Anticoagulation at the end of life: whether, when, and how to treat

Nearly 2 out of 3 patients with venous thromboembolism (VTE) and 1 out of 4 patients with atrial fibrillation (AF) will die within the year. Whether, when, and how to manage anticoagulation at the end of life requires many trade-offs. Patients and clinicians must balance symptom burden, greatly elevated bleeding and thrombosis risks, competing comorbidities and medications, and changing goals over time. This review uses cases of VTE and AF to present a framework for care that draws upon existing disease-specific data and cutting-edge palliative care science. It reviews strategies for the difficult task of estimating a patient's prognosis, characterizes the enormous public health burden of anticoagulation in serious illness, and analyzes the data on anticoagulation outcomes among those with limited life expectancy. Finally, an approach to individualized decision-making that is predicated on patients' priorities and evidence-based strategies for starting, continuing, or stopping anticoagulation at the end of life are presented.