Use of Thromboprophylaxis in Palliative Care Patients: A Survey Among Experts in Palliative Care, Oncology, Intensive Care, and Anticoagulation

Abstract

Study-based guidelines on thromboprophylaxis are not available for palliative care patients. The authors asked a panel of academic medical experts in palliative care, oncology, blood coagulation, and intensive care to select a prophylactic regimen out of 5 predefined options for a virtual patient with advanced bronchial cancer in different clinical settings. Primary prophylaxis for venous thromboembolism was withdrawn by all physicians when the patient had a Karnovsky's index of 10 and was described as dying. It was given by 25% of physicians when the patient had a Karnovsky's index of 20 and by 85% when Karnovsky's index 40 was still 40. Similar results were obtained in the situation of secondary prophylaxis of venous thromboembolism and when the patient was described as having a history of chronic atrial fibrillation. This data clearly show that thromboprophylaxis is delivered according to a compound estimate of risks and benefits of such prophylaxis in a specific palliative care situation.

Impact of a Geriatric Nursing Home Palliative Care Service on Unnecessary Medication Prescribing (766)

“…(18) However, evidence-based guidelines are not available for patients in the palliative care setting. (19) Therefore, the decision to continue or discontinue thromboprophylaxis is often made based on an estimate of the risks and benefits in a specific patient. (19) For example, a low molecular weight heparin may be continued in a cancer patient who is bedridden, but discontinued in a patient with pulmonary disease who is still able to ambulate.…”

Maladie thromboembolique veineuse et cancer

“…Les patients cancéreux soumis à une chirurgie présentent un risque accru de thrombose postopératoire comparativement aux patients non cancéreux [17]. Des essais cliniques ont démontré l'efficacité des HNF dans la prévention de la MTEV chez les patients soumis à une chirurgie lourde.…”

“…L'analyse des huit études ayant inclus des patients opérés pour cancer n'a montré aucune différence entre le traitement par HNF et HBPM en termes de MTEV, de mortalité ou de saignement majeur. En raison de la commodité des HBPM par rapport aux autres anticoagulants, le traitement par HBPM est devenu la référence en prophylaxie de la MTEV du patient opéré pour cancer [17].…”

Finding the evidence for thromboprophylaxis in palliative care: first let us agree on the question

“…Despite a reported prevalence of DVT hospice patients of 50%, palliative care physicians report seeing significantly less and it would be hard to justify thromboprophylaxis for those in whom VTE was a rare occurrence. 7,13 Assuming the prevalence data to be correct, this suggests either or both of two possible explanations. One could be that only a small proportion of thromboses produce symptoms and a subsequent diagnosis; indeed the prevalence study screened the whole of the lower limb and much of the venous flow obstruction detected may have been due to small calf vein thromboses.…”