Anticoagulant use and associated outcomes in older patients receiving home palliative care: a retrospective cohort study

Abstract

Background:The benefits and harms of anticoagulants for people near the end of life are not well understood, nor is it known what proportion of patients discontinue these medications. We aimed to characterize anticoagulant use in older recipients of home palliative care and describe patient and provider characteristics, as well as outcomes associated with anticoagulant discontinuation in this group.

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

“…Anticoagulant use among older American nursing home residents with atrial fibrillation who are entering hospice has not been well described. One study of older adults in Canada receiving home palliative care found that one in four OAC users discontinued anticoagulants after their first home palliative care visit 22 . In this prior study, the percentage who discontinued OACs prior to the start of palliative care was not reported.…”

“…We also tracked the presence of any hospitalizations with inpatient surgery in the past 6 months, as acute events arising in hospitalizations that may affect clinical decision making. From the MDS, we included a history of recent falls (J1800), rejected evaluation or care (E0800), cancer diagnosis (I0100), cognitive impairment based on the Cognitive Function Scale 25 and self-performance of activities of daily living (ADLs) as (low functional dependency [0-7], mild functional dependency [8][9][10][11][12][13][14], moderate functional dependency [15][16][17][18][19][20][21], and high functional dependency [22][23][24][25][26][27][28]). 26 We created a categorical variable that indicated the index date year.…”

“…While decisions to discontinue using OACs before hospice enrollment in older patients approaching the end of life should be individualized consistent with goals of care through a shared decision‐making process, understanding those characteristics which are associated with discontinuing OAC use before hospice enrollment may shed light on whether clinical practice is aligned with current evidence and palliative care principles 18–21 . One study of anticoagulant discontinuation among older patients receiving home palliative care in Ontario found that OAC discontinuation was not associated with any patient‐level comorbidities, consistent with the absence of clear clinical guidance 22 . Evidence is scarce on OAC discontinuation among US nursing home residents prior to hospice enrollment.…”

“…[18][19][20][21] One study of anticoagulant discontinuation among older patients receiving home palliative care in Ontario found that OAC discontinuation was not associated with any patient-level comorbidities, consistent with the absence of clear clinical guidance. 22 Evidence is scarce on OAC discontinuation among US nursing home residents prior to hospice enrollment. The objectives of this large observational study were to: (1) estimate the prevalence of OAC discontinuation before hospice enrollment among nursing home residents with atrial fibrillation; (2) describe sociodemographic and clinical characteristics among residents who discontinued OAC use prior to hospice enrollment and currently on OACs at hospice enrollment; (3) quantify the factors associated with discontinuing OAC use before hospice enrollment.…”

Antikoagulation bei alten Patienten

“…Dabei orientierten sich diese stark an der basalen Funktionalität. Eine große Studie aus der palliativen häuslichen Pflege in Kanada zeigt, dass Antikoagulantien häufig (Prävalenz 15 %) auch in diesen Situationen noch verordnet werden, aber im Verlauf in etwa 25 % der palliativen Patienten abgesetzt werden, wobei kein direkter Einfluss der Diagnose oder von klinischen Aspekten des Patienten festgemacht werden konnte [17]. Diejenige Gruppe, bei der die Antikoagulantien abgesetzt wurden, zeigte eine etwas erhöhte Mortalität, eine geringere Blutungsinzidenz, aber kein eindeutiges, vermehrtes Auftreten von thromboembolischen Ereignissen.…”