The patient’s altered mental status renders her unable to: 1) articulate her goals of care globally, and 2) have decision-specific capacity regarding transfusions and antibiotics. When a patient lacks decision-making capacity, it is appropriate to defer to a suitable surrogate to make healthcare decisions on their behalf. If they have appointed a durable power of attorney (DPOA), then they would be a legal decision maker. However, if the patient has not appointed a DPOA, the default surrogate decision maker for adults is normally the next of kin. Each state’s individual priority order has some variation but typically starts with the person’s spouse or domestic partner, then parents (though likely no longer alive), then children (who hopefully agree), and then possibly other relatives. Importantly, the patient’s surrogate decision makers would know the prior stated wishes of the patient and be encouraged to use that information to make decisions based on what the patient would want, otherwise known as substituted judgement. If the patient’s mental status improves, the team should allow the patient to make her own medical decisions.

Medical interventions should not be proposed or discussed with the patient and family unless they are medically indicated. If an intervention is indicated, eliciting patient or family wishes is also an important component of deciding which therapies, if any, should be used. This is particularly true if the patient’s disease process or current clinical status make certain interventions futile. For this patient, this holds true as she may not be a candidate for curative therapy targeted towards her underlying terminal cancer.

With respect to other interventions that would aim to treat reversible processes, it is important to consider whether there is medical benefit from the intervention in the context of evolving goals of care (if these include short-term prolongation of life in this clinical context). When specific treatments are determined to be non-beneficial/futile, it is not advisable to present them to patients and families as options, thus burdening them with false choices.

Blood products should be used to relieve fatigue or other specific symptoms in a conscious patient, but should not be used indiscriminately at the end of life otherwise. As no national guidelines exist on transfusion at the end of life, discretion is required in these situations in order to optimize benefit and avoid waste. Consultation of your hospital transfusion medicine service may help with suggestions about thresholds (based on clinical scenarios such as active bleeding).

Some patients may require transfusions of blood products such as whole blood, platelets for thrombocytopenia, or packed red blood cells (pRBCs). Each of the products are collected through a time and labor-intensive process that requires willing volunteers, staff, and infrastructure to collect, process, and store blood products. Blood products also have a limited shelf life ranging from 5 days for platelets, 35 days for whole blood, and 1 year for plasma or cryoprecipitate. Platelets are a scarce resource because they are obtained through the costlier process of apheresis and their short shelf life necessitates a consistent donation supply. Patients requiring chronic transfusions may also risk alloimmunization which further narrows the supply of compatible blood products.

In addition to the logistical challenges of blood collection, there is a well-documented, long-term shrinkage of the donor population resulting from decreased participation by younger generations. Furthermore, given the migration to working or learning from home, traditional settings for blood drives, such as workplaces or schools, have become less productive. Shortages are now frequent and blood drives are often required to maintain a continuous supply, particularly for less common blood types.