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Anticoagulation at the End of LifeTime for a Rational Framework

JAMA Intern Med. Published online May 10, 2021. doi:10.1001/jamainternmed.2021.1804

Are there patients for whom common sense suggests that the downsides of anticoagulation clearly outweigh the benefits? This is the premise suggested by Ouellet et al1 in this issue of JAMA Internal Medicine. In a decedent cohort of older nursing home residents with advanced dementia and atrial fibrillation, they found that one-third remained on therapeutic anticoagulation during the last 6 months of life. Those who had longer duration of nursing home residence or had markers of more severe dementia were more likely to remain on anticoagulation at the end of life.

The risks and benefits of therapeutic anticoagulation in severe dementia and other life-limiting illnesses have not been well studied. In real-world practice, many patients with severe dementia have limited life expectancy and would choose to focus on quality of life. However, avoiding the potential morbidity of stroke may still be within patients’ and families’ goals at the end of life. Others might argue that for those with limited prognosis, drugs for chronic conditions that do not directly target symptoms, such as dyspnea or pain, increase the risk of adverse events without clear benefit.

These findings highlight the lack of a rational strategy for managing anticoagulation in those with limited life expectancy owing to age or illness. Guidelines suggest periodic reevaluation of anticoagulation to reassess stroke and bleeding risks.2 However, there is a dearth of information on how to implement this because seriously ill, frail patients are understudied in both clinical trials and observational research.

Traditionally, the net clinical benefit of anticoagulation is driven by difference between ischemic stroke reduction and intracranial hemorrhage risk.2 A more patient-centered framework would expand this narrow definition of net clinical benefit. Consideration of the competing risk of death from other causes, such as dementia or cancer, decreases the net clinical benefit of anticoagulation and should be incorporated.3 Clinicians already report considering geriatric syndromes such as disability and cognitive impairment during risk assessment for anticoagulation, so these should be formally integrated, given their impact on quality of life.4 The bleeding events we factor in should not be limited to intracranial hemorrhage because extracranial and so-called nuisance bleeding are common and highly bothersome to patients and can diminish quality of life and well-being. Studies of decision-making aids and dose reduction or deprescribing clinical trials using this expanded net benefit definition should be performed in this population.

Balancing the tradeoffs required for anticoagulation will remain challenging in patients with limited life expectancy. Our goal should be a framework that combines quantitative information with patients’ values to guide clinicians and patients toward individualized and informed decisions.

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