRANSFUSION IN PALLIATIVE CANCER PATIENTS 89
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;10:
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ere
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aily
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tpat
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ared
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eto
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ter
per
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ance
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us
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2004
;15:
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tom
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gar
din
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ual
ity
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erse
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ns
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edto
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ere
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ce.
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eatm
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ased
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ical
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fin
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nw
ith
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fere
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ued
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bl
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nt
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ue
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thor
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ence
Ty
pe
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ud
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ran
sfu
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pro
du
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yp
eof
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ien
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ain
fin
din
gs
Lie
bo
vit
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,et
al.
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JC
lin
On
col
2004
;27:
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546.
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.34
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.
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ts:
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reed
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ano
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allo
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rfa
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qu
ests
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are
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tin
dic
atio
ns
for
tran
sfu
sio
n.
Fo
r64
%o
fp
arti
cip
ants
,H
ble
vel
was
atr
ansf
usi
on
crit
erio
n(H
b£
7g/
dl
lev
elw
asin
var
iab
lya
tran
sfu
sio
ncr
iter
ion
for
all
gro
up
so
fp
arti
cip
ants
);h
ow
ever
the
cost
of
the
pro
ced
ure
was
irre
lev
ant
for
all
of
them
and
the
maj
ori
tyw
ere
no
tco
nce
rned
wit
hth
esi
de
effe
cts
of
tran
sfu
sio
n.
Asl
igh
tm
ajo
rity
con
sid
erth
atb
loo
dtr
ansf
usi
on
do
esn
ot
pro
lon
gp
atie
nts
’su
ffer
ing
.Att
itu
des
of
nu
rses
dif
fer
fro
mth
em
edic
alo
nes
inas
pec
tssu
chas
wh
ota
kes
the
dec
isio
nto
tran
sfu
sean
dth
etr
igg
erle
vel
for
tran
sfu
sio
n.
Tra
nsf
usi
on
sho
uld
no
tb
ew
ith
hel
dfr
om
term
inal
can
cer
pat
ien
tsan
dit
sho
uld
be
per
form
edo
nan
ind
ivid
ual
bas
is,
mai
nly
acco
rdin
gto
the
pat
ien
t’s
clin
ical
stat
us.
Bro
ok
L,
etal
.M
edP
edia
trO
nco
l20
03;4
0:24
9–25
1.13
Ob
serv
atio
nal
.P
late
lets
12P
atie
nts
.D
iver
sep
edia
tric
can
cers
.O
utp
atie
nts
Hem
ato
log
ical
mal
ign
anci
esn
eed
pla
tele
ttr
ansf
usi
on
mo
refr
equ
entl
yth
anso
lid
tum
ors
,al
tho
ug
hth
ep
rop
ort
ion
of
pat
ien
tsd
oes
no
tex
ceed
40%
.A
hig
hp
rop
ort
ion
of
pat
ien
tsex
per
ien
ceh
emo
stas
isw
ith
pla
tele
ttr
ansf
usi
on
.P
rop
hy
lax
isw
ith
chlo
rph
enir
amin
eis
per
form
ed.
Rea
ctio
ns
are
rare
.P
late
let
tran
sfu
sio
ns
ath
om
ear
een
cou
rag
ed.
Sto
ckel
ber
gD
,et
al.
Su
pp
ort
Car
eC
ance
r19
97;5
:506
–508
.
14O
bse
rvat
ion
al.
RB
C;
pla
tele
tsO
utp
atie
nts
(17)
wit
hh
emat
olo
gic
alm
alig
nan
cies
.P
atie
nts
liv
ing
>40
km
fro
mh
osp
ital
wer
en
ot
incl
ud
ed.
Inm
any
occ
asio
ns
an
urs
est
ayed
wit
hea
chp
atie
nt
un
til
the
tran
sfu
sio
nen
ded
.M
ost
pat
ien
tsw
ere
tran
sfu
sed
ath
om
eb
ecau
seo
fth
eir
po
or
clin
ical
con
dit
ion
;th
isw
ou
ldb
eo
ne
of
the
circ
um
stan
ces
tob
eta
ken
into
acco
un
tw
hen
this
serv
ice
iso
ffer
edat
ho
me.
No
com
pli
cati
on
sw
ere
ob
serv
ed.
Au
tho
rsre
mar
kth
atth
isse
rvic
ep
rov
ides
sup
po
rtto
pat
ien
tan
dre
lati
ves
and
that
they
are
sati
sfied
wit
hth
ese
rvic
e.M
any
pro
ble
ms
can
be
solv
edw
ith
nu
rse’
sv
isit
so
rte
lep
ho
ne
con
sult
atio
n.
Inth
eec
on
om
icst
ud
yp
erfo
rmed
by
the
auth
ors
,th
istr
eatm
ent
mo
del
isec
on
om
ical
lysu
per
ior
toth
etr
adit
ion
alm
od
el(h
osp
ital
assi
stan
ce).
(con
tin
ued
)
92
Ta
bl
e2.
(Co
nt
in
ue
d)
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
yT
ran
sfu
sion
pro
du
ctT
yp
eof
pat
ien
tM
ain
fin
din
gs
Mo
nti
M,
etal
.J
Pai
nS
ym
pto
mM
anag
e19
96;1
2:18
–22.
15O
bse
rvat
ion
al.
Ret
rosp
ecti
ve.
Pre
-an
dp
ost
inte
rven
tio
n(t
ran
sfu
sio
n).
RB
C31
pat
ien
ts.
Alm
ost
excl
usi
vel
yso
lid
tum
ors
.In
-an
do
utp
atie
nts
.
12.6
%o
fp
atie
nts
are
tran
sfu
sed
wit
han
aver
age
of
2.8
con
cen
trat
es.
51.4
%o
fp
atie
nts
rep
ort
edan
imp
rov
emen
tin
wel
l-b
ein
gaf
ter
tran
sfu
sio
n.
Th
isim
pro
vem
ent
was
no
tas
soci
ated
top
retr
ansf
usi
on
Hb
lev
els,
EC
OG
sco
re,
or
the
pre
sen
ceo
fse
ver
esy
mp
tom
sim
pu
tab
leto
anem
ia.
Th
isp
erce
nta
ge
of
imp
rov
emen
tw
ash
igh
erin
pat
ien
tsd
isch
arg
edh
om
e(7
8.6%
).A
nab
sen
ceo
fim
pro
vem
ent
was
asso
ciat
edto
sho
rter
tim
eto
dea
th;
tran
sfu
sio
ns
adm
inis
tere
din
the
last
fou
rw
eek
so
fli
fear
eli
kel
yto
pro
ve
au
sele
ssp
roce
du
reth
atd
oes
no
tin
flu
ence
the
qu
alit
yo
fli
fe.
Gle
eso
nC
,et
al.
Pal
liat
Med
1995
;9:3
07–3
13.
16O
bse
rvat
ion
al.
Pro
spec
tiv
e.P
re-
and
po
stin
terv
enti
on
(tra
nsf
usi
on
).
RB
C91
pat
ien
ts.
Mo
stly
soli
dtu
mo
rs.I
n-/
ou
tpat
ien
ts:
no
tsp
ecifi
ed.
Av
isu
alan
alo
gu
esc
ale
(VA
S)
was
use
dto
mea
sure
stre
ng
th,
deg
ree
of
dy
spn
ea,
and
ov
eral
lse
nse
of
wel
l-b
ein
g.
76%
of
pat
ien
tsfe
elb
ette
rtw
od
ays
afte
rtr
ansf
usi
on
.T
his
per
cen
tag
ere
mai
ns
un
alte
red
atd
ay14
po
sttr
ansf
usi
on
.A
tb
oth
dat
es,
abo
ut
80%
of
pat
ien
tsre
po
rtfe
elin
gth
ep
roce
du
rew
ort
hw
hil
e.D
egre
eo
fan
emia
pri
or
totr
ansf
usi
on
was
no
tco
rrel
ated
wit
hV
AS
sco
re.
Th
em
ost
mar
ked
ben
efit
was
ob
serv
edin
pat
ien
tsw
ho
pre
sen
ted
wea
kn
ess
or
dy
spn
eaas
asy
mp
tom
,b
ut
this
imp
rov
emen
tw
asle
ssin
tho
sew
ith
bre
ath
less
nes
s.P
re-
tran
sfu
sio
nal
Hb
lev
elw
asn
ot
corr
elat
edw
ith
the
imp
rov
emen
t.M
alto
ni
M,
etal
.C
ance
r19
95;7
5:26
13–2
622.
17O
bse
rvat
ion
al.
Pro
spec
tiv
e.M
ult
icen
tric
.R
BC
So
lid
tum
ors
.53
0p
atie
nts
.In
-/o
utp
atie
nts
:n
ot
spec
ified
.
Tra
nsf
usi
on
inth
ela
st15
day
sw
asa
pro
gn
ost
icfa
cto
rfo
rsh
ort
ersu
rviv
alb
yu
niv
aria
tean
aly
sis;
this
con
clu
sio
nw
asn
ot
mai
nta
ined
by
mu
ltiv
aria
tean
aly
sis.
Sci
ort
ino
AD
,et
al.
JP
alli
atC
are
1993
;9:1
4–17
.18
Ob
serv
atio
nal
.P
re-
and
po
stin
terv
enti
on
(tra
nsf
usi
on
).
RB
C24
pat
ien
ts.
Div
erse
can
cers
.O
utp
atie
nts
.M
easu
rem
ent
of
sym
pto
ms
po
sttr
ansf
usi
on
was
per
form
edw
ith
ino
ne
wee
kaf
ter
tran
sfu
sio
n.
No
imp
rov
emen
tin
sig
ns
(ex
cep
th
emat
ocr
it),
sym
pto
ms,
or
per
form
ance
stat
us
was
ob
serv
edan
do
nly
the
qu
alit
yo
fli
fein
dex
com
ple
ted
by
the
pat
ien
tam
elio
rate
s.T
he
pat
ien
tsre
po
rted
feel
ing
mo
reu
sefu
lp
ost
tran
sfu
sio
nth
anp
retr
ansf
usi
on
.T
he
ben
efit
of
tran
sfu
sio
nse
ems
tob
eo
nly
psy
cho
log
ical
for
pat
ien
ts.
(con
tin
ued
)
93
Ta
bl
e2.
(Co
nt
in
ue
d)
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
yT
ran
sfu
sion
pro
du
ctT
yp
eof
pat
ien
tM
ain
fin
din
gs
Wat
chel
TJ,
etal
.T
ran
sfu
sio
n19
85;2
5:27
8–27
9.
19P
art
(fo
cuse
do
ntr
ansf
usi
on
)o
fth
eN
atio
nal
Ho
spic
eS
tud
y(a
mu
ltis
ite
qu
asi-
exp
erim
enta
lst
ud
y).
No
tsp
ecifi
ed20
2p
atie
nts
.D
iver
seca
nce
rs.
In-
and
ou
tpat
ien
ts.
Ter
min
alca
nce
rp
atie
nts
inco
nv
enti
on
alca
re(i
.e.,
gen
eral
acu
teca
reh
osp
ital
s)ar
em
ore
lik
ely
tob
etr
ansf
use
dth
anh
osp
ital
-bas
edh
osp
ices
and
pat
ien
tsin
ho
me-
care
ho
spic
es(fi
ve
tim
esan
dte
nti
mes
resp
ecti
vel
y).
Tra
nsf
usi
on
of
blo
od
com
po
nen
tsto
term
inal
can
cer
pat
ien
tsm
ayb
eo
ver
use
din
con
ven
tio
nal
care
sett
ing
s.T
he
pat
ien
tsin
thei
rla
stsi
xw
eek
so
fli
few
ere
no
tsp
ecifi
call
yan
aly
zed
,so
we
cou
ldsu
pp
ose
the
gro
up
was
mo
reex
po
sed
toth
isp
roce
du
re.
Tan
nen
ber
gS
.E
ur
JO
nco
l20
06;1
1:22
5–23
5.20
Rev
iew
on
anem
iain
pal
liat
ive
pat
ien
ts(d
efin
itio
n,
freq
uen
cy,
role
of
anem
iain
thei
rsy
mp
tom
san
dtr
eatm
ent)
RB
CD
iver
seca
nce
rs.
In-/
ou
tpat
ien
ts:
no
tsp
ecifi
ed.
Incl
inic
alro
uti
ne
pra
ctic
e,tr
ansf
usi
on
sho
uld
be
con
sid
ered
wh
enH
b<
8g
/d
l,al
tho
ug
hin
div
idu
alan
aly
sis
isd
esir
able
.T
he
pre
sen
cean
din
ten
sity
of
anem
iad
on
ot
corr
elat
ew
ith
the
inte
nsi
tyo
fsy
mp
tom
sth
ep
atie
nt
feel
s,es
pec
iall
yfa
tig
ue.
Ap
pro
xim
atel
y50
%o
fad
van
ced
can
cer
pat
ien
tsar
ean
emic
,b
ut
on
lyab
ou
t15
%o
fth
emh
ave
anem
iaw
ith
clin
ical
con
seq
uen
ces
that
wil
lre
qu
ire
trea
tmen
t.T
he
effe
ctiv
enes
so
ftr
ansf
usi
on
inth
isla
tter
gro
up
of
pat
ien
tsre
mai
ns
un
clea
r.S
om
est
ud
ies
hav
eg
ener
ated
the
hy
po
thes
isth
attr
eatm
ent
of
can
cer-
rela
ted
anem
ian
ot
on
lyal
lev
iate
san
emia
-rel
ated
sym
pto
ms
bu
tal
som
od
ifies
tum
or
resp
on
sean
do
ver
all
surv
ival
.T
he
corr
ecti
on
of
anem
iain
pal
liat
ive
can
cer
pat
ien
tsis
pro
bab
lya
seco
nd
ary
ob
ject
ive
com
par
edw
ith
oth
ers
such
asth
eco
ntr
ol
of
pai
n.
Tra
nsf
usi
on
sd
on
ot
seem
tob
ea
risk
yp
roce
du
refo
rp
atie
nts
.T
he
qu
ick
ben
efit
ob
tain
edw
ith
tran
sfu
sio
ns,
alth
ou
gh
itis
no
tsu
stai
ned
,ca
nn
ot
be
ach
iev
edu
sin
ger
yth
rocy
test
imu
lati
ng
agen
ts.
Mo
sto
fth
ese
con
clu
sio
ns
are
sust
ain
edin
arti
cles
cite
dab
ov
e.P
erei
raJ,
etal
.O
nco
log
ist
2004
;9:5
61–5
70.
21R
evie
wo
nm
anag
emen
to
fb
leed
ing
inp
atie
nts
wit
had
van
ced
can
cer.
Pla
tele
ts.
Min
imal
refe
ren
ceto
fres
hfr
oze
np
lasm
a.R
BC
(an
ecd
oti
c)
Div
erse
can
cers
.In
-/o
utp
atie
nts
:n
ot
spec
ified
.G
ener
alg
uid
eo
nth
em
anag
emen
to
fb
leed
ing
inp
atie
nts
wit
had
van
ced
can
cer.
Rev
iew
of
pla
tele
tn
um
ber
asa
trig
ger
for
tran
sfu
sio
n,
and
dif
ficu
ltie
sin
the
man
agem
ent
of
thes
ep
atie
nts
incl
ud
ing
eth
ical
issu
es.
Ind
icat
ion
sfo
rfr
esh
fro
zen
pla
sma
tran
sfu
sio
nin
pal
liat
ive
pat
ien
ts.
(con
tin
ued
)
94
Ta
bl
e2.
(Co
nt
in
ue
d)
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
yT
ran
sfu
sion
pro
du
ctT
yp
eof
pat
ien
tM
ain
fin
din
gs
Bea
rdsm
ore
S,
etal
.E
ur
JC
ance
r20
02;3
8:19
00–
1907
.
22R
evie
wo
nm
anag
emen
to
fca
rein
ped
iatr
icp
atie
nts
wit
had
van
ced
can
cer
(in
clu
din
gtr
ansf
usi
on
aso
ne
of
the
pro
ble
ms
totr
eat)
.
Min
imal
refe
ren
ceto
tran
sfu
sio
no
fre
db
loo
dce
lls
and
pla
tele
ts
Ped
iatr
icca
nce
rp
atie
nts
.In
-/o
utp
atie
nts
:n
ot
spec
ified
.V
ery
gen
eral
and
bri
efre
com
men
dat
ion
so
nth
eu
seo
fb
loo
dp
rod
uct
sin
the
trea
tmen
to
fb
leed
ing
.
Rip
amo
nti
C.
Su
pp
ort
Car
eC
ance
r19
99;7
:233
–243
.23
Rev
iew
on
man
agem
ent
of
dy
spn
eain
adv
ance
dca
nce
rp
atie
nts
(in
clu
din
gtr
ansf
usi
on
aso
ne
of
the
too
lsto
use
).
RB
CD
iver
seca
nce
rs.
In-/
ou
tpat
ien
ts:
no
tsp
ecifi
ed.
Rev
iew
on
the
use
fuln
ess
of
RB
Ctr
ansf
usi
on
sin
the
trea
tmen
to
fd
ysp
nea
.Id
eas
and
con
clu
sio
ns
are
ob
tain
edfr
om
oth
erar
ticl
esm
enti
on
edab
ov
e.
Las
sau
nie
re,
etal
.J
Pal
liat
Car
e19
96;1
2:38
–41.
24P
osi
tio
np
aper
.P
late
lets
Hem
ato
log
ical
pat
ien
ts.
In-/
ou
tpat
ien
ts:
no
tsp
ecifi
ed.
Rev
iew
on
pla
tele
tco
un
tsas
atr
igg
erfo
rtr
ansf
usi
on
(in
crea
sed
risk
of
ble
edin
gis
ob
serv
edw
ith
pla
tele
tco
un
tsu
nd
er20
x10
9/
l,an
des
pec
iall
yu
nd
er10
x10
9/
l).
Pro
ph
yla
ctic
pla
tele
ttr
ansf
usi
on
sar
en
ot
con
sid
ered
man
dat
ory
and
they
sho
uld
be
giv
ento
sto
pcl
inic
ally
sig
nifi
can
tb
leed
ing
.T
he
use
of
sin
gle
-do
no
rp
late
lets
isn
ot
reco
mm
end
ed,
and
po
ole
dra
nd
om
-do
no
rp
late
lets
are
pre
ferr
ed.
Ces
sati
on
of
pla
tele
ttr
ansf
usi
on
ssh
ou
ldb
eco
nte
mp
late
din
div
idu
ally
.
95
Ta
bl
e3.
Ar
tic
le
sF
oc
use
do
nT
ra
nsfu
sio
nin
Pa
ll
ia
tiv
eC
an
ce
rP
at
ie
nt
sw
it
hIn
fr
ast
ru
ct
ur
eA
sp
ec
ts
as
th
eC
en
tr
al
To
pic
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
yT
ran
sfu
sion
pro
du
ctT
yp
eof
pat
ien
tM
ain
fin
din
gs
Bia
nch
ini
E,
etal
.P
edia
trB
loo
dC
ance
r20
10;5
5:98
8.
43E
val
uat
ion
of
acti
vit
yo
fa
‘‘fo
ur
wh
eel
ho
spit
al.’’
Po
ster
abst
ract
.
RB
C,
pla
tele
tsP
edia
tric
can
cer
(hem
ato
log
ican
dn
on
hem
ato
log
ic)
pat
ien
tsn
ot
all
inp
alli
ativ
est
atu
s(1
8p
atie
nts
).O
utp
atie
nts
.
Tra
nsf
usi
on
sat
ho
me
are
feas
ible
,al
low
ing
anim
pro
vem
ent
of
the
qu
alit
yo
fli
feo
fp
atie
nts
(in
clu
din
gas
pec
tssu
chas
rela
tio
nsh
ipw
ith
rela
tiv
esan
dfr
ien
ds)
.
Ger
tzM
A.
Leu
kL
ym
ph
om
a20
09;5
0:31
3–31
4.
44O
pin
ion
arti
cle.
Pla
tele
tsH
emat
olo
gic
mal
ign
anci
es.
In-/
ou
tpat
ien
ts:
no
tsp
ecifi
ed.
Bri
efre
vie
wo
fp
late
let
lev
eltr
igg
erfo
rtr
ansf
usi
on
and
the
pro
ble
ma
term
inal
lyil
lth
rom
bo
cyto
pen
icp
atie
nt
rep
rese
nts
.A
refl
ecti
on
ism
ade
abo
ut
the
adv
anta
ges
of
pla
tele
ttr
ansf
usi
on
ath
om
eco
nsi
der
ing
the
pat
ien
t’s
hig
her
qu
alit
yo
fli
fean
dth
ere
du
ctio
no
fco
sts
com
par
edw
ith
clas
sica
lm
anag
emen
t.L
awlo
rP
,et
al.
Su
pp
ort
Car
eC
ance
r20
09;1
7:96
9.45
Ev
alu
atio
no
fth
erap
euti
cin
terv
enti
on
sin
ho
spic
e.P
ost
erab
stra
ct.
RB
CD
iver
seca
nce
rs.
Inp
atie
nts
.T
her
eis
asi
gn
ifica
nt
incr
ease
inth
era
tes
of
ther
apeu
tic
inte
rven
tio
ns
(in
clu
din
gtr
ansf
usi
on
s)in
pal
liat
ive
pat
ien
tsth
rou
gh
ou
tth
ed
ecad
e19
97–2
007.
Mac
Gra
thP
,et
al.
Su
pp
ort
Car
eC
ance
r20
09;1
7:52
7–53
7.
46In
terv
iew
of
hem
ato
log
ical
nu
rses
,p
alli
ativ
en
urs
es,
and
hem
ato
log
ists
totr
yto
dev
elo
pg
uid
elin
esfo
rb
est
pra
ctic
ein
clin
ical
and
sup
po
rtiv
eca
re.
Pla
tele
ts,
RB
CH
emat
olo
gic
alm
alig
nan
cies
.In
-/o
utp
atie
nts
:n
ot
spec
ified
.
Th
ere
isla
cko
fco
nse
nsu
sin
the
dif
fere
nt
clin
ical
per
son
nel
imp
lica
ted
inth
eca
reo
fh
emat
olo
gic
alp
atie
nts
abo
ut
the
atte
nti
on
toth
ese
pat
ien
tsin
the
case
of
cata
stro
ph
icb
leed
ing
.T
his
cou
ldm
ake
the
dis
char
ge
of
pat
ien
tsm
ore
dif
ficu
lt.
Th
ere
isg
reat
con
tro
ver
syre
gar
din
gth
eca
reo
fh
emat
olo
gic
alp
alli
ativ
ep
atie
nts
wit
ha
gre
atri
sko
fca
tast
rop
hic
ble
eds.
Fo
ra
gro
up
of
par
tici
pan
ts,
this
risk
isp
erce
ived
asan
imp
ort
ant
ob
stac
lefo
rd
yin
gat
ho
me;
ho
wev
erit
isn
ot
per
ceiv
edas
am
ajo
ro
bst
acle
tob
ein
gre
ferr
edto
pal
liat
ive
care
by
oth
ers.
Th
eu
seo
fb
loo
dp
rod
uct
sto
pre
ven
to
rle
ssen
the
ble
edin
gre
mai
ns
con
tro
ver
sial
asw
ell.
Ko
dam
aY
,et
al.
Jpn
JC
lin
On
col
2009
;39:
606–
611.
47R
etro
spec
tiv
e.R
evie
wo
fm
edic
alh
isto
ries
and
inte
rvie
wto
atte
nd
ing
ph
ysi
cian
s.
RB
C;
pla
tele
tsH
emat
olo
gic
mal
ign
anci
es(1
5p
atie
nts
).O
utp
atie
nts
.
Au
tho
rsco
nsi
der
that
for
man
yp
ract
itio
ner
s,tr
ansf
usi
on
sho
uld
be
con
du
cted
inm
edic
alin
stit
uti
on
s.H
om
eca
resh
ou
ldex
clu
de
pat
ien
tsw
ho
nee
dfr
equ
ent
tran
sfu
sio
ns
or
pla
tele
ttr
ansf
usi
on
s.
(con
tin
ued
)
96
Ta
bl
e3.
(Co
nt
in
ue
d)
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
yT
ran
sfu
sion
pro
du
ctT
yp
eof
pat
ien
tM
ain
fin
din
gs
Mer
cad
ante
S,
etal
.P
alli
atM
ed20
08;2
2:76
0–76
7.48
Pro
spec
tiv
e.S
tud
yo
fcl
inic
alan
dfi
nan
cial
anal
ysi
so
fan
acu
tep
alli
ativ
eca
reu
nit
.
RB
CM
ain
lyso
lid
tum
ors
.In
pat
ien
ts.
Tra
nsf
usi
on
rate
sw
ere
rela
tiv
ely
hig
h(1
1.7%
)as
ap
oss
ible
refl
ecti
on
of
no
tco
nsi
der
ing
som
ep
atie
nts
form
ally
pal
liat
ive.
Au
tho
rsco
nsi
der
that
acu
tep
alli
ativ
eca
reu
nit
sar
eco
stef
fect
ive,
incl
ud
ing
tran
sfu
sio
ns
aso
ne
of
the
pro
ced
ure
sp
erfo
rmed
;b
ut
no
spec
ific
cost
stu
die
so
nth
isto
pic
hav
eb
een
per
form
ed.
Dev
lin
B,
etal
.C
om
mu
nit
yP
ract
2008
;81:
32–3
5.49
Ev
alu
atio
no
fd
om
icil
iary
blo
od
tran
sfu
sio
nse
rvic
e.T
elep
ho
ne
inte
rvie
ws
top
atie
nts
.
RB
CC
ance
ran
dn
on
can
cer
(16
pat
ien
ts).
Ou
tpat
ien
ts.
Au
tho
rsan
aly
zeth
eai
ms
and
use
fuln
ess
of
the
serv
ice,
avo
idin
gh
osp
ital
adm
issi
on
,co
mp
osi
tio
no
fth
est
aff
(in
clu
din
gd
iffe
ren
tn
urs
es,
hem
ov
igil
ance
coo
rdin
ato
r,an
dd
iffe
ren
tco
nsu
ltan
ts),
staf
ftr
ain
ing
,an
dre
sou
rce
con
sid
erat
ion
s.P
atie
nts
con
sid
erth
ese
rvic
eas
exce
llen
tan
dth
eyw
ou
ldre
com
men
dth
ed
om
icil
iary
blo
od
tran
sfu
sio
nto
oth
ers.
Fam
ilie
sal
sop
erce
ive
this
po
siti
ve
effe
ct.
Car
ton
iC
,et
al.
Hae
mat
olo
gic
a20
07;9
2:66
6–67
3.
50C
ost
anal
ysi
so
fa
do
mic
ilia
ryp
rog
ram
of
sup
po
rtiv
ean
dp
alli
ativ
eca
re.
RB
C;
pla
tele
tsH
emat
olo
gic
neo
pla
sms
(144
pat
ien
ts,
62%
inp
alli
ativ
esi
tuat
ion
).O
utp
atie
nts
.
Pat
ien
tsin
the
term
inal
ph
ase
of
thei
rd
isea
seh
ave
hig
her
cost
sre
late
dto
thei
rca
re(c
om
par
edto
oth
erp
has
eso
fth
ed
isea
se),
esp
ecia
lly
wh
ena
hig
her
nu
mb
ero
ftr
ansf
usi
on
s(>
4)ar
ere
qu
ired
.T
hes
eco
sts
can
be
exp
lain
edas
wel
lb
yth
eh
igh
ern
um
ber
of
med
ical
and
nu
rse
vis
its.
Sp
ecifi
cco
sts
of
tran
sfu
sio
nar
en
ot
anal
yze
d,
and
this
circ
um
stan
ceis
on
lyre
cog
niz
edas
anac
tiv
ity
that
incr
ease
sth
eco
sto
fth
ese
pat
ien
ts.
Mia
no
M,
etal
.H
aem
ato
log
ica
2002
;87;
637–
642.
51P
rosp
ecti
ve
stu
dy
on
the
feas
ibil
ity
of
ah
om
eca
rep
rog
ram
ina
ped
iatr
ich
emat
olo
gy
and
on
colo
gy
dep
artm
ent.
RB
C;
pla
tele
tsP
edia
tric
can
cer
and
hem
ato
log
ical
tum
ors
no
tal
lin
pal
liat
ive
stat
us
(ov
eral
l45
pat
ien
ts,
8o
fth
emp
alli
ativ
e).
Ou
tpat
ien
ts.
No
con
clu
sio
ns
can
be
dra
wn
spec
ifica
lly
abo
ut
tran
sfu
sio
ns.
Co
nsi
der
edo
ver
all,
the
pro
gra
mre
du
ced
day
so
fo
utp
atie
nt
clin
ican
din
pat
ien
tw
ard
ho
spit
aliz
atio
nti
me.
Mo
reo
ver
,th
ep
rog
ram
was
cost
effe
ctiv
e.
(con
tin
ued
)
97
Ta
bl
e3.
(Co
nt
in
ue
d)
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
yT
ran
sfu
sion
pro
du
ctT
yp
eof
pat
ien
tM
ain
fin
din
gs
Cra
igJI
,et
al.
Tra
nsf
us
Med
1999
;9:3
1–36
.52
Pro
spec
tiv
est
ud
yo
nth
eef
fect
so
fd
edic
atin
ga
nu
rse
tom
anag
eth
ep
rov
isio
no
fb
loo
dp
rod
uct
ssu
pp
ort
inh
osp
ital
ou
tpat
ien
td
epar
tmen
tan
dh
om
eca
re(p
re-
and
po
stin
terv
enti
on
).C
ost
anal
ysi
s.Q
ues
tio
nn
aire
sto
pat
ien
tsto
mea
sure
thei
rsa
tisf
acti
on
wit
hth
ep
rog
ram
.
RB
C;
pla
tele
tsN
on
on
colo
gic
and
hem
ato
log
ical
tum
ors
no
tal
lin
pal
liat
ive
stat
us
(45
pat
ien
ts).
In-
and
ou
tpat
ien
ts.
Th
eo
ver
all
atte
nti
on
tim
eto
the
pat
ien
td
idn
ot
dif
fer
inh
om
eca
re,
bu
ta
sig
nifi
can
tre
du
ctio
nw
aso
bse
rved
inth
eh
osp
ital
ou
tpat
ien
td
epar
tmen
t.In
bo
thp
lace
sth
ew
aiti
ng
tim
efr
om
adm
issi
on
totr
ansf
usi
on
was
red
uce
dsi
gn
ifica
ntl
yan
dth
isw
ases
pec
iall
yap
pre
ciat
edb
yp
atie
nts
.H
om
eat
ten
tio
nre
du
ced
clin
icv
isit
s.A
nec
on
om
ican
aly
sis
(wit
hso
me
asp
ects
excl
ud
ed)
ism
ade
tok
no
wth
eco
sto
fth
isse
rvic
eat
ho
me.
Sp
etti
gu
eB
,et
al.
Nu
rsT
imes
1998
;94:
54–5
5.53
Cas
ere
po
rtd
escr
ibin
gth
efe
asib
ilit
yan
dp
roce
du
refo
rad
min
iste
rin
gh
om
etr
ansf
usi
on
s.
RB
CS
oli
dtu
mo
r.O
utp
atie
nt.
Tra
nsf
usi
on
ath
om
eis
feas
ible
wh
enan
adeq
uat
ein
fras
tru
ctu
reis
pro
vid
ed(m
ult
idis
cip
lin
ary
team
).
Vin
cig
uer
raV
,et
al.
Pro
gC
lin
Bio
lR
es19
86;2
16:1
55–1
64.
54C
om
par
ativ
eco
stan
aly
sis
of
ho
me
and
ho
spit
altr
eatm
ent.
RB
CN
ot
spec
ified
(218
pat
ien
ts,
174
ho
me
care
,an
d44
inst
itu
tio
nal
care
).In
-an
do
utp
atie
nts
.
Tra
nsf
usi
on
sat
ho
me
are
feas
ible
,w
ith
anad
equ
ate
infr
astr
uct
ure
.A
cost
anal
ysi
sre
vea
lsh
igh
erco
sts
inin
stit
uti
on
alca
reco
mp
ared
toh
om
eca
re.
Ho
wev
erth
isco
ncl
usi
on
can
no
tb
ecl
earl
yex
trap
ola
ted
totr
ansf
usi
on
on
ly,
asth
isac
tiv
ity
has
no
tb
een
stu
die
dsp
ecifi
call
y.
98
to improve the patient’s quality of life and reduces patients’and families’ anxiety. However, for others, this option is stillcontroversial, mainly regarding patients with a higher trans-fusion dependency and/or when Plt-T is needed due to theircomplexity, the amount of time these patients take up, or theinfrastructure necessary to perform this service. Also contro-versial are issues such as who should be involved in the de-cision to carry out transfusion (doctors and/or nurses;specialists, etc). (see Table 3.)
The cost analysis articles found do not focus exclusively ontransfusion but rather on patient care in general, transfusionbeing only a part of it. Only one article demonstrates thattransfusion needs of patients with hematologic malignanciessignificantly increase costs in domiciliary programs, regard-less of disease phase but mainly in advanced phases.
Ethical (10 articles)
The decision of transfusing at the end of life can vary ac-cording to patients’ and relatives’ preferences as well asphysicians’ opinions. However, there is a need to remark thatthe decision of whether to transfuse or not must be taken atthe bedside, individualizing every case, considering thepreferences of the patients and their families and with theiragreement. Only a minority of PCPs have written their owndirectives in advance, and transfusion is not considered aconsistent pattern in them. This generates many cases ofsurrogate decisions. When an agreement with the patient andtheir family’s preferences is not achieved, consultation withethics committees should be recommended. (See Table 4.)
Discussion
Transfusion is one of the treatments that can be used toalleviate symptoms derived from cytopenias or coagulationdisorders in PCPs. It is also one of the most striking dilemmasthat palliative care teams must confront, as it represents notonly a medical but also an ethical and structural problem.When confronting these situations, literature could be a greathelp. This is why we have tried to analyze in this descriptivework the information available about transfusions in PCPs,using two of the most representative and widely used searchengines (PubMed and EMBASE). We are aware that our re-view is limited by the relatively narrow terms of our literaturesearch and the restriction to English language only and tojournal articles included in both search engines.
The review undertaken reveals that publications regardingtransfusion in PCP, as contained in PubMed and EMBASE,are scarce and descriptive. Following are the topics treated bythe articles found and selected.
Clinical4–24
No clinical guidelines regarding this group of patients havebeen published. Only one position paper about Plt-T in he-matologic advanced malignancies24 was found. So, if clinicalguidelines are necessary, those concerning general popula-tion25–30 or cancer patients31–32 should be used. Furthermore,there is an almost total lack of clinical studies in pediatricpatients13 and regarding fresh frozen plasma transfusion.21
RBC-T. Contrary to all expectations, PCPs are rarelytransfused (incidence 5%–17.5%),20 and usually in less than
two sessions and most of them receive < 3 units.8,15 A higherproportion of transfusions has been observed in patients withhematological malignancies8 or bleeding solid tumors;8,15,16
those in conventional hospital care (versus hospices and homecare, in this decreasing frequency);10,19 those treated by on-cology units compared with palliative units;6 and inpatients15
(probably due to a better performance status in outpatients).10
The composition of the team attending the patient can alsoinfluence the incidence of transfusions.12 Almost 50% of pa-tients are transfused in their last five weeks of life,10 and 13.7%in their last week.9 An absence of improvement in symptomsrelated to anemia after transfusion has been associated with anearer proximity to death.15 Transfusion has been considereda negative predictor parameter for survival in solid tumorswhen practiced in the last 15 days of life.17 So the usefulness ofRBC-T in the last month of life should be considered withcaution.
PCPs have been demonstrated to be among the groups ofpatients prone to inappropriate transfusions when presetcriteria are used.33 So an Hb level ( £ 8 g/dl was the trigger inmost studies) must not be used as the only factor whenmaking a decision about whether or not to perform a trans-fusion; it should be considered in conjunction with clinicalaspects too. An individual analysis is desirable,20 especially,when the benefits of transfusion do not seem to correlate withthe pretransfusional Hb level.15 Another point for discussionis the objective of the transfusion. As the number of RBC unitstransfused is usually low, the alleviation of symptoms seemsto be the major goal of the procedure. However, some authorshave proposed that, as quality of life is a major objective, atransfusion of up to 12 g/dl in Hb levels should be per-formed.9
Focusing on the benefits of transfusion, this particularaspect remains unclear. Some difficulties should be con-sidered when evaluating this point:34–36 (1) symptoms re-lated to anemia are diverse and subjective (for patients,palliative staff, and between them); (2) the tools used tomeasure these symptoms (when described) are diverse andalso subjective and are not comparable with each other; and(3) no clinical trials comparing the efficacy of transfusionversus placebo or ESA have been performed. In those arti-cles in which an evaluation of the efficiency of transfusionhas been performed, it seems clear that a majority of patients(50% to 82%) benefit from transfusion.4,8,9,15,16 This effect isperceived from very early on (after two days),4,16 and ismaintained for up to almost three weeks (mean 18.5 days).11
This benefit does not seem to be related to age,8 pre-transfusion Hb level, ECOG score, nor severity of pre-transfusion symptoms related to anemia; and it appears tobe greater in patients discharged home (78.6%), probably asa reflection of their better performance status.15 However,these conclusions about a positive effect of transfusioncannot be generalized, with some authors reporting only apsychological benefit for the patient18 or even no benefit atall.10 A recently published review on RBC-T3 (with six pa-pers37–42 not included in the present review) included thesame databases we analysed, plus others (CINAHL, Web ofScience, ZETOC, and CENTRAL), and including random-ized controlled trials, before and after studies, and inter-rupted time series and the outcome of these transfusions inPCP; yet their conclusions do not differ from the conclusionsexpressed above.
TRANSFUSION IN PALLIATIVE CANCER PATIENTS 99
Ta
bl
e4.
Ar
tic
le
sF
oc
use
do
nT
ra
nsfu
sio
nin
Pa
ll
ia
tiv
eC
an
ce
rP
at
ie
nt
sw
it
hE
th
ic
al
Asp
ec
ts
as
th
eC
en
tr
al
To
pic
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
y/l
ocat
ion
Tra
nsf
usi
onp
rod
uct
Ty
pe
ofp
atie
nt
Mai
nfi
nd
ing
s
Oh
SY
,et
al.
An
nO
nco
l20
10;2
1(S
up
pl
8):3
65.
56R
etro
spec
tiv
ere
vie
wo
fad
van
ced
irec
tiv
es.
Co
ng
ress
po
ster
.S
ou
thK
ore
a.
No
tsp
ecifi
edD
iver
seca
nce
rs(2
32p
atie
nts
).In
pat
ien
ts.
On
lya
min
ori
tyo
fp
atie
nts
wro
teth
eir
ow
nd
irec
tiv
esin
adv
ance
;m
ost
of
them
wer
ew
ritt
enb
yth
eir
rela
tiv
es.
Tra
nsf
usi
on
isn
ot
con
tem
pla
ted
asa
con
sist
ent
pat
tern
inte
rmin
ally
ill
can
cer
pat
ien
ts’
dir
ecti
ves
inad
van
ce.
Neu
ssM
N.
JO
nco
lP
ract
2010
;6:1
68.
57C
ase
rep
ort
.U
.S.
RB
CD
iver
seca
nce
rs.
Inp
atie
nt.
Th
ep
aper
illu
stra
tes
the
nee
dto
ind
ivid
ual
ize
each
pat
ien
tw
hen
con
sid
erin
ga
tran
sfu
sio
n.
Pat
ien
t’s
dec
isio
ns
sho
uld
be
resp
ecte
d,
alth
ou
gh
dis
agre
emen
tsw
ith
do
cto
rs’
op
inio
ns
can
occ
ur.
Esk
ewS
,et
al.
JC
lin
Eth
ics
2009
;20:
192–
200.
58C
ase
rep
ort
s.U
.S.
No
tsp
ecifi
edC
ance
ran
dn
on
can
cer
pat
ien
ts(o
ne
Jeh
ov
ah’s
Wit
nes
s).
Inp
atie
nts
.
Th
ep
aper
illu
stra
tes
tho
seca
ses
inw
hic
hcl
inic
ian
sd
edu
ceth
ata
surr
og
ate’
sre
lig
iou
sm
oti
vat
ion
sp
rod
uce
dec
isio
ns
con
trar
yto
the
pat
ien
t’s
bes
tin
tere
st.
Hin
kk
aH
,et
al.
JM
edE
thic
s20
02;2
8:10
9–11
4.59
Po
stal
surv
eyo
ntr
eatm
ent
op
tio
ns
tob
ew
ith
hel
do
rto
wit
hd
raw
ina
pal
liat
ive
pat
ien
tsc
enar
io.
Fin
lan
d.
No
tsp
ecifi
edN
ot
spec
ified
ifal
lp
atie
nts
wer
eca
nce
rp
atie
nts
(th
eo
nly
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crib
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enar
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asa
can
cer
pat
ien
t).
In-/
ou
tpat
ien
ts:
no
tsp
ecifi
ed.
Blo
od
tran
sfu
sio
nin
term
inal
pat
ien
tsis
on
eo
fth
em
ost
oft
enfo
rgo
ne
mea
sure
sta
ken
by
ph
ysi
cian
s.A
uth
ors
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yze
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ses
affe
ctin
gth
ese
dec
isio
ns,
bu
tth
ose
reg
ard
ing
tran
sfu
sio
nar
en
ot
spec
ified
.
Do
ug
las
SP
,et
al.
Am
JM
edS
ci20
01;3
22:1
45–1
50.
60C
ase
rep
ort
.U
.S.
RB
CC
ance
rp
atie
nt
Th
ep
aper
illu
stra
tes
the
use
fuln
ess
of
eth
icco
mm
itte
esas
inst
rum
ents
of
agre
emen
tam
on
gp
atie
nts
’an
dd
oct
ors
’o
pin
ion
s.T
his
par
ticu
lar
case
emp
has
izes
wh
eth
era
tran
sfu
sio
nin
ate
rmin
alca
nce
rp
atie
nt
can
be
con
sid
ered
futi
leo
rn
ot.
(con
tin
ued
)
100
Ta
bl
e4.
(Co
nt
in
ue
d)
Au
thor
sR
efer
ence
Ty
pe
ofst
ud
y/l
ocat
ion
Tra
nsf
usi
onp
rod
uct
Ty
pe
ofp
atie
nt
Mai
nfi
nd
ing
s
Ch
iuT
Y,
etal
.J
Med
Eth
ics
2000
;26:
353–
357.
61S
urv
eyto
hea
lth
care
wo
rker
sto
iden
tify
and
kn
ow
the
freq
uen
cyo
fet
hic
ald
ilem
mas
.T
aiw
an.
RB
CC
ance
rp
atie
nts
.In
pat
ien
ts.
Tra
nsf
usi
on
isre
cog
niz
edas
on
eo
fth
eet
hic
ald
ilem
mas
pal
liat
ive
care
team
sm
ust
face
.N
ever
thel
ess
its
freq
uen
cyis
low
(bu
tn
oh
emat
olo
gic
alp
atie
nts
wer
ein
clu
ded
inth
est
ud
y).
Th
isfr
equ
ency
do
esn
ot
sig
nifi
can
tly
chan
ge
du
rin
gth
ew
eek
so
fh
osp
ital
izat
ion
.T
ran
sfu
sio
nas
ad
ilem
ma
was
no
tas
soci
ated
wit
ha
pat
ien
t’s
gen
der
;h
ow
ever
ito
ccu
rred
inv
aria
bly
inp
atie
nts
yo
un
ger
than
18y
ears
old
.G
lass
E,
etal
.O
nco
lN
urs
Fo
rum
1996
;23:
117–
118.
62C
ase
rep
ort
s.U
.S.
RB
C;
pla
tele
tsH
emat
olo
gic
aln
eop
lasm
s.In
pat
ien
ts.
Itis
qu
ite
imp
ort
ant
toh
ave
aw
ell-
defi
ned
po
licy
for
tran
sfu
sio
nin
ever
yh
osp
ice
toav
oid
dif
fere
nce
sin
the
man
agem
ent
of
pat
ien
ts.
Asa
iA
,et
al.
Lan
cet
1995
;346
:356
–359
.63
Po
stal
surv
ey.
Co
mp
aris
on
of
atti
tud
eso
fJa
pan
ese
and
Jap
anes
e-A
mer
ican
sto
war
ds
life
-su
stai
nin
gtr
eatm
ent
inp
alli
ativ
esc
enar
ios.
Jap
anan
dU
.S.
No
tsp
ecifi
edC
ance
rp
atie
nts
.In
-/o
utp
atie
nts
:n
ot
spec
ified
.
Jap
anes
ep
hy
sici
ans
(co
mp
ared
toJa
pan
ese-
Am
eric
anp
hy
sici
ans)
wo
uld
reco
mm
end
blo
od
tran
sfu
sio
ns
for
term
inal
lyil
lca
nce
rp
atie
nts
ind
epen
den
to
fth
ep
atie
nt’
sk
no
wle
dg
eo
fh
iso
rh
erd
iag
no
sis
and
ou
tlo
ok
.T
his
con
clu
sio
nw
asal
soap
pli
cab
leto
the
ph
ysi
cian
sth
emse
lves
.S
can
lon
C,
etal
.N
urs
Cli
nN
ort
hA
m19
89;2
4:97
7–98
6.64
Rev
iew
arti
cle
reg
ard
ing
eth
ical
issu
esin
adv
ance
dca
nce
rp
atie
nts
.E
ach
issu
eis
illu
stra
ted
wit
ha
case
rep
ort
.U
.S.
No
tsp
ecifi
edN
ot
spec
ified
.T
ran
sfu
sio
nis
anet
hic
ald
ilem
ma
inp
alli
ativ
eca
nce
rp
atie
nts
.E
ach
situ
atio
nn
eed
sto
be
con
sid
ered
ind
ivid
ual
ly.
Co
nse
nsu
sb
etw
een
the
do
cto
r’s
and
pat
ien
t’s
op
inio
ns
isd
esir
able
,b
ut
inth
eca
seo
fd
isag
reem
ent,
aco
nsu
ltat
ion
wit
han
eth
ics
com
mit
tee
or
anet
hic
ist
mig
ht
be
app
rop
riat
e.B
og
gs
DR
.H
osp
Pra
ct19
85;2
0:92
,94–
95,9
8.65
Cas
ere
po
rts.
Rev
iew
arti
cle
reg
ard
ing
eth
ical
issu
esin
adv
ance
dca
nce
rp
atie
nts
.E
ach
issu
eis
illu
stra
ted
wit
ha
case
rep
ort
.U
.S.
RB
C;
pla
tele
tsH
emat
olo
gic
aln
eop
lasm
s.In
pat
ien
ts.
Th
ep
aper
illu
stra
tes
the
dif
ficu
ltie
so
fm
anag
ing
Jeh
ov
ah’s
Wit
nes
ses
suff
erin
gfr
om
seri
ou
sh
emat
olo
gic
aln
eop
last
icd
isea
ses.
Th
ere
fusa
lo
ftr
ansf
usi
on
(wh
enn
eed
ed)
du
eto
reli
gio
us
bel
iefs
bec
om
esan
imp
ort
ant
eth
ical
con
flic
tfo
rd
oct
ors
.
101
Finally, three additional aspects have to be considered:(1) The analytical investigation of the possible cause of anemiaseems to be rarely investigated.9 This could be interesting, as itis minimally disturbing for the patient, costs are low, and thefinding of deficiency anemia could be treated, avoidingtransfusions. (2) Risks and adverse reactions derived fromRBC-T seem to be so rare that these circumstances cannotbe an obstacle when in favor of a policy of home transfusions.(3) ESA cannot be routinely recommended except in thecontext of clinical trials due to the four to eight weeks’ delaybefore maximum benefit is achieved, possible side effects,their efficiency in only a few patients, and their cost.20
Plt-T. This is an ever increasing and valuable interventionin PCPs,5 especially in hematologic patients.7,13 The use of Plt-T for a prophylactic purpose is not recommended andshould be abandoned. However, its use to control significantclinical bleeding (when moderate to severe thrombocyto-penia occurs) could be mandatory.7,13 Two theoretical clin-ical aspects of Plt-T can be considered obstacles whenfacilitating this procedure at home:5 (1) the expected highfrequency of transfusion-related reactions and (2) the shortlifespan of platelets. Regarding the first, this circumstancehas not been observed,7,13,14 so the procedure cannot be ruledout just by considering this obstacle. Regarding the second,the short platelet lifespan makes a high number of transfu-sions necessary, and these can be very difficult to maintainand carry out if the patient lives far from his palliative teambase. A true recommendation in this aspect cannot be ex-pressed. However, its implementation is widely encouraged.
Infrastructure43–54
For most authors, home transfusions are desirable for thepatient and family’s comfort, as the displacement to hospitalsfor transfusion is disturbing.43,44,46,49,52–54 Moreover, it hasbeen published that 40% of unnecessary hospital admissionsare due to transfusions,55 so this is a potential way to reducehospitalization costs. While all authors consider this should bea priority, this service requires a very well organized infra-structure,49 which is time consuming and puts a strain onother resources (financial, transport, etc.), making it impos-sible in those places where the infrastructure is not organizednor guaranteed. However, some authors believe that homemanagement of patients with high transfusional needs couldbe very difficult and should be avoided.47 This latter extremeis still controversial even among the different members of thesanitary staff attending the patient.46
As most cost studies do not focus on transfusional activityalone but rather on the total cost of hospital or home care, it isdifficult to draw conclusions exclusively regarding transfusionalactivity. Demonstrating that home care of PCPs54 or that thedevelopment of acute palliative care units in hospitals48 are cost-effective measures does not necessarily mean that transfusioncosts in these circumstances are also lower. Only one articleabout hematological patients50 reflects that costs are increasedby transfusions in home programs, especially in terminal phases,due to the higher transfusional need of these patients and theincrease in the number of medical and nursing visits. In fact, thishigh need for transfusion may differentiate the costs and theorganizational model of home care for hematological patients(more complex) from that of patients with solid tumors.
Ethical56–65
Most of the articles found refer to American realities andthis must be taken into account, as other sociocultural envi-ronments can differ in their conclusions. Other cultures(Mediterranean and Far Eastern) are less represented.
Although transfusion in PCPs is recognized invariably as anethical problem, its frequency, however, does not seem to behigh and does not increase with the time of the patient’s ad-mission. Only the patient’s age being under 18 seems to be afactor that favors it.61 This could be a reflection of the tendencyfor more intensive treatment in younger patients and also thedifficulty that medical teams have to confront when surrogateddecisions are encountered. When making the decision totransfuse or not, pros (mainly improvement of quality of life)versus cons (mainly infrastructure and costs required) or risks(transfusion reactions) must be considered, not just from a teampoint of view, but also in conjunction with patients’ and rela-tives’ wishes and expectations.57,64 Cultural factors also influ-ence the physician’s decision to carry out transfusion in PCPs.Japanese physicians would recommend transfusion for PCPsregardless of the patient’s outlook and condition,63 whileFinnish doctors most often forgo this measure in these samepatients.59 So, a well-defined transfusion policy in every palli-ative care team is desirable to avoid differences in the man-agement of patients.62 This reduces problems with patientsand/or relatives and also within the team.
Only a minority of these patients have written down theirdirectives in advance and these rarely include transfusion.56
Surrogate decisions, sometimes even contrary to the patient’sbest interests, create another scenario for potential conflict.58
Some religious beliefs ( Jehovah’s Witnesses) are also prone tocreate ethical conflicts. This attitude can cause doctors to feelthat these patients are not receiving the best treatment avail-able.65 A fluid and profound communication with the patientsand their families is essential to avoid or reduce these prob-lems. In those cases in which the conflict has a difficult solu-tion, ethical committees should be consulted.60,64
In conclusion, with the limitations stated above in our study,the literature provided by PubMed and EMBASE regardingtransfusion in PCPs is scarce and unconnected between them,the level of evidence to make decisions based on it is very lowand no clear recommendations can be carried out. This pre-carious situation is reflected in the present article. When con-sulting literature on this topic, the use of more than one searchengine is desirable, although the number of relevant articlesdoes not increase substantially. Further clinical studies aredesirable to establish transfusion criteria or the objectives oftransfusion in this specific group of patients. In the same way,home transfusions seem to be preferable, but the infrastructureneeded to perform them is not widely agreed upon and aconsensus should be reached. Research should be done to re-veal whether this sole procedure is cost effective or not and inwhich patients. Finally, ethical studies focusing on transfusionas a specific point are also necessary. This would mainly be toidentify groups of people causing conflict, its incidence, itscauses, and the strategies needed to reach a solution. Thesestudies should be performed considering the different geo-graphical and social realities in which we live.
Author Disclosure Statement
No competing financial interests exist.
102 UCEDA TORRES ET AL.
Acknowledgments
The authors thank Dr. J. M. Nunez Olarte from the pallia-tive care unit of the Hospital ‘‘Gregorio Maranon’’ (Madrid,Spain) for his review of the manuscript.
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Address correspondence to:Juan Nicolas Rodrıguez Rodrıguez, MD, PhD
U.G.C./Servicio de HematologıaHospital ‘‘Juan Ramon Jimenez’’
21005 Huelva, Spain
E-mail: [email protected]
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