Saturday, February 4, 2006

Low Molecular Weight Heparin in Palliative Care Patients

E-published by BMJ this week is an article (full text pdf) discussing the attitudes of 28 inpatients with advanced, incurable cancer admitted for spinal cord compression treatment or symptom control treatment. The authors used qualitative analysis and semi-structured interviews to see if patients felt any benefit from receiving low molecular weight heparin (LWMH) for DVT prophylaxis. All patients were ECOG 4 and most had good insight into the incurable nature of their cancer. They were all already on LMWH when interviewed and they all knew death could result from a DVT->PE. Most explained they could not see why they should not have it and saw it as just a routine part of their care. A few of my favorite quotes from a patient is this one (it helps to say with a British accent):

"...there’s nothing to it, you don’t feel it, and you’ve got to have ‘nasties’ to have ‘nices’ haven’t you?”

"I’d like to do a few things before I pop my clogs. I’ve got enough to worry about without having to worry about deep vein thrombosis.”

'Pop my clogs'...I gotta remember that one.

Most also expressed disgust at compression stockings, and would rather have the injections. I am glad the authors did this study as it does rock the boat of common wisdom in the palliative care community, namely one of always decreasing medication burden and limiting costs. Burden is a personal perception and some patients do see positives in continuing their statins, coumadin and LMWH. They did not extrapolate that every bed bound palliative/hospice patient at home should have LMWH, which would seem like a natural extension of the logic that all patients (not just inpatients) with advanced cancer have thromboembolism.

The major take home point I gleaned from this article is that (as always) it does not pay to assume what the patient sees as a burden, but rather to ask them for their insight.

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