Should I discontinue aspirin (ASA) for prevention in a hospice patient?

Discontinuation of Aspirin in Hospice Patients

Yes, you should discontinue aspirin for prevention in hospice patients, as the bleeding risks and lack of short-term benefit outweigh any cardiovascular protection when life expectancy is limited and the focus is on comfort care. 1, 2

Rationale for Discontinuation

Hospice patients are explicitly excluded from quality measures requiring aspirin continuation. The AHA/ACC performance measures for myocardial infarction specifically exclude "patients who are on comfort care measures only or hospice" from the denominator when measuring aspirin prescription at discharge, recognizing that the goals of care have fundamentally shifted away from long-term cardiovascular prevention. 1

Time-to-Benefit Considerations

• Aspirin's cardiovascular benefits accrue over months to years, not days to weeks 3
• In hospice patients with limited life expectancy (typically <6 months), there is insufficient time to realize any mortality benefit from continued aspirin therapy 4
• The bleeding risks from aspirin are immediate and ongoing, while cardiovascular protection requires sustained use 1, 5

Bleeding Risk in This Population

• Aspirin increases major bleeding risk by a factor of 1.5 across all patient populations 5
• Hospice patients often have multiple bleeding risk factors including:
  • Advanced age (>70 years increases bleeding risk) 2
  • Concurrent medications (opioids, corticosteroids) 2
  • Nutritional deficiencies and thrombocytopenia from underlying disease 2
  • Renal or hepatic dysfunction 2

Evidence from Hospice Deprescribing Studies

A quality improvement project at Mayo Clinic Hospice demonstrated successful and safe deprescribing of aspirin in hospice patients. After implementing an evidence-based deprescribing protocol, the percentage of hospice patients taking aspirin, multivitamins, or statins decreased by 24%, with improved nursing staff comfort and satisfaction. 4

Key Implementation Points

• Use a structured communication framework to discuss deprescribing with patients and families 4
• Educate staff that continuing preventive medications in hospice contradicts comfort-focused goals of care 4
• Document the rationale: "Aspirin discontinued as goals of care focus on comfort; bleeding risks outweigh cardiovascular benefits given limited life expectancy" 4

Critical Exceptions Requiring Individualized Assessment

The only scenario where aspirin continuation might be considered is active thrombotic disease causing symptoms. 1

• If the patient has recent acute coronary syndrome (within 30 days) causing ongoing angina symptoms, aspirin may provide symptom relief 1
• If the patient has a coronary stent placed within the past month and is experiencing chest pain, discuss with cardiology before discontinuation 1
• Even in these cases, if the patient is truly hospice-appropriate with very limited life expectancy, comfort measures typically supersede antiplatelet therapy 1

Common Pitfalls to Avoid

• Do not continue aspirin "just in case" - this reflects failure to align medications with goals of care 4
• Do not substitute with other antiplatelet agents - this defeats the purpose of deprescribing and maintains bleeding risk 2
• Do not taper aspirin - it can be stopped abruptly in hospice patients as the rebound thrombotic risk (which peaks at 7-10 days) 1 is irrelevant when life expectancy is measured in weeks

Documentation and Communication

• Document that aspirin was discontinued as part of hospice medication reconciliation focused on comfort care 4
• Explain to family that stopping preventive medications is standard hospice practice and does not constitute "giving up" 4
• Note that this aligns with established quality measures that exclude hospice patients from aspirin continuation requirements 1