Use of antithrombotics at the end of life: an in-depth chart review study

Abstract

Background Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered. Methods We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease. Results In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics. Conclusions Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient.

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

“…[11][12][13][14][15][16][17][18][19][20][21] However, because no high-quality studies have considered patients receiving palliative care, the benefits and risks of anticoagulation near the end of life are not known. 10,[22][23][24] Recent articles have highlighted the importance of studying anticoagulant use in patients with limited life expectancy [25][26][27][28] to gain a better understanding of anticoagulant practices, the factors influencing the decision to continue or stop anticoagulants, the outcomes associated with those decisions, and the im portance of shared decision-making. However, the characteristics of anticoagulant use in a population-based home palliative care cohort are unknown.…”

“…The prevalence of therapeutic anticoagulant use at the time of enrolment in palliative care in our study is similar to the rates of 14%-33% reported in other cohorts. 25,27,[52][53][54][55] However, previous studies focused primarily on inpatient settings and did not consistently differentiate between therapeutic and transient prophyl actic indications for anticoagulation. 25,27,[52][53][54][55] Aside from the small number of patients who had undergone recent orthopedic surgery (0.3%), analysis of outpatient prescription claims in our study suggests that most patients received anticoagulation for therapeutic reasons and not as transient thromboprophylaxis.…”

“…25,27,[52][53][54][55] However, previous studies focused primarily on inpatient settings and did not consistently differentiate between therapeutic and transient prophyl actic indications for anticoagulation. 25,27,[52][53][54][55] Aside from the small number of patients who had undergone recent orthopedic surgery (0.3%), analysis of outpatient prescription claims in our study suggests that most patients received anticoagulation for therapeutic reasons and not as transient thromboprophylaxis. 56 The prevalence of 15.5% in our population-based cohort therefore represents an estimate of therapeutic anticoagulant use among older people initiating home palliative care in Ontario.…”

Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation

“…Due to the lack of evidence, the clinicians may tend to overestimate the benefits of anticoagulation treatments and be inclined to continue a potentially inappropriate treatment in the last phase of life [ 81 ]. Accordingly, studies have shown that up to 50% of patients with life-limiting diseases continue to use antithrombotic treatment in the last weeks of life [ 82 , 83 , 84 ]. This may unnecessarily result in bleeding complications, suboptimal quality of life, or death for patients with a life-limiting illness.…”

Uso de Antitrombóticos nos Doentes em Fim de Vida

“…Em 75,9% dos doentes (n = 82), os antitrombóticos foram mantidos até à última semana antes do óbito. 1 Estes dados obrigam-nos a uma reflexão retrospetiva sobre a nossa prática clínica e à revisão de situações e atitudes que experienciamos e em que identificamos potenciais semelhanças, no contexto da manutenção destes fármacos em doentes em fim de vida. Estas atitudes podem estar relacionadas com barreiras desenvolvidas pelos profissionais de saúde, tais como o medo resultante da ausência de estudos de segurança sobre a descontinuação dos fármacos, a inexistência de guias e protocolos de atuação específica desta área, assim como pela complexidade clínica dos casos.…”