For a patient with a saddle pulmonary embolus who is on apixaban (5 mg twice daily) and metoprolol, needs assistance with activities of daily living but can feed herself and has had no falls, does the family or medical power of attorney need the patient to be enrolled in hospice before stopping anticoagulation?

No, hospice enrollment is NOT required before stopping anticoagulation

The decision to discontinue anticoagulation is a medical decision based on goals of care, patient/surrogate preferences, and clinical status—it does not require hospice enrollment as a prerequisite. However, given this patient's clinical context (saddle PE with functional decline), concurrent hospice enrollment would be appropriate if the decision is made to stop anticoagulation, as this represents a transition to comfort-focused care.

Legal and Ethical Framework

The medical power of attorney (POA) has the legal authority to make treatment decisions, including discontinuation of medications, when the patient lacks decision-making capacity. This authority exists independently of hospice enrollment. The key considerations are:

• Goals of care alignment: Does continuing anticoagulation align with the patient's values and goals?
• Risk-benefit assessment: What are the burdens versus benefits of continued treatment?
• Prognosis and quality of life: What is the trajectory with or without anticoagulation?

Clinical Context for This Patient

This patient has a saddle pulmonary embolism, which appears radiologically severe but has variable clinical outcomes. Research shows that most patients with saddle PE are hemodynamically stable and respond well to standard anticoagulation 1, 2. The mortality rate for saddle PE managed with anticoagulation is relatively low (approximately 4-5%) when patients are stable 1, 2.

Current anticoagulation status: The patient is on apixaban 5 mg twice daily, which is the standard treatment dose for PE 3. According to CHEST guidelines, patients with unprovoked VTE (which a saddle PE likely represents) should receive extended-phase anticoagulation, with decisions reevaluated at least annually and at times of significant health status changes 4.

Decision-Making Algorithm

Step 1: Assess Current Clinical Status

• Is the patient hemodynamically stable?
• What is the functional trajectory (improving, stable, declining)?
• Are there new complications or comorbidities affecting prognosis?

Step 2: Clarify Goals of Care

With the medical POA, determine:

• What would the patient want in this situation?
• Is the goal life prolongation, comfort, or both?
• What are acceptable trade-offs between treatment burden and benefit?

Step 3: Evaluate Risks of Stopping Anticoagulation

Critical FDA warning: Premature discontinuation of apixaban increases the risk of thrombotic events 3. If anticoagulation is stopped for reasons other than pathological bleeding or completion of therapy, consider coverage with another anticoagulant 3.

For this patient with saddle PE:

• Risk of recurrent PE/death: Substantial if anticoagulation is stopped without alternative coverage
• Timeframe: The pharmacodynamic effect persists for at least 24 hours after the last dose 3

Step 4: Make the Decision

If the decision is to CONTINUE anticoagulation:

• Continue apixaban 5 mg twice daily
• Reassess goals of care regularly, especially with health status changes 4
• Monitor for bleeding risk given functional decline and fall risk

If the decision is to STOP anticoagulation (comfort-focused care):

• This represents a fundamental shift in goals of care
• Hospice enrollment should occur concurrently because:
  • Stopping anticoagulation for saddle PE carries high mortality risk
  • Hospice provides symptom management for potential complications (dyspnea, pain)
  • This aligns with comfort-focused rather than life-prolonging care
• Simply discontinue apixaban; no bridging or alternative anticoagulation needed if comfort is the goal 3

Critical Pitfalls to Avoid

1. Don't stop anticoagulation without clear goals of care discussion: The FDA explicitly warns against premature discontinuation 3. If life prolongation remains a goal, stopping anticoagulation for saddle PE is medically inappropriate.

2. Don't confuse hospice eligibility with decision-making authority: The POA can make decisions about treatment withdrawal regardless of hospice enrollment status.

3. Don't underestimate saddle PE based on current stability: While many patients with saddle PE are stable 5, 1, stopping anticoagulation dramatically increases recurrence risk.

4. Consider palliative care consultation even if not stopping treatment: Given functional decline and complex decision-making, palliative care can help optimize symptom management and clarify goals regardless of anticoagulation decisions 6.

Practical Approach

If the POA wants to stop anticoagulation, the conversation should include:

• Understanding that this decision likely shortens life expectancy
• Simultaneous hospice referral for symptom management
• Clear documentation of goals of care and decision-making process
• Preparation for potential complications (worsening dyspnea, hemodynamic collapse)

The sequence should be: Goals of care discussion → Decision to stop anticoagulation → Hospice enrollment (can occur simultaneously or within days, not as a prerequisite).