Appendix 1.

Investigate anaemia thoroughly	● Reversible causes of anaemia (iron, B12 or folate deficiency, bleeding amenable to tranexamic acid) must be more thoroughly investigated and treated. ● In patients who had haematinics checked (30%), the data highlighted the lack of use of alternative treatments such as B12, folate and iron. ● These should be considered instead of or alongside blood transfusion if appropriate.
Adopt restrictive trigger threshold for transfusion	● Hospices should follow NICE guidance: for patients without concurrent heart problems, use a trigger threshold of 70 g/L with a target haemoglobin concentration of 70–90 g/L; ● For patients with acute coronary syndrome (e.g., unstable angina) use a trigger threshold of 80 g/L with target haemoglobin of 80–100 g/L.
Discuss evidence-based risks and benefits	● Clinicians should discuss the limited benefit versus risks with patients to allow true informed consent. ● Fewer than 1 in 5 patients may experience sustained benefit (as assessed by a clinician or performance status for 30 days or more) and most patients have two or more factors that place them at high risk of TACO. ● Patients should be assessed for risks of TACO prior to transfusion. Informed consent must be documented.
Weigh patients to determine transfusion requirements	● Patients must be weighed prior to red blood cell transfusion to estimate volume of blood required. ● Transfusing a volume of 4 ml/kg will typically give a haemoglobin increment of 10 g/L.15 Therefore, a patient weighing less than 70 kg requires less than 1 unit;15 ● Higher volumes put patients at risk of TACO which may be mis-interpreted as worsening of underlying disease.
Minimise the risk of TACO and observe for signs	● Only transfuse if benefits of transfusion outweigh risks. ● If patient is at risk of TACO, unless patient is actively bleeding, give one unit transfusion slowly (over 3–4 h) and consider concomitant use of a diuretic. ● Monitor closely during transfusion and reassess after each unit transfused.
Review clinical outcomes rigorously	● Assessment should include both a haemoglobin level measurement (between 1–24 h post-transfusion) and a performance status within 7–14 days. ● 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.