Should anticoagulant (blood thinner) therapy be continued in patients receiving hospice care?

From the Guidelines

Discontinuing blood thinners is often recommended for patients in hospice care, as the risks of bleeding and the burden of medication management may outweigh the benefits of preventing thrombotic events. The American Society of Hematology 2021 guidelines for management of venous thromboembolism suggest that the decision to continue anticoagulation should be based on individual patient factors, including their cancer status, treatment, comorbidities, and personal values and preferences 1. In patients with advanced cancer, the risk of bleeding associated with anticoagulation is a significant concern, particularly in the last weeks of life. Studies have shown that the majority of cancer patients receiving treatment for venous thromboembolism remain anticoagulated up to the point of death, but this is associated with a clinically relevant bleeding rate of 7-9.8% in the last week of life 1.

Key factors to consider when deciding whether to continue blood thinners in hospice care include:

• The patient's prognosis and current symptoms
• The risk of thrombotic events if anticoagulation is discontinued
• The risk of bleeding complications associated with anticoagulation
• The patient's wishes regarding medical interventions and their goals of care
• The burden of medication management and monitoring required for anticoagulation.

In general, the focus of care in hospice shifts from preventing long-term complications to maximizing comfort and quality of remaining life, and discontinuing blood thinners may be consistent with this goal. However, the decision should be individualized and involve discussions between the patient (if able), family members, and the hospice medical team to weigh the benefits and burdens of continuing anticoagulation 1.

From the Research

Decision to Continue Blood Thinners on Hospice Care

• The decision to continue blood thinners, such as antithrombotics, for patients on hospice care should be made on a case-by-case basis, taking into account the patient's individual needs and circumstances 2, 3.
• Studies have shown that antithrombotics are often continued until shortly before death, but clinical guidance may support physicians in reconsidering the use of these medications 2.
• Factors such as inability to swallow, bleeding complications, or the dying phase may influence the decision to discontinue antithrombotics 2.
• The risk of bleeding complications with warfarin is a significant concern, particularly in patients with multiple comorbidities or a limited life expectancy 3, 4.
• Low molecular weight heparins (LMWH) may be a suitable alternative to warfarin in some cases, as they do not require monitoring of anticoagulant effect and can be administered once daily 4, 5.

Considerations for Discontinuing Blood Thinners

• The risk of recurrent venous thromboembolism after stopping warfarin is estimated to be 2-10% per year 3.
• The CHADS(2) index can be used to estimate stroke risk in patients with atrial fibrillation, but the decision to discontinue anticoagulation should be individualized 3.
• Patients with cancer may be at higher risk of bleeding due to tumor site, complications of treatment, and concurrent medication use 4.
• The use of LMWH may be preferred in patients with cancer, as it has been shown to prevent more recurrences than vitamin K antagonists 5.

Clinical Guidance and Recommendations

• Clinical practice guidelines recommend first-line treatment with a vitamin K antagonist for at least 3 months in patients without cancer, and continuation of LMWH therapy in patients with cancer 5.
• The choice between LMWH and warfarin should be made on a case-by-case basis, taking into account patient preferences, monitoring constraints, and the risk of bleeding and interactions 5.
• Outpatient treatment with LMWH has been shown to be feasible in many patients, and offers the potential for cost-savings and improvements in health-related quality of life 6.