Facing Death: A Journey Through Pictures, Prose, Poetry, and Plainsong (509)

Abstract

Objectives 1. Discuss indications for anticoagulation therapy in the hospice and palliative care population. 2. Identify risks and benefits associated with anticoagulation therapy in the hospice and palliative care population. 3. Identify drug-drug and drug-herb interactions for hospice and palliative care patients undergoing anticoagulation therapy. Anticoagulation therapy is common among hospice and palliative care patients, many of them requiring lifelong treatment for conditions such as atrial fibrillation or recurrent pulmonary embolism (PE). In addition, these patients have an increased risk of venous thromboembolism (VTE) compared with a healthy population, due to overall debility, immobility, and coagulopathies (especially in cancer patients). Untreated VTE can lead to increased pain infection, loss of limb, and, more seriously, fatal PE. It is important to carefully weigh the risks and benefits of anticoagulation therapy in order to preserve quality of life, as these patients have an increased risk of bleeding inherent in their disease process (ie, liver failure, renal impairment, tumor extension). Complications of treatment and concurrent palliative medications, such as steroids, as well as nonsteroidal anti-inflammatory agents, also increase their risk. Indications for anticoagulation therapy (including atrial fibrillation, myocardial infarction, heart valve replacement, PE, and VTE) and length of therapy in a healthy populationwill be compared and contrasted to the indications for and appropriateness of therapy in the hospice and palliative care population. The incidence, clinical presentation, and management of VTE in cancer patients will be explored. Low molecular weight, heparins, oral anticoagulation therapy (OAT), antiplatelet drugs, and the use of aspirin will be presented. Warfarin will be highlighted with thorough examination of indications for OAT, drug-drug and drugherb interactions, risks, andbenefits,monitoring, and treatment of complications such as bleeding. In addition, we will describe indications for Greenfield filter placement to prevent PE. Current literature and research in anticoagulation among this patient populationwill behighlighted and principles of safe clinical management of patients undergoing anticoagulant therapies will be outlined. Case study presentations will aid in encouraging discussion regarding challenges faced in the clinical implications of anticoagulation therapy in this patient population.