Background:Red blood cell transfusions are commonly used in palliative care to treat anaemia or symptoms caused by anaemia. In patients with advanced disease, there is little evidence of benefit to guide treatment decisions in the face of increased risk of harms.Aim:To determine national transfusion practice in hospices and compare this against National Institute for Health and Care Excellence and British Society of Haematology guidelines to develop recommendations to improve practice.Design and Setting:Prospective data collection on red blood cell transfusion practice in UK adult hospices over a 3-month census period.Results:A total of 121/210 (58%) hospices participated. A total of 465 transfusion episodes occurred in 83 hospices. Patients had a mean age of 71 years, and 96% had cancer. Mean pre-transfusion haemoglobin was 75 g/L (standard deviation = 11.15). Anaemia of chronic disease was the largest cause of anaemia (176; 38%); potentially amenable to alternative treatments. Haematinics were not checked in 70% of patients. Alternative treatments such as B12, folate and iron were rarely used. Despite transfusion-associated circulatory overload risk, 85% of patients were not weighed, and 84% had two or more units transfused. Only 83 (18%) patients had an improvement maintained at 30 days; 142 (31%) had <14 day improvement, and 50 (11%) had no improvement. A total of 150 patients (32%) were dead at 30 days.Conclusion:More rigorous investigation of anaemia, increased use of alternative therapies and more restrictive approach to red cell transfusions are recommended. Clinicians should discuss the limited benefit versus potentially higher risks with patients in hospice services to inform treatment decisions.

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This is the first study to engage directly with palliative care patients and to establish their views on the timing of corneal donation discussions. Patients are willing to discuss donation, and further exploration of patient views in this area should be undertaken.

PurposeAnaemia is a common complication of cancer causing symptoms including fatigue. It is also associated with shorter survival. Cancer causes systemic inflammation which interrupts iron metabolism leading to a functional iron deficiency (FID). There are few data on prevalence or aetiology of anaemia in those with advanced cancer. We aimed to establish the prevalence of anaemia and estimate extent of FID anaemia in patients with advanced cancer. MethodsAll patients with advanced cancer referred to two UK specialist palliative care services over one year were identified. Demographic and clinical data were linked with routinely collected haematological and biochemical profiles. We assessed the numbers of patients with abnormal values for haemoglobin, %hypochromic red cells (>5% indicates iron restricted erythropoiesis) and CRP (>10 indicates systemic inflammation). We judged that FID anaemia was likely when patients had all three abnormalities and ferritin 30-800ng/ml. Results 1797/2416 patients had a cancer diagnosis and laboratory data available. Mean haemoglobin was 116g/L. 63% of patients were anaemic; mild 25%, moderate 35% and severe 3%. Women had significantly higher mean haemoglobin than men and there was wide variation in anaemia prevalence across tumour sites. Thirty nine percent of patients' who had all four parameters checked met our criteria for FID anaemia. There were significant relationships between haemoglobin, %hypochromic red cells and CRP (p=0.0001). ConclusionsAnaemia was common in this population and we estimate this was caused by FID in 66% of anaemic patients. Further research is needed to validate our diagnostic criteria before this approach can be used in clinical practice.

Palliative care practice is varied and not consistent with a restrictive blood transfusion policy. More recently trained doctors follow less liberal practices than senior colleagues. More direct evidence of benefits and harms of blood transfusion is needed in palliative care to inform practice.