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Beyond "futility thresholds": An ethical framework for massive transfusion decisions.

Jay R Malone1

  • 1Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.

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PubMed
Summary

Massive transfusion protocols should differentiate between patient-specific futility and system limitations. A new framework proposes capability-sensitive time-outs to improve accountability and transparency in critical care decisions.

Keywords:
decision makingethicsmassive transfusiontransfusiontrauma

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Area of Science:

  • Critical Care Medicine
  • Health Systems Management
  • Medical Ethics

Background:

  • Massive transfusion is a life-saving but resource-intensive intervention performed under pressure.
  • Existing literature on
  • futility thresholds
  • may inappropriately translate population data into bedside rules.

Purpose of the Study:

  • To differentiate between patient-centered futility and system-based limitations in massive transfusion.
  • To propose a new framework for decision-making during massive transfusions.

Main Methods:

  • Distinguishing three established rationales for futility: physiologic, inappropriate treatment, and stewardship.
  • Introducing a fourth category: system-limited salvageability.

Main Results:

  • System-limited salvageability occurs when transfusion cannot bridge to hemorrhage control due to infrastructure limits.
  • A capability-sensitive massive transfusion protocol (MTP) time-out is proposed, triggered by clinical trajectory.

Conclusions:

  • Capability gaps, not patient physiology, should trigger structured review as sentinel events.
  • This framework enhances transparency, assigns accountability, and prevents implicit rationing in critical care.