Anticoagulation for patients with mechanical heart valves at the end of life: understanding clinician attitudes and improving decision making

BACKGROUND: Decisions regarding continuation or cessation of anticoagulation for patients with mechanical heart valves nearing the end of life represent a difficult balance of risks. The risk of suffering and disability that may result from thromboembolism must be weighed against the burden of continued anticoagulation therapy and the excess bleeding risk this confers. Data allowing quantification of the relative risks are scarce, and this translates to a lack of published guidance on the topic. Here we describe how this lack of guidance is impacting upon healthcare professionals and their patients through misconception of risk and under-confidence in decision-making. We also present local guidance we have developed that aims to improve objective risk assessment and promote individualised, patient-centred decision-making. METHODS: Our survey was developed by specialists in palliative care and cardiology. The survey explored respondents' conception of the risks of stopping anticoagulation for patients with mechanical heart valves at the end of life, as well as their ability to identify patient factors that modify this risk. Respondent decision-making, confidence, and readiness to accept further guidance were also explored. Healthcare professionals at two university teaching hospitals were invited to participate in the survey. The study population included hospital specialists, generalists, and trainees. RESULTS: Fifty-two healthcare professionals completed the survey, including 16 palliative care specialists. 47 (90%) of respondents felt poorly informed of the risks of stopping or continuing anticoagulation. 6 (12%) correctly identified risk of thromboembolism in patients with mechanical heart valves who are not anticoagulated. The remainder overestimated risk by a factor of two (18, 35%) or five (27, 52%). 49 (94%) would find further guidance on this issue helpful. CONCLUSIONS: The healthcare professionals we surveyed felt poorly informed and ill-equipped to make decisions regarding anticoagulation for patients with mechanical heart valves at the end of life. They were objectively poor at estimating the risks involved. In the absence of robust data to support protocolisation of practice, we believe these decisions must be taken in conversation with the patient, taking account of individual circumstances and priorities. We have developed guidance for local use to support such individualised decision-making.