Letter to editor: an observational study of red cell transfusion in specialist palliative care. Assessment of fatigue after blood transfusion in palliative care patients: a feasibility study. Use of red blood cell transfusion in palliative care services: is it still up to date or is cancer-related anaemia controlled better with erythropoietic agents? Use of red blood cell transfusions in terminally ill cancer patients admitted to a palliative care unit. Survey of blood transfusion practice for palliative care patients in Yorkshire: implications for clinical care. Blood transfusion and its benefits in palliative care. Effects of red blood cell transfusion on anemia-related symptoms in patients with cancer. The use of transfusion in terminal cancer patients. Hospice versus conventional care setting.
nan Blood transfusions are often used as a potential treatment for cancer-related fatigue in anaemic palliative care patients. However, evidence of benefit using validated outcomes measures is lacking.
                The aim of this study was to test the feasibility of using two such tools; the Brief Fatigue Inventory and FACT F-fatigue subscale, to measure change in fatigue following a blood transfusion.
                Anemic cancer patients receiving specialist palliative care and undergoing transfusion for fatigue, completed the tools pre- and 3 days post-transfusion.
                Thirty patients with cancer-related fatigue who received a blood transfusion completed the study. Both measures were capable of detecting statistical and clinically significant change in fatigue following transfusion. Furthermore, the measures showed significant differences between patients that did, or did not, report an overall improvement in fatigue. Patients found the measures easy to complete with no preference for one over another. Future clinical trials of blood transfusion for the management of fatigue should incorporate these validated outcome measures. nan Anemia is often associated with neoplastic disorders. Blood transfusions are used to alleviate the discomfort of anemic cancer patients. Of 246 terminally ill cancer patients admitted to our palliative care unit from October 1991 to December 1993 (128 women and 118 men), 31 patients (12.6%) (17 men and 14 women; age, 69.5 +/- 12 years) received on average 2.8 units of packed red blood cells (PRBCs) (range, 2-7 units/patient) in 35 separate admissions. PRBCs were transfused in the presence of low hemoglobin (Hb) levels ( < or = 8 g/dL) and/or severe fatigue or dyspnea. Pre-transfusion performance status, cognitive function, dyspnea, and fatigue at rest (evaluated by a four-point scale), complete blood count, serum albumin, and C-reactive protein were determined. The day after transfusion, subjective well-being was recorded as "yes/no" improvement in comparison with the pre-transfusion day. Improved subjective well-being after blood transfusion was reported in 51.4%, without significant relationship to pre-transfusion Hb levels or performance status. The influence of blood transfusion on subjective well-being was not related to the severity of dyspnea or fatigue. Twenty-one patients (60%), including seven with subjective improvement, died during the same hospitalization, a median of 49 days after transfusion. Pre-transfusion Hb level did not differ significantly in patients who benefited and did not benefit from transfusion, whereas time before death was significantly (P < 0.001) shorter in patients who did not benefit. In the discharged patients (40%), the median interval between transfusion and discharge was 13 days and the frequency of subjective improvement in well-being was 78.6%. Our data suggest that two main areas should be investigated, namely the relation between low Hb levels and symptoms and signs in terminally ill cancer patients, and the correct timing for effective blood transfusion. A combination of criteria is needed for effective transfusion; they must include not only Hb levels but also type and severity of anemic symptoms and signs. Furthermore, the identification of reliable prognostic indicators for survival would be useful. Blood transfusions can be used to palliate the symptoms of fatigue or dyspnea in the presence of anemia. We studied the transfusion practices of 8 hospices in our cancer network over a 1-year period. We identified 164 patients who received 650 units of blood in 230 transfusions. The majority of patients received a single transfusion (71%), of 2 or 3 units of blood (76%), as an inpatient (83%). Blood transfusions occurred in 140 (5.7%) of 2460 hospice admissions. Median survival following first transfusion was 42 days and significantly longer for outpatients compared to inpatients (median of 104 days and 36 days, respectively, p = 0.006). The value of blood transfusion as a supportive treatment in haematological disease and oncology is well established and is seen as an essential part of treatment. The place of blood transfusion in the alleviation of symptoms within palliative care units is less well established. There has been no evaluation of its benefits in terms of symptom relief and impact on the quality of life. This study was designed to identify the benefit achieved by transfusion as well as possible indicators for its appropriate use in the future. Ninety-seven patients were recruited over one year, from the beginning of September 1992 to the end of August 1993, from eight centres, all members of the South West Thames Palliative Medicine Collaborative Audit Group. Patients completed visual analogue scales before and on two occasions after transfusion, to assess its impact on dyspnoea, weakness and overall sense of well-being. Results indicated that a significant proportion showed improvement in all three parameters. Those whose main indication for transfusion was weakness showed a particular benefit. The group of patients entered into the study were anaemic in comparison with our normal patient population, but the degree of improvement seen did not correlate with the degree of anaemia prior to transfusion. We conclude that transfusion does offer symptom relief and improvement in well-being in patients with advanced malignant disease. It should be considered as a worthwhile option in palliative treatment of weakness, dyspnoea and impaired overall sense of well-being, when associated with anaemia. The aim of this study was to assess the effects of red blood cell transfusion, and the subsequent increase in hemoglobin values, on anemia-related symptoms in a cohort of patients with cancer with different survival times. A red blood cell transfusion was recommended to a consecutive sample of patients with hemoglobin levels of 8 +/- 0.5 g/dL. The number of units to be ordered was decided according the hemoglobin values with a mean target of increasing the hemoglobin values by approximately 2 g/dL. Hemoglobin values, anemia-related signs and symptoms, including well-being, fatigue, and dyspnea, were recorded at admission (T0), 1 day after the last transfusion (T1), and 15 days afterward (T2) by telephone contact or visit. Well-being, fatigue, and dyspnea were measured on a numerical scale of 0-10. Sixty-one patients were recruited in the period of study. One hundred thirty-three units of red blood cells were transfused (mean 2.18, 95% confidence interval [CI] 0.6). Complete data were available for 40 patients. Hemoglobin values and well-being significantly increased after transfusion (T1), maintaining acceptable values 15 days afterward (T2). Significant changes in fatigue and dyspnea were found immediately after transfusion, although the effect was partially lost 15 days after transfusion. No statistical differences were found between patients with different survival times. Fatigue was significantly lower in patients with longer survival times in comparison with patients with shorter survival times (p = 0.04). Blood transfusion in patients with hemoglobin values of approximately 8 g/dL improved anemia-related symptoms on a short-term basis. This benefit is independent of the stage of disease and survival. However, the effects on dyspnea and fatigue tend to decrease within 15 days, despite the maintenance of hemoglobin values attained after transfusions, suggesting that other factors may play a role. This study examines the usage of blood component products by terminal cancer patients in hospice and conventional care settings. Our results show that patients in conventional care settings are five times more likely to be transfused than are patients in hospital-based hospices and ten times more likely to be transfused than are patients in home-care hospices (p = 0.003). Since the outcome of care was comparable for the three types of care settings, the transfusion of blood component products to terminal cancer patients may be overused in conventional care settings.
Higher-quality studies are required to determine the effectiveness of blood transfusion at the end of life and, in particular, to determine which patients are most likely to respond and which are not, and the duration of any response. Potential harms of blood transfusion at the end of life (indicated by high 14-day mortality) need to be distinguished from inappropriate transfusion in patients who are dying from advanced cancer.