Critical bleeding requiring massive transfusion is associated with significant mortality and morbidity 1. Many complications of massive transfusion and critical bleeding are interrelated and may perpetuate one another. It is clear that preventing the 'vicious cycle' of coagulopathy, hypothermia and acidosis is pivotal in the survival of patients with critical bleeding requiring massive transfusion 1-3. Calcium is an important cation in the body and has a fundamental role as a co-factor in enzymatic reactions, transmembrane ion flux, muscle contraction, neuronal activity, coagulation cascade, platelet aggregation, regulation of vasomotor tone and cardiac contractility 4,5. Hypocalcaemia may occur in patients with critical bleeding requiring massive transfusion, leading to worsening coagulopathy 6,7 and prolonged QT interval and ventricular arrhythmias in the presence of co-existing hypomagnesaemia 8. The minimum acceptable ionised calcium concentration during critical bleeding remains controversial and uncertain. Although an in vitro study demonstrated that ionised calcium concentrations >0.56 mmol/l would be adequate for clot formation 9 , clinical studies indicate that ionised calcium concentrations <0.90 mmol/l during critical bleeding are associated with worse outcomes, although it is not clear that this is through an effect on coagulation 2. Citrate toxicity has been suggested as the mechanism of hypocalcaemia during massive transfusion 6,10. However, recent evidence suggests that intravenous colloid solutions and ischaemiareperfusion can also cause hypocalcaemia and exacerbate hypocalcaemia-induced coagulopathy 11,12 .

Unrefrigerated young whole blood transfusion was not associated with a reduced mortality of patients requiring massive transfusion in a civilian setting when other blood products were readily available.

BACKGROUND: Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions. OBJECTIVE: This study explored patients' perspectives of the GOC discussion in the hospital setting. DESIGN: An explorative qualitative design was used within a social constructionist framework. PARTICIPANTS: Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview. APPROACH: Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes. KEY RESULTS: Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most