Management of venous thromboembolism in far-advanced cancer: current practice.

OBJECTIVES: Venous thromboembolism (VTE) is common in advanced cancer. Guidelines suggest that indefinite anticoagulation be considered for patients with ongoing active cancer. There are no data on the management of cancer-associated thrombosis (CAT) at the end of life or when to stop anticoagulation as death approaches. We reviewed current practice and associated symptoms at the end of life for patients with advanced cancer who had been anticoagulated for VTE. METHODS: Data on patients attending a regional CAT service were cross-referenced with death notifications. Hospital, hospice and community notes were reviewed to evaluate the end-of-life care within the context of VTE management. Data specific to discontinuation of anticoagulation, complications of anticoagulation and symptoms associated with VTE were recorded. RESULTS: 214 patients died over a 2-year period; 98 (46%) home, 59 (27%) hospice, 53 (25%) acute hospital and 4 (2%) community hospital. 108 (50%) continued low-molecular-weight heparin (LMWH) until death, 23 (11%) up to 7 days prior to death, 23 (11%), 1 week to 1 month 29 (13.5%), over 1 month 40 (18%). Clinically relevant non-major bleeding occurred in 9/131 (7%) of the patients who continued LMWH to death or 7 days up to death. No symptoms attributable to VTE were recorded. CONCLUSION: The majority of CAT patients with metastatic disease remain anticoagulated up to or within days of death. Despite the limitations of retrospective data across healthcare settings, it appears that anticoagulation as death approaches confers a significant bleeding risk without additional benefit of preventing VTE symptoms.

Paramedics and serious illness: communication training.

OBJECTIVES: The need to empower Ambulance Service staff at the point of delivery of end of life care (EoLC) is crucial. We describe the delivery, outcomes and potential impact of the Serious Illness Conversation project delivered to Welsh Ambulance Service Trust (WAST) staff. Over an 18-month period, 368 WAST staff attended face-to-face teaching, which included serious illness conversation communication skills, symptom control and 'shared decision making'. METHOD: Data collected from WAST staff were used to gain insight on perception of their role and challenges within the context of EoLC, understand the impact of teaching on self-confidence and identify impact on the wider service. A mixed methods approach was used for data analysis. RESULTS: WAST staff view themselves in several important roles, acting as 'facilitators' to patient-centred, seamless care, providing support, liaison between services and practical help in patient care at the end of life. The difficult questions and situations pertaining to EoLC were related to discussions on death and dying and managing expectation. The predominant barriers identified related to communication. Quantitative outcomes on the six communication domains indicate statistically significant improvement in self-assessed confidence. The overall impact to the wider ambulance service suggests a trend towards better use of resources. CONCLUSION: The perceived roles and challenges identified by paramedics can help in customising training objectives. The initial outcomes from the ongoing project with WAST demonstrate increased confidence in handling communication issues. Initial successive surveys suggest teaching is making a real life impact on patient care at end of life.