Palliative care-withholding coumadin-your opinions

caroladybelle, BSN, RN · Oct 11, 2009

In regards to a brain tumor, many practitioners do not want to thin the blood as brain tumor (depending on the type) pts often develop bleeding, especially around the site of the tumor. And if they do thin blood, they prefer a shorter acting/easily reversed form.

In addition, cancers often develop clotting issues (DIC, clots, etc.). Putting some cancer pts on long acting blood thinners can be very problematic.

Also, if the pt is being treated, even palliatively, with chemo/rad, this often drops the platelet count, resulting in more bleeding. And the pts are often weak and at higher fall risk.

The MD has to balance the risk of TIAs (possibly due more to the tumor, rather than clots), vs intracranial bleeding.

If the clots were a really big issue, there is also the option of a Greenfield filter.

allnurses Guide · Oct 11, 2009

I don't know, someone with a past history of thromboembolism, who is going to be laid out in bed? I would want the warfarin. My mother recently had 2 PEs and it was NOT fun and would not be a pleasant way to go. Cancer increases your chance of TE and PE considerably.

caroladybelle, BSN, RN · Oct 11, 2009

Is the pt going to be bedridden?

(I have had plenty of elderly patients that were not)

Was the TIAs d/t a clot or the tumor?

Morning-glory · Oct 11, 2009

My mother-in-law was at home. She had been on coumadin for a year. CHF and renal failure. After a big nose bleed, she decided that she would take her chances on going without the coumadin. In the last couple of months, we d/c'd most of her meds, went from a renal diet, including fluid restrictions to DAT. Marshmellows, jello and boost were her food choices. She stayed on her lasix because it made her feel better.

She understood the risks and the doctor agreed that she could manage her own care. Eventually she went into a coma and died 4 days later at home with family at the bedside.

Be_Moore · Oct 11, 2009

The first response nailed it--bleeding at tumor sights is very common. Think of the cliche of the man who discovered he had lung cancer after coughing up blood. The same is true of the brain. A patient with a brain tumor will eventually bleed intracranially and the coumadin would basically ensure that it would be a fatal bleed.

tencat · Oct 11, 2009

Well, if the patient can swallow and wants to take it, then why not? If the patient chooses not to, then that's ok, too. It's really up to him, if he can make his own decisions. If not, then it's up to the caretakers. Can he swallow? Is he prone to falls? Is he bedbound? How is his PT/INR right now? If he can't swallow, I'd say go ahead and leave it out. Palliative care is about comfort, and coumadin could add to comfort by preventing DVT, etc. But it could cause its own set of problems with bleeding and excessive bruising. The main question to ask is: How does coumadin add to his comfort? If the answer is considerably, then keep it. If not, it can go.

mamamerlee, LPN · Oct 11, 2009

All excellent responses. Much more info really needs to be available for a definitive answer. I don't know that there is a corelation between TIAs and DVTs. If you have a questions, ask the MD for his reasoning.

Otessa, BSN, RN · Oct 11, 2009

Thank you for all of your responses.

otessa

Jules A, MSN · Oct 11, 2009

Very intersting thread. Speaking only for myself however when it comes to palliative care all I want is pain meds, and lots of them.

RNKITTY04 · Oct 11, 2009

Amen sister