Venous thromboembolism is a major risk factor for patients with malignancy. VTE may reduce survival time in patients receiving palliative care, with one in seven inpatients with cancer dying from pulmonary embolism. The American College of Chest Physicians recommend low molecular weight heparin (LMWH) in hospitalized patients with cancer as level 1A evidence in their 2004 consensus statement on VTE. There are no thromboprophylaxis guidelines in the United Kingdom. Many physicians view daily injections of LMWH as unnecessary distress for palliative care patients. This study focused on what inpatients with advanced cancer receiving palliative care thought about the effect of thromboprophylaxis on overall quality of life.
This was a qualitative study of 28 inpatients receiving palliative care who had advanced metastatic cancer and who were in a regional cancer center in Wales. The patients had received LMWH for at least five consecutive days. The patients were audiotaped and then had semi-structured interviews transcribed regarding cancer treatments they had received. These interviews covered the patients’ insight into prognosis, their understanding of thromboprophylaxis, their beliefs concerning the effects of thromboprophylaxis on overall quality of life, and the negative aspects of heparin treatment.
The main outcome measures were recurring themes of the effect of thromboprophylaxis on overall quality of life. Major themes identified were insight into prognosis, knowledge and understanding of thromboprophylaxis, acceptability of heparin thromboprophylaxis, reassurance, and optimism. Minor themes identified were bruising, negative impact of antiembolic stockings, and anger at paternalistic views toward terminally ill patients.
Most patients showed clear insight into the nature of their condition and understood heparin prophylaxis for VTE. Many patients identified immobility and surgery as VTE risk factors, with little understanding of cancer as a risk factor. All knew that VTE could cause death, but none were aware of the common symptoms. All patients found LMWH thromboprophylaxis acceptable. Patients believed taking measures to prevent symptoms might improve their quality of life and felt that the medical team had not given up on them.
The only negative experiences of LMWH thromboprophylaxis was bruising. All of the patients who wore antiembolic stockings during previous admissions found them uncomfortable. Patients expressed their need to be involved in decision-making, particularly with respect to withdrawal or non-administration of treatment.
This small, qualitative study showed that, contrary to many physicians’ beliefs, patients in palliative care units believe that LMWH injections are acceptable as thromboprophylaxis, but antiembolic stockings are not. The effect of daily injections had little or no effect on the quality of life, with many patients having positive feelings that things were being done to prevent new problems from occurring.
This study was limited by the small sample size, the qualitative nature that could introduce interpretation bias, and the fact that only patients using LMWH were included. Additionally, the United Kingdom has aggressively educated the public on the risks of VTE associated with long flights such that baseline knowledge may differ in other parts of the world. Resource utilization, including drug costs and length of stay, as well as effect on mortality were not studied.
The implications for hospitalists are that many inpatients with advanced cancer receiving palliative care may find LMWH thromboprophylaxis acceptable therapy, and that discussions with the patient regarding this option should be explored together.
Cost Analysis: Intensive Glycemic Control in Critically Ill Adults
By Whitney Woodmansee, MD
Krinsley JS, Jones, RL. Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2006;129:644-650.
Several studies have demonstrated improved outcomes and decreased mortality in ICU patients treated with intensive control of blood glucose levels. This study sought to identify the costs associated with intensive glycemic control in the ICU.