Transfusions and Hospice Care: A Path Forward?

For some patients with advanced blood cancers, enrolling in hospice care can mean forgoing access to palliative transfusions that can help alleviate fatigue, shortness of breath or bleeding related to low blood counts.

Thomas LeBlanc, MD, MA, a hematologic oncologist at Duke Cancer Center who treats patients with acute leukemias and various myeloid diseases and is board-certified in hospice and palliative medicine, described this scenario—deciding between palliative transfusions or home-based hospice care—as an “awful, impossible choice” for patients and their families. Patients may be told they can continue supportive care, including transfusions and antimicrobials, to help manage debilitating symptoms. But they may also be told they cannot elect hospice if they want to continue transfusions.

“In many areas, patients can’t do both,” he said. “I’ve seen several cases where patients were incredibly distraught about being forced to give up transfusions and felt it was unfair to choose between receiving help at home through hospice services and continuing transfusions that made them feel better. It becomes a deeply distressing situation. When we’re able to offer both, you can see the relief. It’s palpable.”

Although research indicates that transfusions can address palliative needs, some hospice agencies and clinicians have expressed concern that transfusion support is not consistent with the goals of hospice care.  

Pamela Egan, MD, a hematologist who studied concurrent hospice and transfusion care at Brown University, said the tension reflects a contradiction in how hospice care is structured for patients with blood cancers.

“It’s a logical inconsistency to say you should transition to comfort-focused care, but we have to take away the thing that provides you comfort,” Egan told AABB News. “Transfusions for patients with blood cancers are like pain medications for patients with solid tumors. We would never say a patient can enroll in hospice, but we can’t treat their pain anymore. It’s a very similar situation.”

“It’s a logical inconsistency to say you should transition to comfort-focused care, but we have to take away the thing that provides you comfort.” Pamela Egan, MD

LeBlanc said he fundamentally disagrees with the argument that transfusions represent disease-directed therapy. He has witnessed firsthand the truly palliative benefits of red blood cell transfusions and their ability to significantly improve fatigue in patients nearing the end of life. Often, he noted, patients report feeling better after receiving a blood transfusion.

“As people approach the end of life with these diseases, the biggest symptom they often have is fatigue,” he said. “There really isn’t a medical intervention that improves fatigue other than correcting symptomatic anemia if that’s what’s causing it. That’s why I feel strongly that transfusions can be consistent with the principles of hospice care, which are no longer about treating the disease or lengthening life, but about improving or maintaining quality of life and addressing bothersome symptoms.”

Although transfusions can improve quality of life for hospice patients, LeBlanc acknowledged that not every patient will feel better, and there is no reliable way to predict which patients are most likely to benefit from the procedure, aside from prior experience with individual patients. Even then, responses can change over time, he added.

“In hospice care, we don’t treat the number; we treat the patient and the symptoms,” he said. “In routine oncology practice, we may transfuse based on a hemoglobin threshold. But in hospice, if a patient feels okay and isn’t experiencing significant dyspnea or fatigue, the hemoglobin value alone doesn’t matter. Giving blood to someone dying of leukemia is not treating the leukemia. It’s supporting the patient and often improving symptoms.”

Medicare: The Per Diem Dilemma

Although Medicare hospice benefits do not explicitly prohibit transfusions, many hospice agencies are hesitant to provide them, due to financial and logistical concerns. Under Medicare’s current per diem payment system, hospice agencies receive a flat daily rate that must cover all aspects of patient care, including nursing services, medications and equipment.¹

Egan, who led a pilot study at Brown University examining concurrent hospice enrollment and symptom-driven transfusions in partnership with HopeHealth, said the structure of the Medicare hospice benefit is the central barrier to wider adoption of these models.

“The way the Medicare hospice benefit is structured is the driving force in this issue,” she said. “Hospice agencies receive a daily lump sum payment, and transfusions can be expensive. Many agencies simply say they can’t shoulder that cost.”

In the Brown University pilot program, patients were able to enroll in hospice while continuing symptom-driven transfusions administered through the cancer center. Egan noted that removing the requirement to stop transfusions made it easier for clinicians to guide patients toward hospice care.

“What struck us most was how much easier it was to help patients transition to hospice when transfusions weren’t part of the discussion,” Egan said. “As things stand in the current system, we often have these really fraught conversations where we say you should enroll in hospice because it’s the gold standard for end-of-life care, but then we have to say you have to give up this intervention that makes you feel better. Patients who feel ready to transition to hospice often assume they will still receive comfort-focused care and are surprised when they learn transfusions may not be available.”

LeBlanc noted that a single blood transfusion could wipe out the entire per diem for several days, making it difficult for agencies to absorb the cost.

“Some hospice agencies will allow them in certain situations, depending on how often they’re needed and what the goals are, but many hospice agencies can’t or won’t,” LeBlanc explained. “What often happens is that patients are told by their hematologist or oncologist that their disease has progressed, that time is likely short, and that there’s no further disease-modifying therapy that will help.”

LeBlanc co-authored a study published in Blood that examined hospice use among Medicare beneficiaries with leukemia in the U.S. using Surveillance, Epidemiology and End Results-Medicare (SEER)-Medicare data. The authors analyzed beneficiaries with acute and chronic leukemia who died in 2001-2011.

LeBlanc and his colleagues identified a clear association between transfusion dependence and failure to use hospice care. Shorter hospice stays among transfusion-dependent patients suggest that these patients face barriers to timely referral and meaningful use of hospice services. Because hospice use overall was associated with better end-of-life care quality measures and lower costs regardless of transfusion status, the authors concluded that policies supporting palliative transfusions could help maximize the benefits of hospice care for patients with leukemia.²

“At the same time, patients with leukemia who did use hospice had markedly lower costs of care in the last month of life and markedly better end-of-life care quality outcomes based on established measures,” he said. “It’s a rare win-win: it’s the kind of care people want, delivered where they want it, and it costs less while being higher quality.”

Evidence and Policy

New research from investigators at Dana-Farber Cancer Institute and Yale Cancer Center found that access to palliative blood transfusion is the most influential factor affecting hospice enrollment among patients with blood cancers.

In a multicenter survey, investigators asked 200 adults with a physician-estimated life expectancy of six months or less to rate the importance of routine and non-routine hospice services. Participants ranked transfusion access as the top service, while routine hospice services were considered relatively less important. Researchers concluded the findings underscore the need to develop and test novel hospice delivery models that combine palliative transfusions with routine hospice services to effectively alleviate discomfort and optimize the quality of life for patients with blood cancers near the end of life.³

LeBlanc commended Oreofe O. Odejide, MD, MPH, lead researcher and principal investigator of the study, and her team for providing data that identifies transfusion access as a central factor influencing hospice decision making.

“I’m grateful that Dr. Odejide conducted that study and that it’s been published, because many of us had been observing this anecdotally for years, but we didn’t have definitive proof that this was truly the issue,” he said. “Her body of work has very clearly demonstrated that transfusion access is the major barrier we need to fix. It’s the primary obstacle preventing so many of these patients from enrolling in hospice care.

“What’s especially troubling is that we’ve known for decades that hospice care in the U.S. is the highest quality end-of-life care available,” LeBlanc continued. “If someone knows they’re dying and wants to be at home, hospice is the best way to meet those objectives. When a patient with terminal leukemia can’t access that care because of this technical issue around transfusions, it’s really upsetting.”

In 2019, the American Society of Hematology (ASH) issued a statement supporting palliative blood transfusion in hospice settings and urged the Centers for Medicare and Medicaid Services (CMS) to work with hospice agencies to create innovative reimbursement models, such as allowing palliative transfusions to be paid for separately under Medicare Part B.

LeBlanc noted that the structural barrier has continued to garner attention at the federal level. In partnership with the American Society of Hematology (ASH), he and colleagues supported the introduction of Senate Bill 1936, the Improving Access to Transfusion Care for Hospice Patients Act. The bipartisan bill, reintroduced in 2025, would establish a demonstration program to create a separate Medicare payment for blood transfusions provided as part of hospice care.⁴

“This is part of why, in partnership with ASH, we worked to have a bill introduced… to determine whether a supplemental payment for transfusion episodes would improve access,” LeBlanc said. “Part of that effort came from an earlier analysis we conducted, published in Blood. That’s part of why there was bipartisan support for introducing the bill. It’s been introduced in two separate congressional sessions, but it hasn’t yet come up for a vote.”

Reshaping Delivery

Duke Home Care and Hospice created a policy in which transfusions are provided only if they are clearly palliating a symptom and remain effective. If they become ineffective, LeBlanc noted, the service stops. If a patient becomes too ill to travel to the clinic for transfusion, that is also an indication that it may no longer be appropriate.

“Patients are not receiving blood at home. They come to our blood cancer center infusion clinic. The treating oncology team orders and administers the transfusion, even though the patient is enrolled in hospice through Duke Home Care and Hospice,” LeBlanc said. “The hospice agency is billed for the transfusion, which likely means that patient’s care runs at a financial loss. But the agency is large enough to absorb that cost because it’s the right thing to do.”

Looking ahead, LeBlanc advocates for adopting an open hospice model in the U.S. that would allow patients to receive both active treatment and palliative care services. In pediatrics and the Veterans Administration system, open hospice models allow both, he pointed out.  

“Transfusions can be consistent with the principles of hospice care, which are no longer about treating the disease or lengthening life, but about improving or maintaining quality of life. - Thomas LeBlanc, MD, MA,

“I would love to see a model where someone with end-stage leukemia could begin receiving home-based palliative services that resemble hospice, while still continuing treatments that provide benefit,” LeBlanc said. “Instead of waiting for a crisis hospitalization and then flipping a switch to hospice, transitions could happen gradually and more smoothly at home. There’s strong evidence that integrating palliative services earlier in cancer care improves patient and caregiver experiences and outcomes.”

Even when transfusions are available during hospice enrollment, he noted that patients typically only require a limited number of transfusions before their condition deteriorates.

“As patients decline, they often become too ill to travel or are no longer interested,” LeBlanc said. “It doesn’t typically become prolonged. But it can make a tremendous difference in how that transition feels. Patients don’t feel like something essential is being taken away from them at the very end.”

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References

1. Centers for Medicare & Medicaid Services. Medicare Hospice Benefits. Medicare.gov. Published 2020.  https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.PDF
2. LeBlanc TW, Egan PC, Olszewski AJ, et al. Transfusion dependence, use of hospice services, and quality of end-of-life care in leukemia. Blood. 2018;132(7):717-726. https://ashpublications.org/blood/article/132/7/717/39444/Transfusion-dependence-use-of-hospice-services-and 
3. Raman HS, Cronin AM, Huntington SF, Odejide OO, et al. Perceived Value of Transfusion Access and Hospice Services Among Patients With Blood Cancers. JAMA Netw Open. 2025;8(11):e2541719. doi:10.1001/jamanetworkopen.2025.41719 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2840995
4. American Society of Hematology. (2019). ASH Statement in Support of Palliative Blood Transfusions in Hospice Setting. Retrieved from https://www.hematology.org/advocacy/policy-statements/2019/palliative-blood-transfusions-in-hospice