Discussing the deprescribing of an anticoagulant with patients and/or caregivers can be daunting. Helping them understand the risks of continuing such a medication can be a difficult task, especially if they have been told of certain conditions that can increase the risk of clot formation. Thankfully, there are validated tools that can help bolster your stance when attempting to help a patient understand the benefits of deprescribing.

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The Mayo Clinic Anticoagulation Decision Aid is a powerful tool designed to assist clinicians and patients in making informed choices about anticoagulation therapy, particularly when the benefits and risks must be carefully evaluated. In hospice care, where the focus is on comfort and quality of life, this tool plays a crucial role in guiding decisions that align with the patient’s overall goals while helping to quantify the risk of continuation.

The Decision Aid integrates risk assessments with patient values and provides clear communication strategies, helping hospice nurses and administrators ensure that decisions about continuing or discontinuing anticoagulation therapy are made thoughtfully and with the patient's best interests in mind. This Pharmacist Corner was created to serve as a resource to hospice administrators and clinicians by providing guidance on the following:

Pharmacist Corner Objectives

1. Equip hospice nurses and administrators with the knowledge and tools necessary to effectively utilize the Mayo Clinic Anticoagulation Decision Aid, ensuring clinical decisions align with patient-centered goals and safety.
2. Enable clinicians to identify hospice patients for whom the risks of continuing anticoagulation therapy, particularly the increased risk of bleeding, outweigh the potential benefits, thereby supporting informed decision-making that prioritizes patient comfort and quality of life.
3. Ensure practice standardization and clear communication of decisions made using the Anticoagulation Decision Aid, integrating these decisions into the patient’s overall hospice care plan while maintaining consistent and ethical care across the multidisciplinary team.

 

Understanding When to use the Decision Aid 

In hospice settings, determining when to utilize the Mayo Clinic Anticoagulation Decision Aid is essential. This tool is particularly useful for patients who are either currently on anticoagulation therapy or being considered for it due to conditions like atrial fibrillation, deep vein thrombosis, or pulmonary embolism.

However, in the context of hospice care, the decision to continue anticoagulation therapy must be carefully weighed, as the risks—most notably the increased risk of bleeding—often outweigh the potential benefits.

The Decision Aid helps identify patients for whom the continuation of anticoagulation therapy poses a significant risk of bleeding, which may lead to a decline in quality of life or cause distressing symptoms. By using the Decision Aid, healthcare providers can assess whether the reduction in stroke risk justifies the potential for severe bleeding, considering the patient’s prognosis and overall care goals.

 

Understanding How to use the Decision Aid 

The tool can be accessed at: https://anticoagulationdecisionaid.mayoclinic.org/

After clicking the “Let’s get started” button, the user is taken to the following screen:

• Due to the anticipated life expectancy of six months or less, please be sure to toggle the risk period to 1 Year Risk, found in the upper left-hand corner.
• After filling out the initial demographic and co-morbidity information, the risk of stroke is calculated, and the user is given the option to compare risk with and without anticoagulation.

However, this information only tells a fraction of the story. To determine the risk of bleeding, click the ISSUES tab. Here, you can select bleeding from a column on the right and fill in the specific patient information to determine the risk of bleeding.

 

Navigating the Decision Aid with Patients and Families 

Before engaging with the Decision Aid, it’s important for hospice nurses to review the patient’s medical history, current treatment plan, and overall care objectives. This preparation helps frame the conversation with the patient and their family in a way that is both empathetic and informative.

The Decision Aid serves as a guide to discussing the risks and benefits of continuing or discontinuing anticoagulation therapy. It allows healthcare providers to clearly explain how, in some cases, the risk of serious bleeding associated with continued anticoagulation might outweigh the benefit of stroke prevention.

Through this process, nurses can help patients and families understand the potential outcomes, enabling them to make decisions that align with their values and priorities. Open communication is key, and the Decision Aid encourages questions and discussions about what matters most to the patient, whether it’s extending life or maximizing comfort in their final days.

 

Best Practices and Considerations

In hospice care, the patient’s comfort and personal goals should always guide decision-making. The Mayo Clinic Anticoagulation Decision Aid is a supportive tool that helps align medical decisions with what matters most to the patient, particularly in evaluating the risks of continued anticoagulation therapy.

In many cases, the risk of bleeding may far outweigh the potential benefit of preventing a stroke, especially when considering the patient’s limited life expectancy and desire for comfort.

Hospice nurses and administrators must carefully balance these factors, ensuring that the patient’s and family’s input is central to any decision. Ethical considerations, such as differing opinions among the patient, family, and care team, should be approached with sensitivity. In more complex situations, an ethics consultation may be warranted.

Ultimately, the use of the Anticoagulation Decision Aid should always respect the patient’s autonomy and ensure that informed consent is obtained, upholding the principles of compassionate, patient-centered care in the hospice setting.

 

References

1. Anticoagulationdecisionaid.mayoclinic.org. Accessed 7/29/2024
2. Holmes HM, Bain KT, Zalpour A, Luo R, Bruera E, Goodwin JS. Predictors of anticoagulation in hospice patients with lung cancer. Cancer. 2010 Oct 15;116(20):4817-24.
3. Noble S. Venous thromboembolism and palliative care. Clin Med (Lond). 2019 Jul;19(4):315-318.
4. Sera L, McPherson ML, Holmes HM. Commonly prescribed medications in a population of hospice patients. Am J Hosp Palliat Care. 2014;31(2):126-31.

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