{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T14:20:03Z","timestamp":1788013203931,"version":"build-2784847793"},"reference-count":50,"publisher":"Wiley","issue":"S1","license":[{"start":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T00:00:00Z","timestamp":1766361600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T00:00:00Z","timestamp":1766361600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Transfusion"],"published-print":{"date-parts":[[2026,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Massive transfusion can be lifesaving and resource\u2010intensive, undertaken under time pressure, prognostic uncertainty, and variable system capability. Recent literature suggesting unit\u2010based \u201cfutility thresholds\u201d risks translating population\u2010level mortality correlations into bedside stopping rules.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Design and Methods<\/jats:title>\n                    <jats:p>This essay distinguishes three ethically distinct rationales commonly conflated under \u201cfutility\u201d: (1) physiologic futility\u2013inability to reach the intended clinical goal; (2) potentially inappropriate treatment\u2013contestable judgments about benefits, burdens, and values; and (3) stewardship\/rationing\u2013opportunity costs due to scarcity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>It introduces a fourth category: \u201csystem\u2010limited salvageability,\u201d where transfusion cannot bridge to hemorrhage control within existing infrastructure, distinguishing capability\u2010time mismatch from patient\u2010centered futility. A capability\u2010sensitive massive transfusion protocol (MTP) time\u2010out is proposed, triggered by clinical trajectory rather than unit count, requiring clear rationale labeling, rapid capability assessment, and minimal documentation to support accountability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>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\u2010based thresholds become self\u2010fulfilling limits or mask implicit rationing. By clarifying whether stopping reflects patient physiology or system constraints, it appropriately assigns accountability and enhances transparency in scarcity\u2010driven decisions while maintaining rapid clinical judgment.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/trf.70048","type":"journal-article","created":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T12:48:17Z","timestamp":1766407697000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Beyond \u201cfutility thresholds\u201d: An ethical framework for massive transfusion decisions"],"prefix":"10.1111","volume":"66","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7239-7623","authenticated-orcid":false,"given":"Jay R.","family":"Malone","sequence":"first","affiliation":[{"name":"Department of Pediatrics Washington University in St. Louis School of Medicine  St. Louis Missouri 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