Thromboseprophylaxe bei Palliativpatienten in Deutschland

Abstract

Introduction: There is just few data available regarding the prophylaxis of thromboembolic disease in patients under palliative care. The decision for an anticoagulant treatment is complex and needs to be in balance between medical and patient-centered aspects. The coherence between malignant disease and venous thromboembolism (VTE) is well known. Opposed to internal medicine or oncology, in 2009 there were no clear treatment standards for patients in palliative care - and for Germany there were no information existing concerning the distribution of VTE-prophylaxis in palliative patients, the choice of anticoagulant drugs or the reasons to start or terminate an anticoagulant treatment. This survey had the purpose to overview the state of thromboprophylaxis in Germany. Methods and results: We developed a modular VTE questionnaire as a part of the German Hospice and Palliative Care Evaluation (HOPE) to get a first overview of the actual practise of anticoagulant treatment and underlying decision making in PC and hospice settings. Of 334 invited institutions (188 PC units, 146 hospices), 9 PC units and 1 hospice completed HOPE basis assessments and VTE questionnaires for 233 (of 2293) patients. The results show that 121 of the 233 documented patients received any kind of anticoagulant therapy (51,9%); in 37 patients, anticoagulation was newly initiated. The rate of anticoagulation was much higher in the PC units than in the hospice. Most frequently the low molecular weight heparins (LMWH) were used (93 patients, 68,9%), followed by aspirin (18 patients, 13,3%). The leading indication for anticoagulant therapy was primary prophylaxis (68 patients), followed by secondary prophylaxis after a previous VTE (24 patients). In only 4 patients, a new VTE was reported within the survey period (2 of those received full anticoagulant dose LMWH, none got a coumarin derivative). In 3 patients, anticoagulation therapy was assessed to contribute to pain control; bleeding (epistaxis) was reported in 1 patient. Although malignant disease was documented in 89,3% of the patients it had just been specified as a thromboembolic risk factor in 79% followed by immobility (56,2%). General risk factors, as smoking, infections or a myocardial failure, had not been reported in any patient. For 48 patients (20,6%), an internal standard operating procedure existed at the respective institution. Discussion: This survey gives a first overview on the use of anticoagulant therapies in PC in Germany. The results show the divergent situation that on the one hand primary prophylaxis was the major indication although no official guidelines existed at the time of the survey and on the other hand it seems as if venous thromboembolism is still underestimated in PC. The amount of intern standards for the prophylaxis of VTE was higher than expected. The anticoagulation concepts relied on LMWH and were rarely modified during the observational period. Taken together venous thromboembolism is an important aspect in the care of palliative patients especially because of the increasingly broader spectrum of therapeutic and prophylactic measures in PC. This study is limited by low figures, and contributing institutions have not been selected by random.