Blood transfusion at home?

[HomeBloods]

Are there any nurses or hospital clinicians about who can tell me whether it is possible to receive a blood transfusion (type O positive) at home?

My parent, very frail with terminal cancer, and under the local hospice's palliative care team has been advised, following a routine blood test at home, that she would benefit from an urgent blood transfusion due to a very low blood count.

DParent has stated on their Respect form that they do not wish to receive any care to prolong life, but this has thrown them a bit; the doctor has warned of a stroke or heart attack if they decline.

DParent really doesn't want to travel to hospital as they're entirely bedbound and very weak. We're wondering whether there is a possibility that a transfusion can be administered at home? DParent can't get through to the hospice line or district nurses as it's a weekend evening, so I thought I'd ask here. Any ideas?

I am a haematology nurse and have never heard of home transfusion - there is a risk of reaction so needs observation throughout and the blood can only be out of a controlled fridge for 4hrs so logistically it’s very complicated. Some hospices give blood for symptomatic relief. I am very surprised the palliative care team have advised a transfusion, my cohort almost always have critically low haemoglobin and platelets and we don’t continue transfusion when patients are no longer able to attend hospital/approaching end of life.

I don’t know how low their count is but without exertion and with a slow decline then the body can tolerate very low numbers. If your parent was still active I would encourage symptomatic relief with transfusion but as bed bound it is less beneficial and certainly doesn’t mean it will be a painful death with appropriate palliation.

In your shoes I would respect your parents wishes, especially if their wish is to die out of hospital. I’m very sorry you are going through this.

@otherstories
Thank you so much for your reply -this is why I love MN. I really appreciate you taking the time to explain so thoroughly, especially with your experience in palliative care, saving us the mental energy of thinking this may be an option.

The duty out-of-hours GP has just called to say he'll be making a house call in the next six hours to discuss a transfusion, so we'll be better informed when speaking with him, having read your response.

DParent is a bit blindsided by the apparent sense of urgency as, as far as they're concerned, they're just busy with trying to have a 'good death'. It's hard to figure out how close to the end DParent actually is, as they've already outlived their 'best-case-scenario' prognosis by months and it's hard to imagine them getting any weaker or thinner while still remaining lucid. And if a transfusion would really be as beneficial as the team are suggesting, perhaps improving the quality of the life that remains, then perhaps we ought to consider it? It's so confusing.

Thank you again.

It’s a really hard balance. I think if it could be arranged in a hospice/frailty unit and your parent had the physical strength to get there then it wouldn’t be a terrible clinical decision. You are prolonging life and that must have quality to make that worthwhile.

However, if it’s a busy A&E for multiple hours, or if your parent strongly wishes not to die in hospital (just because things happen and there is always a risk that there will be a complication which delays discharge or they become more frail etc), or really just wants peace at home at this point then you are chasing more time without quality.

To explain the practicalities in case it helps: if a group and save blood sample wasn’t sent with the blood tests then the reality is another blood draw (not an issue with long term IV access but unpleasant if taken from the vein) with usually a 1 hour processing time to match blood (it can be much longer if any antibodies are present), plus the time for a clinical review and prescription of blood and I would expect a slow 3 hour transfusion if red cells - it all adds up even though the procedure is a few hours. These are the timings I work with in a unit which transfuses routinely, obviously a&e will be different due to acuity.

I hope the house call provides some clarity for you all and takes away some of the decision burden. It sounds like your parent has the right priorities, as tough as it is to live through dying.

if they do go for a transfusion then I would ask some questions about cause of low counts if this is not directly related to their terminal diagnosis. For example if bleeding then the process may need repeating. I would also use this as an opportunity to discuss their wishes around ongoing blood tests as we have a duty to advise treatment when things are abnormal but repeated visits to hospital may not be suitable, in which case monitoring is futile.

Thank you again, this really is invaluable.

The reason for the low blood count is that DParent is no longer able to eat due to the location of the tumour (duodenum) obstructing the opening to the stomach, so has eaten little but a couple of plain crackers a day and occasional cups of warm milk for months as nothing else is tolerated despite best efforts with lovely oncology dietician. DParent is basically deeply malnourished.

Ask them to consider whether a transfusion in Same Day Emergency Care (SDEC) might be appropriate rather than admission and then transport home again

@Wowzel The OOH GP came before I noticed your response. He listened to DParent's reservations about going into hospital and, as a compromise, took more bloods and asked whether DParent would prefer a call as soon as results were ready (around 3am, apparently) or whether she'd prefer to wait until the morning. Isn't the NHS amazing? He said a transfusion would be offered as he did not suspect a significant change since the sample earlier today, but he did suggest it would be 'same day' with hospital transport to and from -I wonder if that was it (SDEC)? We'll ask when they call in the morning with the new results.

Thanks again.