Transfusion · 2025
Beyond "futility thresholds": An ethical framework for massive transfusion decisions.
СтатьяОбзорНазвание и аннотация: Перевод пока не подготовлен
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Malone Jay R
Аннотация
BACKGROUND: Massive transfusion can be lifesaving and resource-intensive, undertaken under time pressure, prognostic uncertainty, and variable system capability. Recent literature suggesting unit-based "futility thresholds" risks translating population-level mortality correlations into bedside stopping rules.
STUDY DESIGN AND METHODS: This essay distinguishes three ethically distinct rationales commonly conflated under "futility": (1) physiologic futility-inability to reach the intended clinical goal; (2) potentially inappropriate treatment-contestable judgments about benefits, burdens, and values; and (3) stewardship/rationing-opportunity costs due to scarcity.
RESULTS: It introduces a fourth category: "system-limited salvageability," where transfusion cannot bridge to hemorrhage control within existing infrastructure, distinguishing capability-time mismatch from patient-centered futility. A capability-sensitive massive transfusion protocol (MTP) time-out is proposed, triggered by clinical trajectory rather than unit count, requiring clear rationale labeling, rapid capability assessment, and minimal documentation to support accountability.
DISCUSSION: When limitations reflect capability gaps rather than patient physiology, institutions should treat these as sentinel events requiring structured review and potential systems improvement. This framework addresses the risk that unit-based thresholds become self-fulfilling limits or mask implicit rationing. By clarifying whether stopping reflects patient physiology or system constraints, it appropriately assigns accountability and enhances transparency in scarcity-driven decisions while maintaining rapid clinical judgment.
STUDY DESIGN AND METHODS: This essay distinguishes three ethically distinct rationales commonly conflated under "futility": (1) physiologic futility-inability to reach the intended clinical goal; (2) potentially inappropriate treatment-contestable judgments about benefits, burdens, and values; and (3) stewardship/rationing-opportunity costs due to scarcity.
RESULTS: It introduces a fourth category: "system-limited salvageability," where transfusion cannot bridge to hemorrhage control within existing infrastructure, distinguishing capability-time mismatch from patient-centered futility. A capability-sensitive massive transfusion protocol (MTP) time-out is proposed, triggered by clinical trajectory rather than unit count, requiring clear rationale labeling, rapid capability assessment, and minimal documentation to support accountability.
DISCUSSION: When limitations reflect capability gaps rather than patient physiology, institutions should treat these as sentinel events requiring structured review and potential systems improvement. This framework addresses the risk that unit-based thresholds become self-fulfilling limits or mask implicit rationing. By clarifying whether stopping reflects patient physiology or system constraints, it appropriately assigns accountability and enhances transparency in scarcity-driven decisions while maintaining rapid clinical judgment.