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Blog articles are provided as informational purposes only and are not intended to constitute medical advice. Medication protocols are subject to patient’s medical provider’s authorization.

 

Hospice goals of care focus on optimizing comfort and quality of life, rather than treatment and prevention. Anticoagulation therapy and monitoring are not aligned with comfort and quality of life, and can cause harm from bleeding. Anticoagulation does not provide comfort or control symptoms. For these reasons, anticoagulation is frequently discontinued.

There is a single, serious reason why anticoagulants are commonly discontinued in hospice: potentially serious (or sometimes deadly) bleeding.

 However, taking an anticoagulant does not mean you are going to bleed. Taking an anticoagulant increases your bleed risk. And other factors can additionally increase your risk of bleeding while taking an anticoagulant. The more bleeding risk factors a patient has, the more reasons why an anticoagulant should be stopped. Typically, hospice patients have many risk factors for bleeding.

 Here is an overview of risk factors for bleeding aside from taking an anticoagulant (not all-inclusive):

 

Another reason anticoagulants are stopped is because the patient no longer has any reason to be taking one. For example, for stroke prevention in patients with atrial fibrillation, patients without symptoms under the age of 65 and no other stroke risk factors should not be taking anticoagulants. Also, anticoagulants should be stopped after 3-6 months if a clot in the leg (deep vein thrombosis) or lung (pulmonary embolus) was a first event and caused by a temporary risk factor such as trauma, surgery, or use of hormonal contraception. Sometimes anticoagulants are unintentionally continued when they should have been stopped.

 Finally, one of the oldest and most common anticoagulants, warfarin, requires INR monitoring and a consistent diet, which can be cumbersome, and potentially causes more anxiety in end-of-life due to the need to keep INR levels within range.

 A quick note about aspirin – this is an antiplatelet, which has a different mechanism from anticoagulants, but nonetheless increases bleed risk, also. Many of the same concepts above also apply to aspirin. Aspirin, however, does not require INR monitoring and does not participate in as many drug interactions. There is no reversal agent, but its duration of action is generally shorter than anticoagulants. For these reasons, aspirin may be a more attractive alternative. Unfortunately, aspirin is not very effective for preventing or treating all of the same events as anticoagulants. Thus, if aspirin is used to replace anticoagulants, it may simply increase bleed risk and pill burden without any meaningful reduction of the risk of clotting events. Generally, aspirin is recommended to be discontinued in hospice.

 It is best to discuss your concerns about stopping clot-prevention therapy with your hospice team. They can help answer any questions you might have, and help weigh the risks and benefits of continuation or discontinuation. Ultimately, they can help you feel more comfortable about your decision either way.

 

 References:

  1. Li L, Geraghty OC, Mehta Z, Rothwell PM. Oxford Vascular Study. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Lancet. 2017;390(10093):490-499.
  2. Lip GYH, et al. Antithrombotic therapy for atrial fibrillation. CHEST. 2018;154(5):1121 – 1201.
  3. Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST. 2012;141(2 Suppl):e419S.

 

 

 

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