If you are caring for someone who is terminally ill, you may have heard of anticoagulants. Anticoagulants are medicines that prevent blood clots from forming or growing. They are often prescribed to people who have conditions such as atrial fibrillation, deep vein thrombosis, pulmonary embolism, or heart valve problems. These conditions can increase the risk of stroke, heart attack, or other serious complications.
However, anticoagulants are not without risks or challenges. They can cause bleeding, which can be dangerous or even life-threatening. They can also interact with other medicines, foods, or supplements. They require regular blood tests and dose adjustments. They can be costly and inconvenient. They can affect the quality of life and comfort of the person taking them.
That is why it is important to review anticoagulants regularly and consider whether they are still needed or appropriate for the person who is terminally ill. This process is called deprescribing. Deprescribing means reducing or stopping medicines that are no longer beneficial or may cause harm. Deprescribing can help to avoid unnecessary side effects, simplify the medication regimen, reduce the burden of care, and focus on the person’s goals and preferences.
In this article, we will explain why anticoagulants should be reviewed regularly for deprescribing for those who are terminally ill. We will discuss the risks and benefits of anticoagulants in end-of-life care. We will outline the factors to consider when making decisions about anticoagulant deprescribing. We will suggest some strategies and resources to support anticoagulant deprescribing. We hope this article will help you make informed and compassionate choices about anticoagulant therapy for your loved one.
Risks and Benefits of Anticoagulants in the End-of-Life Care
Anticoagulants can be helpful for some people who are terminally ill. They can prevent blood clots that can cause serious problems, such as stroke or heart attack. They can also reduce the symptoms and complications of some conditions, such as pain, swelling, or shortness of breath.
However, anticoagulants are not always effective or safe for terminally ill people. The evidence on the benefits and risks of anticoagulants in end-of-life care is limited and conflicting. Some studies have shown that anticoagulants can improve survival or quality of life for some patients with a life-limiting disease. Other studies have found no benefit or harm from anticoagulants in this population.
Anticoagulants can also cause many problems and challenges for people who are terminally ill and their caregivers. One of the most severe risks of anticoagulants is bleeding. Bleeding can occur in different body parts, such as the stomach, the brain, or the skin. Bleeding can be hard to stop and can lead to anemia, infection, or death. Bleeding can also affect the comfort and dignity of the person who is bleeding and the emotional well-being of the caregiver who is witnessing it.
Anticoagulants can also interact with other medicines, foods, or supplements that the person who is terminally ill may be taking. These interactions can increase or decrease the effect of anticoagulants, making them either too strong or too weak. This can increase the risk of bleeding or clotting. Therefore, anticoagulants require regular blood tests and dose adjustments to ensure they work properly. This can be stressful and inconvenient for the person who is terminally ill and the caregiver who has to arrange and attend the appointments.
The main risk of anticoagulants on hospice is internal bleeding caused by falls which are extremely common in the last few months of life. Often the internal bleeding is not caught timely, and this can result in dying faster than the terminally ill loved one or family anticipated.
Anticoagulants can also be challenging to take or manage for people who are terminally ill and their caregivers. Anticoagulants come in different forms, such as pills, injections, or infusions. Some anticoagulants have to be taken at specific times or with specific foods. Some anticoagulants have to be stored or disposed of in a certain way. Some anticoagulants have to be monitored by a device or a nurse. These factors can make anticoagulants costly and complicated to use. They can also affect the adherence or compliance of the person taking them. Adherence means taking the medicine as prescribed. Poor adherence can reduce the effectiveness or safety of anticoagulants.
There is also a lot of uncertainty and variability in the clinical practice and guidelines regarding anticoagulant use in end-of-life care. Different doctors may have different opinions or recommendations about anticoagulants for terminally ill people. Different guidelines may have different criteria or evidence for anticoagulant use in this population. Countries or regions may have different policies or regulations for anticoagulant use in this setting. This can make it hard to know what is the best or most appropriate option for the terminally ill person.
Factors to Consider When Making Decisions about Anticoagulant Deprescribing
Deciding whether to continue or stop anticoagulants for a terminally ill person is not easy. There is no one-size-fits-all answer. Each person’s situation is unique and may change over time. That is why it is crucial to make individualized and patient-centered decisions. This means considering the person’s medical condition, personal values, and wishes, as well as the best available evidence and expert advice.
There are several factors to consider when making decisions about anticoagulant deprescribing. Here are some of the key ones:
The indication, duration, type, and dose of anticoagulant. Anticoagulants are prescribed for different reasons, such as preventing stroke, treating blood clots, or protecting artificial heart valves. Some anticoagulants have to be taken for a short time, while others have to be taken for a long time or indefinitely. Some anticoagulants are more potent or risky than others. Some anticoagulants have more alternatives or options than others. These factors can affect the benefits and harms of anticoagulants and the feasibility and consequences of deprescribing them.
The patient’s prognosis, preferences, and goals of care. The prognosis is the expected outcome or course of the disease. The preferences are the person’s choices or opinions about their care. The goals of care are the person’s hopes or priorities for their quality of life. These factors can help to determine the person’s risk of bleeding or clotting, as well as their values and expectations of anticoagulants. For example, a person who has a short life expectancy, a high bleeding risk, and a preference for comfort may benefit more from stopping anticoagulants than a person who has a longer life expectancy, a low bleeding risk, and a preference for prevention.
The availability of palliative interventions. Palliative interventions are treatments or services that aim to relieve symptoms, improve comfort, and enhance quality of life. They can include medicines, devices, procedures, or counseling. They can also address physical, emotional, social, or spiritual needs. Palliative interventions can help to manage the symptoms and complications of anticoagulants, such as bleeding, pain, or anxiety. They can also help to prevent or treat conditions that require anticoagulants, such as blood clots, stroke, or heart failure.
To illustrate how these factors can be applied in practice, let us look at some examples or case vignettes:
Case 1: Mary is a 78-year-old woman who has advanced lung cancer and a history of atrial fibrillation. She has been taking warfarin, an oral anticoagulant, for the past ten years to prevent stroke. She has a life expectancy of less than six months. She has frequent nosebleeds and bruises, which bother her and her family. She has difficulty swallowing and taking pills. She wants to spend her remaining time at home with her loved ones. She does not want to go to the hospital or have any invasive procedures. She values comfort and dignity over prolonging her life. In this case, deprescribing warfarin may be appropriate and beneficial for Mary. Warfarin has a low chance of preventing stroke in her situation but a high chance of causing bleeding and distress. Warfarin also requires regular blood tests and dose adjustments, which can be burdensome and inconvenient for Mary and her family. Stopping warfarin can simplify her medication regimen, reduce her bleeding risk, and improve her comfort and quality of life. Palliative interventions, such as painkillers, oxygen, or sedatives, can help manage her symptoms and support her goals of care.
Case 2: John is a 65-year-old man who has end-stage heart failure and a mechanical heart valve. He has been taking heparin, an injectable anticoagulant, for the past three months to protect his heart valve. He has a life expectancy of less than three months. He has no signs of bleeding or clotting. He has a good appetite and can take oral medicines. He wants to try any treatment that can improve his heart function or extend his life. He is willing to accept the risks and inconveniences of anticoagulants. He values survival and function over comfort and quality of life. In this case, deprescribing heparin may not be appropriate or beneficial for John. Heparin has a high chance of preventing clotting and infection in the heart valve but a low chance of causing bleeding or harm. Heparin also has few alternatives or options for his condition. Stopping heparin can increase his risk of serious complications, such as stroke, heart attack, or valve failure. Palliative interventions, such as diuretics, pacemakers, or surgery, can help to treat his heart failure and optimize his anticoagulant therapy.
Case 3: Lisa is a 52-year-old woman who has metastatic breast cancer and a history of deep vein thrombosis. She has been taking rivaroxaban, an oral anticoagulant, for the past six months to treat her blood clot. She has a life expectancy of less than 12 months. She has mild bleeding from her gums and nose, which do not bother her much. She has a poor appetite and often vomits or forgets to take her pills. She wants to stop any treatment that is not helping her cancer or making her feel worse. She is not afraid of dying, but she wants to die peacefully and painlessly. She values comfort and quality of life over survival and function. In this case, deprescribing rivaroxaban may be appropriate and beneficial for Lisa. Rivaroxaban has a low chance of treating her blood clot, which may have resolved or become chronic. Rivaroxaban also has a high chance of causing bleeding or nausea, which can affect her comfort and quality of life. Rivaroxaban also has alternatives or options, such as switching to a lower dose, a different anticoagulant, or a non-pharmacological intervention, such as compression stockings or elevation. Stopping rivaroxaban can reduce her bleeding risk, improve her appetite, and simplify her medication regimen. Palliative interventions, such as antiemetics, opioids, or chemotherapy, can help manage her symptoms and support her goals of care.
These cases show that anticoagulant deprescribing is not a one-time or a yes-or-no decision. It is a dynamic and ongoing process that requires regular review and reassessment. It also requires collaboration and communication among the person who is terminally ill, the caregiver, and the health care team. It is important to have honest and open discussions about the pros and cons of anticoagulants, the person’s values and preferences, and the available options and alternatives. By doing so, we can ensure that anticoagulant therapy is aligned with the person’s best interests and wishes.
Strategies and Resources to Support Anticoagulant Deprescribing
You do not have to do anticoagulant deprescribing alone or without help. There are many ways to make anticoagulant deprescribing easier and safer for you and your loved one. Here are some tips and suggestions:
Review anticoagulant therapy regularly and systematically. Anticoagulant therapy should be reviewed at least every 3 to 6 months or whenever there is a change in the person’s condition, preferences, or goals of care. You can use a calendar, a reminder, or a checklist to keep track of the review dates and the factors to consider. You can also ask your healthcare team to schedule regular appointments or follow-ups to review anticoagulant therapy.
Use a structured approach to anticoagulant deprescribing. Anticoagulant deprescribing should follow a clear and logical process, such as the one proposed by the Primary Health Tasmania guide to deprescribing anticoagulants. This process involves four steps: 1) identify the person who may benefit from anticoagulant deprescribing, 2) assess the person’s risk of bleeding and clotting, 3) discuss the person’s values and preferences, and 4) decide and implement the anticoagulant deprescribing plan. You can use this process as a guide or a template to make anticoagulant deprescribing more consistent and comprehensive.
Involve a multidisciplinary team in anticoagulant deprescribing. One person or one doctor should not do anticoagulant deprescribing. It should involve a team of healthcare professionals with different skills and expertise, such as a primary care provider, a cardiologist, a hematologist, a pharmacist, a nurse, a social worker, or a palliative care specialist. You can ask your healthcare team to coordinate and collaborate to provide the best possible care and advice for anticoagulant deprescribing. You can also seek a second opinion or a referral if you are unsure or unhappy with the current anticoagulant deprescribing plan.
Communicate effectively with the patient and family about anticoagulant deprescribing. Anticoagulant deprescribing should be based on the person’s informed consent and shared decision-making. This means that the person and the family should be fully aware and involved in the anticoagulant deprescribing process. You can ask your healthcare team to explain the benefits and risks of anticoagulants, the options and alternatives for anticoagulant deprescribing, and the expected outcomes and consequences of anticoagulant deprescribing. You can also ask questions, express concerns, or share opinions about anticoagulant deprescribing. Use simple, clear language, avoid medical jargon, and repeat or summarize key points to ensure understanding and agreement.
Document the rationale and plan for anticoagulant deprescribing. Anticoagulant deprescribing should be recorded and communicated clearly and accurately. You can ask your health care team to write down the reasons and the details of the anticoagulant deprescribing plan, such as the indication, duration, type, and dose of anticoagulant, the person’s prognosis, preferences, and goals of care, and the availability of palliative interventions. You can also ask your healthcare team to share this information with other healthcare providers involved in the person’s care, such as the hospice, the pharmacy, or the emergency department. You can keep a copy of this information for your reference and use.
You can access reliable and relevant resources for more guidance and information on anticoagulant deprescribing. For example, you can check out the NHPCO Hospice Medication Deprescribing Toolkit, which provides practical tools and tips for hospice providers and caregivers to deprescribe medications, including anticoagulants, for patients who are terminally ill. You can also visit the Primary Health Tasmania guide to deprescribing anticoagulants, which offers a comprehensive and evidence-based approach to anticoagulant deprescribing for patients who are terminally ill. These resources can help you to make anticoagulant deprescribing more effective and appropriate for your loved one.
Conclusion
Anticoagulants are medicines that prevent blood clots. They can be helpful for some people who are terminally ill, but they can also cause problems and challenges for them and their caregivers. That is why anticoagulants should be reviewed regularly and carefully for deprescribing. Deprescribing means reducing or stopping medicines that are no longer beneficial or may cause harm. Deprescribing can help to avoid unnecessary side effects, simplify the medication regimen, reduce the burden of care, and focus on the person’s goals and preferences.
However, anticoagulant deprescribing is not a simple decision. It depends on many factors, such as the person’s medical condition, personal values, and wishes, as well as the best available evidence and expert advice. It also requires collaboration and communication among the terminally ill person, the caregiver, and the health care team. It also requires support and guidance from reliable and relevant resources and tools.
We hope this article has helped you understand why anticoagulant deprescribing is essential and how to do it safely and appropriately for your loved one. We also want to acknowledge that anticoagulant deprescribing is not a perfect or complete solution. There are still many limitations and gaps in the current evidence and practice. There is still a lot of uncertainty and variability in the outcomes and consequences of anticoagulant deprescribing. There is still a need for more research and education on anticoagulant deprescribing in end-of-life care. We encourage you to stay updated and informed on this topic and share your experiences and feedback with others. Together, we can make anticoagulant deprescribing more effective and compassionate for those who are terminally ill.
