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

BACKGROUND

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.

AIM: 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.

DESIGN

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

SETTING/

PARTICIPANTS

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.

RESULTS

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.

CONCLUSIONS

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.