Antithrombotic Therapy in Terminal Illness – A Double Edged Sword

By Christine Pham, Pharm.D., BCGP

Antithrombotic Therapy in Terminal Illness – A Double Edged Sword

In hospice care and dealing with terminal illness, the transition of care shifts from a curative and treatment perspective to a palliative and symptom-management perspective. The best way to look at antithrombotic therapy in a hospice patient is evaluating the effect on remaining quality of life. It is important to evaluate the consequences of continued therapy versus discontinued therapy – which is worse? The answer is not always to discontinue; although, there are many factors that should not be taken lightly. Antithrombotic therapy is usually started in the acute setting for the treatment and prophylaxis of stroke and thromboembolism. Clinical guidelines discuss the appropriate use of antithrombotic therapy in several patient populations; however, it does not discuss when it is appropriate to discontinue the use of therapy for primary prevention in a hospice patient. There are many other factors to consider in a hospice patient versus a geriatric patient that does not have a terminal prognosis.

One Edge of the Sword

The hospice patient population is at higher risk of a thromboembolic event due to older age, presence of advanced stage cancer, and decreased ambulation. Particularly, if a patient is experiencing symptomatic thromboembolism (DVT, pleuritic chest pain, swelling in extremities), it may be appropriate to continue therapy as symptom management is in line with the overall goals in hospice and palliative care. When a hospice patient receives antithrombotic therapy for an active DVT or PE, it may serve a palliative purpose as thrombosis can be associated with multiple distressing symptoms that may lower quality of life.

The Other Edge of the Sword

Hospice patients have a higher risk of bleeding due to multimorbidity, older age, frailty, renal impairment, and liver dysfunction. Geriatric and debilitated patients particularly have a higher risk of major gastrointestinal or intracranial hemorrhage. Additionally, cancer patients have a higher risk of bleeding due to cancer- or chemotherapy-induced thrombocytopenia. Antithrombotic medications have well-known bleeding risks and are an important cause of adverse drug events requiring emergency department admissions. Regarding antiplatelet therapy, many geriatric patients are inadvertently left on antiplatelet therapy as they lose follow-up with the prescribing physician, particularly if they reside in a long-term care facility and their medications are refilled routinely and indefinitely. Given that these clinical factors are highly prevalent in the hospice population, it is important to evaluate each individual’s unique risk profile. If the patient does not have an active clotting disorder and has multiple risk factors for major bleeding, it may be appropriate to discontinue preventative antithrombotic therapy to align with the goals of palliative care.

Widespread Agreement

The consensus is that hospice patients should continue anticoagulant therapy in the presence of symptomatic thromboembolism, active thromboembolic disorder, or when receiving cancer treatment, with periodic reassessment of the risks and benefits. Due to the short prognosis of hospice patients, the reassessment should be conducted at each interdisciplinary team meeting since there may be changes that occur quickly in the terminally ill patient. As with the overall management of medications in hospice care, it is important to evaluate the role of medications used for primary prevention versus symptom management and quality of life. Either edge of the sword can result in a terminal event, but we should use our best clinical judgement to evaluate the appropriateness of antithrombotic therapy given the continual increase of risk factors as a patient nears the end of life.

 


 

About the Author

Dr. Christine Pham is a board-certified geriatric pharmacist with specialized focus on hospice and end-of-life care. She earned a Doctor of Pharmacy degree from the University of Colorado Skaggs School of Pharmacy in Denver, Colorado and a Bachelor of Science degree in Biochemistry from San Francisco State University. She has extensive experience in clinical program development, drug information, pharmacy education, curating clinical resources, and providing consultations on optimal pharmacotherapy. She has presented at several hospice and palliative care organization and medical director conferences. She has also served as a mentor and preceptor to pharmacy students throughout her career and has worked closely with palliative care and hospice nurses to provide patient-centered care. She is committed to creating innovative methods of delivering clinical content to nurses, medical directors, patients, and caregivers.

References

Lee AYY. When can we stop anticoagulation in patients with cancer-associated thrombosis? Blood. 2017 doi: 10.1182/blood-2017-05-787929

Kowalewska CA, Noble BN, Fromme EK, McPherson ML, Grace KN, Furuno JP. 2017. Prevalence and clinical intentions of antithrombotic therapy on discharge to hospice care. J Palliat Med 20:1225–1230. doi:10.1089/jpm.2016.0487