Decision-making regarding anticoagulant therapy in the last phase of life: In-depth interview study with healthcare professionals (the OPTIMA trial)

TL;DR

Healthcare professionals struggle with deciding whether to continue or stop anticoagulant therapy for patients nearing the end of life due to uncertainty and lack of evidence.

Contribution

The study provides new insights into the challenges and decision-making processes of healthcare professionals regarding anticoagulant therapy in end-of-life care.

Findings

Healthcare professionals find decision-making difficult due to lack of evidence on risks and benefits of continuing or stopping anticoagulants.

Uncertainty leads to defensive and reactive decisions, often triggered by events like bleeding or patient preferences.

Decision-making is influenced by a range of factors including comorbidities, patient characteristics, and prognostic uncertainty.

Abstract

Many patients in the last phase of life use anticoagulants. There is little evidence on the benefits and risks of (dis)continuation of anticoagulant therapy in this phase, leaving healthcare professionals with a complex clinical dilemma.

To gain an in-depth understanding of the experiences, perspectives, and preferences of healthcare professionals regarding decision-making about anticoagulant therapy in the last phase of life.

Semi-structured in-depth interviews were conducted and analyzed using a thematic content analysis.

This study was performed in the Dutch Federation of Anticoagulation Clinics, two hospitals, two hospices, and two palliative home care groups in the Netherlands. Thirty-two healthcare professionals regularly involved in care for patients in the last phase of life were interviewed.

Healthcare professionals experienced decision-making regarding anticoagulant therapy in the last phase of life as difficult and multifactorial, due to a lack of knowledge on the incidence of events after (dis)continuing therapy, the uncertain risk trade-off between events with major consequences, the variety of indications for therapy, the variety of comorbidities and patient characteristics, and prognostic uncertainty. As a result, healthcare professionals act defensively when considering discontinuation, due to concerns about being held accountable for potential thrombotic events. Uncertainty in decision-making results in reactive decision-making in response to triggers such as active bleeding, low performance score, recognition of the dying phase, and patient’s preference.

This study highlighted the complexity of decision-making regarding anticoagulant therapy in the last phase of life. This results, in practice, in reactive instead of proactive decision-making.

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