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.

Recorded infection control messages delay inter-professional communication but are not associated with COVID-19 prevalence or mortality: insights from a national switchboard analysis.

Appropriate dissemination of information to the general public is a key component of the pandemic response. In 2018, recorded infection control advice messages were affixed to 30% of England's automated hospital switchboards during the seasonal influenza and norovirus outbreaks. As the majority of messages were mandatory for all callers, healthcare professionals using the hospital switchboard - including during time-critical emergencies - had their enquiries significantly delayed by these measures. Importantly, published analyses did not demonstrate an association between these messages and patient outcomes. As of May 2020, 85% of NHS trusts made use of infection control messages; on average, these delayed healthcare professionals by 59.4 seconds per call, but had no clear association with patient outcomes from COVID-19. An ongoing national switchboard quality improvement project seeks to establish a gold standard whereby healthcare professionals with urgent enquiries can press 'X' to skip past infection control messages and have their calls triaged immediately.