Clinical, Ethical, and Financial Considerations With Red Blood Cell Transfusion Support at the End of Life in Hematologic Malignancies

Patients with advanced hematological malignancies often have red blood cell (RBC) transfusion needs at the end of life (EOL) to improve debilitating anemia-related symptoms. Given that patients with hematologic malignancies and their caregivers find that transfusions improve energy and quality of life, access becomes a critical factor influencing hospice enrollment decisions, given variable access to transfusions in hospice settings. Additionally, because blood is a finite resource, this raises important questions about its availability in hospice care. This paper aims to explore the clinical, ethical, financial considerations surrounding RBC transfusions at the EOL for patients with hematological malignancies by drawing on literature in hematology, bioethics, and palliative care. One notable clinical consideration is that RBC transfusions improve anemia-related symptoms, such as fatigue, weakness, and dyspnea. At the same time, ethical considerations include the scarcity of blood. Moreover, some financial factors to consider include the cost of blood transfusions and reimbursement rates. These complex considerations impact hospice agencies’ capabilities to provide RBC transfusions at EOL. As a result, patients often delay enrolling in hospice, resulting in more aggressive treatments at the EOL and poorer EOL outcomes. Having a better understanding of such considerations will help create protocols that balance justice for all patients while improving EOL care for patients with hematological malignancies.