Antithrombotic therapy at the end-of-life—continue or stop?
Gerard Gurumurthy 1,2; Naisthika Kumar 1; Lianna Reynolds 3; Biddy Bassam 4; Marc Carrier 5; Simon Noble 6; Alok A. Khorana 7,8; Jecko Thachil 9.
1) The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust, King’s Lynn, UK
2) Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
3) Department of Haematology, Manchester University NHS Foundation Trust, Manchester, UK
4) Department of Palliative Care, The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust, King’s Lynn, UK
5) Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
6) Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
7) Cleveland Clinic Taussig Cancer Center, Department of Hematology Oncology, Ohio, USA
8) Case Comprehensive Cancer Center, Cleveland, Ohio, USA
9) Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
Abstract
Antithrombotics at the end-of-life pose a clinical challenge where indication-specific time-to-benefit, bleeding risk, and patient priorities must be reconciled over short prognostic horizons. In this review of the literature, we found that a substantial number of individuals remain on anticoagulants and antiplatelet therapy till the point of death. Prospective ultrasound surveillance studies show a high baseline incidence of asymptomatic proximal deep vein thrombosis at admission but a low short-term incidence of new events during typical hospice stays. Additionally, large home palliative cohorts suggest that deprescribing anticoagulants does not increase clinical thrombosis and may reduce bleeding and facilitate home death. Bleeding on antithrombotics is also common in the last months of life. Clinically relevant bleeding occurs in up to 1 in 10, and fatal hemorrhage has been reported. Cancer-specific factors, chronic or end-stage kidney disease, cytopenias, and drug interactions heighten the risks. Where anticoagulation is pursued, the choice of agent and route should reflect swallowing, nutrition, renal or hepatic function, monitoring capacity, and reversal intent. Structured, shared decision making and proactive deprescribing when benefits no longer outweigh harms are central.