Anticoagulation in the Hospice Setting

• Published in: BMJ supportive & palliative care Vol. 2; no. Suppl 1; p. A63
• Main Authors: Steel, Kim, Leith, Marion, Brooks, Lindy, Butcher, Lowrie, Hill, Jenny, Waterman, David, Lomax, Philip
• Format: Journal Article
• Language: English
• Published: London British Medical Journal Publishing Group 01.03.2012; BMJ Publishing Group LTD
• ISSN: 2045-435X; 2045-4368
• DOI: 10.1136/bmjspcare-2012-000196.183

Background In March 2007, NPSA issued a safety alert regarding the oral anticoagulant warfarin. In palliative care the focus of care is on quality of life and the burdens and benefits of medications require consideration. Following the NPSA alert St Ann's Hospice undertook an audit to examine its practice. The first audit was undertaken from February 2008–August 2008; this audit was then extended to August 2008–August 2010. Method Patients were identified through an INR history obtained from the local laboratories. A retrospective case note audit was undertaken. The standards incorporated in the NPSA audit were used. These consider four key areas: (1) admission history, (2) dosing warfarin, (3) monitoring and prescribing and (4) safe discharge of patients Results Twenty-five cases were considered. The majority were anticoagulated for either VTE (14/25) or atrial fibrillation (8/25). 7/25 patients suffered adverse events of which bleeding accounted for 5/25. 16/25 had their warfarin stopped during their admission (2 at the point of admission); 6/16 were commenced on low molecular weight heparin. 47% of INRs were in the therapeutic range. When a dose was altered INRs were checked on average 4-5 days postchange. 8 patients were discharged from the hospice on warfarin, 2/8 had INRs within the therapeutic range and poor communication of follow up, target INR and last INR to the community was found. Conclusion In palliative care the benefits and burdens of all medicines needs to be considered. The benefits of anticoagulation in patients with advanced disease are unknown but this audit shows there can be significant risks. To minimise these risks requires a robust approach. In response to this audit the hospice instituted a compulsory e-learning for prescribers, a new oral anticoagulant policy and, due to the infrequency of patients on warfarin, a pharmacy system to highlight patients.