Is it wise to continue a patient on Eliquis (apixaban) for a previous pulmonary embolism (PE), deep vein thrombosis (DVT), or stroke while on hospice care and at risk of falls?

Discontinuing Eliquis in Hospice Patients at Fall Risk

In hospice patients on Eliquis for prior PE, DVT, or stroke who are at high fall risk, discontinuation of anticoagulation is generally appropriate given the shift in goals of care toward comfort and quality of life rather than prevention of future thrombotic events. 1

Rationale for Discontinuation in Hospice

Goals of Care Alignment

• Hospice care fundamentally changes the risk-benefit calculus by prioritizing symptom management and quality of life over prevention of future events 1
• The time-to-benefit for stroke/thromboembolism prevention may exceed the patient's anticipated life expectancy, making continued anticoagulation less meaningful 1
• The potential consequences of major bleeding (pain, hospitalization, transfusions) directly conflict with hospice comfort goals 1

Fall Risk and Bleeding Considerations

• Fall risk is explicitly recognized as a relative contraindication to anticoagulation in patients who are "too risky" to anticoagulate 1
• Elderly patients at high fall risk have significantly higher rates of clinically relevant non-major bleeding (16.7 vs. 8.3 events per 100 patient-years) when anticoagulated 2
• While major bleeding risk is only modestly increased (9.6 vs. 6.6 events per 100 patient-years), the impact of any bleeding event is magnified in hospice patients 2
• Patients >75 years of age with renal impairment, falls, and frailty have increased bleeding risk that should prompt consideration for deprescribing 1

Clinical Decision Framework

When to Discontinue (Most Hospice Patients)

Discontinue anticoagulation when:

• Patient has transitioned to hospice care with comfort-focused goals 1
• Life expectancy is limited (typically <6 months in hospice) 1
• Fall risk is documented and ongoing 1
• The burden of continued anticoagulation (monitoring, bleeding risk, medication administration) outweighs uncertain future benefit 1

Rare Exceptions to Consider Continuation

Consider continuing only if:

• The patient explicitly expresses strong preference to avoid severe debilitation from stroke/PE despite understanding bleeding risks 1
• Life expectancy extends beyond typical hospice timeframes and patient remains relatively functional 1
• The original indication was very recent (within past 3 months) and represents active treatment phase rather than secondary prevention 1

Practical Implementation

Discontinuation Process

• Stop Eliquis without bridging - no need for transitional anticoagulation when discontinuing for goals-of-care reasons 3
• Document the shared decision-making discussion and rationale 1
• Educate patient/family that discontinuation aligns with comfort-focused care 1
• No need for gradual taper; apixaban can be stopped abruptly 3

Common Pitfall to Avoid

Do not continue anticoagulation simply because "the patient has always been on it" - this represents inappropriate continuation of home medications without reassessing appropriateness in the hospice context 1. The indication for anticoagulation fundamentally changes when goals shift from life prolongation to comfort care 1.

Monitoring After Discontinuation

• No routine laboratory monitoring needed after stopping 3
• Focus on symptom management if thrombotic or bleeding events occur 1
• Avoid hospitalization for thrombotic events unless absolutely necessary for comfort 1

Evidence Quality Note

The 2024 American Heart Association palliative care guideline provides the most direct guidance, explicitly stating that anticoagulation time-to-benefit may exceed life expectancy in end-stage cardiovascular disease, and bleeding risks from falls and frailty should prompt deprescribing consideration 1. This represents the highest quality, most recent evidence directly addressing this clinical scenario.