Transfusion in Hospice-Palliative Care

Abstract

Transfusion in hospice and palliative care remains a complex issue as it is viewed as either a futile life-prolonging treatment or a legitimate intervention for symptom relief. These differing views result in inconsistent clinical practices. Anemia is common in terminally ill patients and is associated with fatigue, dyspnea, dizziness, palpitations, cognitive decline, and an impaired quality of life. Although red blood cell transfusion may provide short-term symptomatic improvement in selected patients, its benefits are often transient; repeated transfusions may be necessary, and its effect on patient survival is limited. Additionally, access to transfusion varies considerably across care settings, with relatively greater availability in tertiary hospitals and substantial barriers in many inpatient hospice units and home hospice services due to institutional and logistical constraints. This brief communication described an 88-year-old man with myelodysplastic syndrome whose transfusion-dependent fatigue substantially influenced decisions regarding hospice care. As a nearby hospice facility did not offer transfusion, the patient and family continued long-distance hospital visits to maintain symptom control. Hospice admission was delayed until his condition rapidly worsened. This case demonstrated that transfusion in patients with terminal illness may carry clinical significance not only in relation to survival, but also in providing symptom relief and in shaping patient and family preferences. Therefore, transfusion in hospice and palliative care should be considered case-by-case within an individualized, goal-concordant framework based on symptom burden, prognosis, patient values, treatment burden, institutional feasibility, and ethical principles, supported by shared decision-making and careful reassessment.

INTRODUCTION

In hospice and palliative care, transfusion is a complex issue that is viewed as either a futile life-prolonging treatment or a therapeutic intervention for symptom relief. These differing views render consistent clinical decision-making difficult. In terminally ill patients, anemia-related fatigue and dyspnea are typically multifactorial in origin. Consequently, the benefits of transfusion vary across individuals and may be limited and transient [1]. Furthermore, because transfusion requires adequate infrastructure, staffing, patient observation, monitoring, and safety management, its availability is not uniform across hospice care settings. Although it is feasible in some hospice units within general or tertiary hospitals, access remains limited in many other hospice facilities and home hospice settings because of institutional and structural constraints. Accordingly, decisions regarding transfusion in terminally ill patients should be guided not only by clinical considerations but also by patient values and preferences, treatment burden, and ethical principles [2]. This case report aimed to highlight these issues.

CASE: MYELODYSPLASTIC SYNDROME

An 88-year-old man presented with fatigue at a local medical institution. Medical history included anemia and renal dysfunction. The patient was transferred to a regional university hospital in June 2024 and was subsequently diagnosed with myelodysplastic syndrome. The patient’s main symptom was fatigue, rather than pain. Regular red blood cell transfusions provided partial symptomatic relief. However, with disease progression, the frequency of transfusions increased from once every 2~3 weeks initially to once weekly after November, and 2~3 times per week from January onward. Repeated transfusions and long-distance travel (approximately 1.5 hours) to the university hospital placed a considerable burden on the patient and his family, leading to discussions about transitioning to hospice care for symptom relief.

An inpatient and home care hospice facility operated by a local general hospital, located approximately 30 min by car from the patient’s home, did not provide transfusions for hospice patients. As the patient was highly reliant on transfusions to relieve his fatigue (their most burdensome symptom), the patient and his family declined hospice care at that institution and continued to receive transfusions at a distant university hospital. Subsequently, the patient’s consciousness decreased. However, admission to the original hospital was not possible because of limited inpatient bed availability.

Consequently, the patient was admitted to the hospice unit of our tertiary hospital in late January 2025. At admission, his hemoglobin level was 3.5 g/dL, and his platelet count was 8,000/µL. He received 1 unit of single-donor platelets. However, his condition rapidly deteriorated. Transfusions were ceased, and care was redirected toward comfort-focused and end-of-life care. The patient died on the third day of hospitalization.

This case demonstrated that in terminal hematologic disease, transfusion may have important implications not only in relation to life prolongation but also as a means of symptom relief. Decisions regarding transfusion should be shaped by multiple interrelated factors, including symptom burden, patient and family preferences, end-of-life care goals, travel burden, access to inpatient care, and availability of institutional transfusion.

DISCUSSION

Terminally ill patients commonly develop anemia, which is closely associated with fatigue, dyspnea, and an impaired quality of life. Red blood cell transfusion may provide symptomatic relief and improve the quality of life in selected patients. However, these benefits are usually transient, repeated transfusions are often required, and survival benefits are limited [3-5]. Transfusion also carries potential risks, including transfusion reactions, infection, and circulatory overload, and therefore requires appropriate safety measures, including regular observations and monitoring [4]. In small medical institutions and home hospice settings, access to transfusion may be restricted because of staffing and infrastructure limitations. Meanwhile, hospital visits may impose additional physical and emotional burdens on patients and their families [6].

Decision-making regarding transfusion in terminally ill patients is not merely a matter of correcting laboratory values. Instead, ethical judgment grounded in the goals of care is crucial. Ethical considerations, including beneficence, non-maleficence, autonomy, and justice, are particularly relevant in balancing symptom relief against treatment burden, risks, and resource allocation. For terminally ill patients, transfusion should be considered on a case-by-base basis within an individualized goal-concordant framework [2,7].

Under the Korean Life-Sustaining Treatment Decision-Making Act, transfusion falls within the category of life-sustaining treatment. However, transfusion should not be uniformly withheld on that basis alone. Before the dying phase, decisions should be made through sufficient discussion with the patient and the family about care goals, symptom burden, prognosis, values, and preferences. The 2025 Korean Hospice and Palliative Care Program Guidelines recommend that inpatient hospice facilities establish policies and procedures for necessary medical services, including transfusion, and specify that transfusions for patients with hematological malignancies are eligible for separate reimbursement [8]. Nevertheless, in clinical practice, transfusions are often unavailable in institutions other than tertiary hospitals. A gap remains between policy and practice. Considering this, when transfusion is likely to be relevant, institutions should clarify during the initial consultation whether transfusion can be provided and how related decisions can be made.

In hospice and palliative care, transfusion should be understood primarily as an intervention for symptom relief, rather than for the normalization of laboratory values. Indications should be individualized according to symptom severity, overall condition, life expectancy, treatment burden, and patient preference. When transfusion is provided, the treatment goals should be clearly defined, intervention should be performed with the least possible burden, and symptoms and functional changes should be reassessed to determine whether transfusion should be continued or discontinued. Patients and families should also receive balanced information about the expected benefits and limitations of transfusion to support shared decision-making, and when appropriate, advance care planning [6].

In summary, transfusion in terminally ill patients should neither be categorically excluded based on it being a life-sustaining treatment nor routinely provided as part of practice protocol. Transfusion should be individualized based on expected symptom relief, patient values, treatment burden, institutional resources, and ethical considerations. A balanced approach to decision-making is needed. Shared decision-making should be supported with sufficient explanation of the benefits versus the uncertainties and limitations.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2026.29.2.51.