Methods
The decision to order a transfusion is essentially subjective, so it seemed appropriate to use a qualitative approach, with semi-structured recorded interviews. We gathered a purposive sample of GPs, with heterogeneous age, gender, place of work (rural ou urban) and seniority. A single physician interviewed GPs likely to care for elderly outpatients in the Calvados Department (Normandy) in northwestern France.
Data collection
Twenty GPs seemed to be a number of participants high enough so the probability of reaching data saturation, ie, that no new property, dimension, or relation will emerge during the analysis, was high. Twenty-nine GPs chosen at professional meetings were telephoned to explain the study aims and procedure and to ask them to participate. Twenty agreed and were recontacted to organize a meeting at their office. Had this saturation not been reached, a new sample would have been recruited [
28]. An interview guide (Additional file
1) designed for a 30-min individual interview served as a basis. This semi-structured approach was based on the following themes relevant to older adults (>80 years): definition, consequences and prevalence of chronic anemia, indications, non-indications, and consequences of transfusion. These non-remunerated interviews guaranteed confidentiality and anonymity and were conducted between January and July 2013. They were recorded and typed up verbatim.
Data analysis
Each interview was coded inductively, based on content, using observed data leading to a hypothesis or model. No a priori hypothesis was applied. Emergent themes, related to the GPs’ attitudes, were sought. Two researchers who are GPs experienced in geriatrics and worked independently to code all interviews by themes and categories, before cross-referencing the results. This coding was done in two stages: first, analysis and summary of statements, interview by interview, and second, organization of statements by target theme. Validation of the survey results confirmed that the statements were reproduced faithfully.
Results
Characteristics of the population and interviews
The 20 GPs (13 men, 7 women) interviewed were aged 30 to 65, and worked in rural [
9], semi-rural [
6], or urban [
5] settings. They had more than 15 years (12 GPs), 5 to 15 years [
5], or less than 5 years [
3] of experience of general medicine. Thirteen of the interviewed GPs worked within 30 km of several transfusion centers. The interviews lasted 16 to 43 min.
The Table
1 summarizes main spontaneous replies to our questions, with the number of occurrence. Two questions do not appear in that table as the replies were too heterogeneous.
Table 1
Main replies to the interview guide
Applied transfusion treshold | < 8 g/dL Hb | 16 |
< 9 g/dL Hb | 1 |
< 7 g/dL Hb | 3 |
Definition and attitude toward anemia | Same definition and attitude | 6 |
Different definition and attitude | 12 |
No answer | 2 |
Apprehended geriatric complications | General complications | 20 |
Speficic geriatric complications | 14 |
Falls | 10 |
Influence of cognitive impairments | No influence | 6 |
Influence | 14 |
Influence of autonomy loss | Fear of autonomy loss or autonomy loss as a treshold | 6 |
Positif effect of transfusion over anemia | 5 |
Family opinion over transfusion decision-making process | Family opinion in a palliative care context | 5 |
Family opinion about withholding tranfusion | 4 |
Family opinion in a cognitive impairment context | 6 |
Image of transfusion | Positive image for GPs | 19 |
Family satisfaction | 4 |
Improved items thanks to transfusion | General status | 15 |
Psychomotor status | 12 |
Feared complications of transfusion | Circulatory overload | 13 |
No fear | 5 |
Most GPs applied an absolute hemoglobin level of 8 g/dL as a transfusion threshold. None of the GPs referred to any specific guidelines. Cardiac comorbidities were considered to increase this threshold. The cause of anemia did not appear as a determining factor in the decision-making process of transfusion. The poor clinical safety of anemia was considered as the most important factor, without consideration of the threshold.
“If the patient’s clinical condition is poor, I don’t bother with figures […] I always think first of the patient. Because statistics are all very well, but they also make us do stupid things. There’s common sense and there’s experience.” (GP man 18).
These elements can be found in French or American recommendations [
20‐
22], in fact used without being cited.
Age seems to have paradoxical effect on GPs attitudes: they tolerate a lower hemoglobin concentration before starting lab tests for older patients, but propose transfusion earlier. In other terms, the presence of a moderate anemia will be trivialized, but in case of worsening they will react faster.
Falls strongly motivated GPs to order a transfusion. The GPs apprehended other geriatric complications like loss of autonomy, worsening of cognitive disorders, and orthostatic hypotension. More than the slow and insidious complications of chronic anemia, the events of rapid occurrence trigger the process of requesting a transfusion.
The presence of cognitive impairments makes the situation more complex. GPs freely mentioned cognitive disorders and their influence on decision making. However, the GPs’ comments revealed contradictions regarding how cognitive disorders affect their attitudes. Fear of worsening cognitive disorders linked to anemia leads to earlier transfusion, but cognitive disorders also complicate assessment of the safety of chronic anemia, and the risk of behavioral problems during transfusion tends to reduce requests.
“It’s true that if a patient with dementia starts pulling all the tubes out…”(GP man 13).
Overall, GPs’ attitudes varied greatly, ranging from those for whom transfusion is conditional upon preservation of higher functions to those who assert that cognitive disorders do not influence their decision, not to mention those who above all are baffled.
Institutionalization of the patient was spontaneously associated with severe cognitive disorders and dependence, with a twofold effect: it complicates assessment of the impact of anemia and potentially worsens its effects, through loss of residual autonomy.
When cognitive disorders are severe, or loss of autonomy major, or sometimes just because of a very old age, transfusion may appear futile.
“If the patient is in a wheelchair all day, we’re not really going to see any difference, are we?” (GP man 14).
The GPs held differing opinions regarding palliative care for an incurable disease. Some favored transfusion at the end of life, while others were in theory opposed, perhaps because they lacked experience. A perceived unpleasantness of death caused by anemia (drawn out, physical and mental discomfort) increased the likelihood that a transfusion would be ordered.
“I won’t let somebody die of anemia. It would be like letting someone die of hunger.” (GP man 18).
All GPs were of the opinion that there is no indication for blood transfusion when death is imminent, citing cost and availability. So palliative care situations, as cognitive impairment, very old age or loss of autonomy, can lead to opposite decisions: early transfusions because of patients’ frailty, or transfusion avoidance because this treatment is seen as invasive and useless.
Attitudes to transfusion
Physicians unanimously see transfusion as “magical”, with “spectacular” effects.
“We prolong life.” (GP woman 7).
“It’s crazy, almost like vitamins, like doping […]Suddenly they wake up!” (GP man 13).
This excellent image of transfusion seems to be shared with the patients and their families, who retain the immediate effects of this quite simple therapeutic act. One GP recalled a patient with end-stage kidney disease who refused dialysis but agreed to transfusion.
“He didn’t want to be dialyzed: he already had been once or twice […], but he did want transfusions, because he experienced an immediate effect” (GP man 13).
The satisfaction of patients, and consequently of their families, is for the physician a token of recognition.
Furthermore, most GPs interviewed considered the risk-benefit ratio as always being favorable, and pointed to psychomotor improvement, as well as improved general condition or mood, and a favorable impact on daily activities. Cognitive improvement in particular was highlighted. No concern was expressed regarding the risk of infection or of incompatibility. The only risks mentioned were volume overload and sometimes delirium.
“If it bothers a patient to undergo transfusion, if he comes back afterwards highly agitated and with behavioral problems…”(GP man 14).
Compared with the extraordinary efficacy of transfusion, these risks seem insignificant.
Despite these very positive descriptions of transfusion, GPs frequently expressed unease when taking the decision to recommend a transfusion, as they did not feel sufficiently competent or experienced.
“I don’t feel comfortable with it […]I haven’t had enough training, or perhaps I haven’t been interested enough, or maybe I haven’t had to face the problem often enough.” (GP man 16).
The impression of lack of competence is easily understandable since there are no precise recommendations in this type of situation. Moreover, the low frequency of confrontation with this situation does not allow learning by experience. But beyond lack of knowledge and experience, the unease expressed may be linked to ambivalence regarding transfusion, which is seen as extraordinarily effective in the short term, but completely useless in the long term.
“We make do by filling a vase with a hole in it.” (GP man 1).
So the patient and/or the patient’s family bestow recognition on the GP, who feels at a loss in the more or less long term. The power of medicine therefore seems illusory if the question of disease progression has not been addressed with the patient.
A lone decision
GPs faced with decisions regarding transfusions feel that they are responsible for a weighty decision, as they attribute to transfusion the power to prolong or even to restore life. But despite the complexity of the decision, few practitioners reported seeking support of specialists or decision sharing with patients and family. The relation with the specialist who performs the transfusion was mentioned by only two of the 20 GPs interviewed. One GP anticipated a refusal by the specialist, with no possibility of dialogue, above a hemoglobin threshold of 8 g/dL. The other was the only one thinking in terms of a collaborative approach, useful in decision making.
“I’d propose it jointly with the specialist. We could agree on it together.” (GP man 16).
It is surprising, in a complex situation where the physician feels uncomfortable and uncertain, that the specialist physician is not contacted either for decision support or for shared responsibility, but rather to confirm the orientation proposed by the general practitioner and to perform the act as a service provider.
Patient’s family circle finally appears as more influent than specialist in decision making. First of all, because the very presence of the family made an order for transfusion more likely. And second, because the GPs involved the family in decision making, notably in complex situations such as transfusion at the end of life and in the case of cognitive disorders.
“And then afterwards, regarding the family… To know whether or not they wish to prolong their loved one’s life.” (GP woman 11).
Only one of the GPs interviewed generally preferred not to include the family in decision making.
Interestingly, the patient’s opinion was not explicitly referred to as guiding decision making, and did not seem to be systematically sought, even if some patients expressed weariness after repeated transfusions.
“There are a lot of patients over 80 who don’t want to be bothered anymore, who don’t want a transfusion.” (GP woman 12).