Background Anaemia is a common complication of advanced disease with associated symptoms having a negative impact on quality of life. A recent national hospice audit suggested a need for improvement in the management of anaemia in hospices, with a particular focus on investigation and more restrictive use of blood. As a result, we have updated local hospice guidelines and reviewed their use to assess the impact on patient care.

Method Alongside the introduction of updated guidelines, prospective data were collected from hospice inpatients with symptoms related to anaemia, who were being investigated for potential treatment. The data, collected over three months, included blood parameters to assess cause of anaemia and guide treatment options.

Results Of the seven patients investigated, four were folate deficient and five had either iron deficiency or functional iron deficiency.

Two were treated with folate replacement; one subsequently deteriorated rapidly. One was too unwell to be treated and the folate level improved in one without treatment. Four out of six patients (one not measured) had reduced serum iron yet ALL ferritin results were >30 microgram/L and five had a ferritin >1000 microgram/L (range 186–3383). CRP results ranged from 95 to 206.

Conclusion This case series highlights the complexity of interpreting results to guide management of anaemia in the hospice inpatient population. When a deficiency is identified, treatment with folic acid or iron carries less risk than treatment with blood. However, with ferritin levels this high, treatment with oral or intravenous iron is not usually recommended. Iron may not represent a frequently useful treatment option in this population. We are not aware of evidence confirming a positive clinical response to these treatments in hospice patients with complex underlying aetiologies contributing to anaemia. We believe this highlights a need for research to demonstrate clinical benefit to support these treatments.