Problems of anticoagulation within a palliative care setting: an audit of hospice patients taking warfarin

Patients with cancer have an increased risk of venous thromboembolism (VTE) compared with a healthy population. The risk increases as cancer progresses and this is reflected in the number of hospice inpatients with VTE. These patients also have an increased risk of bleeding due to tumour site, complications of treatment, progressive liver involvement and concurrent medication such as nonsteroidal anti-inflammatory agents. Therefore anticoagulation of cancer patients with VTE is fraught with difficulty. This audit of hospice inpatients taking warfarin showed a high incidence of bleeding which was possibly improved with very stringent international normalized ratio (INR) monitoring: 15 episodes in 17 patients improved to 11 episodes in 18 patients. Patient numbers were small and the two groups heterogeneous, thus formal statistical analysis could not be applied. One patient in each group continued to thrombose despite overanticoagulation with warfarin. Monitoring of INR increased from an average of once every six days to once every 2.4 days. Such frequent monitoring is likely to be highly impractical in many hospice and general practice settings. Control of warfarin as measured by average percentage of INRs in, above or below the therapeutic range if anything appeared to be worse in the second group. Any bleeding in these patients was distressing. As a result of this audit, practice in Huntershill Marie Curie Centre has changed. Low molecular weight heparins are proven to be efficacious in the treatment of VTE, are renally excreted and therefore do not interact with many commonly used concurrent medications. They can be administered once daily and do not need monitoring of anticoagulant effect. Thus they will be used in patients for whom anticoagulation is indicated during a six-month period, after which practice will be again reviewed.