title: The ethical decisions UK doctors make regarding advanced cancer patients at the end of life--the perceived (in) appropriateness of anticoagulation for venous thromboembolism: a qualitative study.
abstract: BACKGROUND
  Cancer patients are at risk of developing blood clots in their veins - venous thromboembolism (VTE) - which often takes the form of a pulmonary embolism or deep vein thrombosis. The risk increases with advanced disease. Evidence based treatment is low molecular weight heparin (LMWH) by daily subcutaneous injection. The aim of this research is to explore the barriers for doctors in the UK when diagnosing and treating advanced cancer patients with VTE.
  
  
  METHODS
  Qualitative, in-depth interview study with 45 doctors (30 across Yorkshire, England and 15 across South Wales). Doctors were from three specialties: oncology, palliative medicine and general practice, with a mixture of senior and junior staff. Framework analysis was used.
  
  
  RESULTS
  Doctors opinions as to whether LMWH treatment was ethically appropriate for patients who were symptomatic from VTE but at end of life existed on a shifting continuum, largely influenced by patient prognosis. A lack of immediate benefit coupled with the discomfort of a daily injection had influenced some doctors not to prescribe LMWH. The point at which LMWH injections should be stopped in patients at the end of life was ambiguous. Some perceived 'overcaution' in their own and other clinicians' treatment of patients. Viewpoints were divergent on whether dying of a PE was considered a "good way to go". The interventionalism and ethos of palliative medicine was discussed.
  
  
  CONCLUSIONS
  Decisions are difficult for doctors to make regarding LMWH treatment for advanced cancer patients with VTE. Treatment for this patient group is bounded to the doctors own moral and ethical frameworks.
authors.affiliation: Area 2, Health Sciences, Seebohm Rowntree Building, University of York, York YO10 5DD, England. Laura.sheard@york.ac.uk
authors.forename: Laura
authors.initials: L
authors.lastname: Sheard
authors.forename: Hayley
authors.initials: H
authors.lastname: Prout
authors.forename: Dawn
authors.initials: D
authors.lastname: Dowding
authors.forename: Simon
authors.initials: S
authors.lastname: Noble
authors.forename: Ian
authors.initials: I
authors.lastname: Watt
authors.forename: Anthony
authors.initials: A
authors.lastname: Maraveyas
authors.forename: Miriam
authors.initials: M
authors.lastname: Johnson
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D002755:Choice Behavior / Q000941:ethics; D003657:Decision Making / Q000941:ethics*; D011307:Drug Prescriptions / Q000592:standards*; D004992:Ethics, Medical; D005260:Female; D058006:General Practice / Q000592:standards; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage; D017051:Hospice Care / Q000941:ethics*; D006801:Humans; D008297:Male; D008495:Medical Oncology / Q000592:standards; D008875:Middle Aged; D033262:Narration; D009369:Neoplasms / Q000150:complications* / Q000473:pathology; D010166:Palliative Care / Q000592:standards; D010820:Physicians / Q000941:ethics*; D011379:Prognosis; D011655:Pulmonary Embolism / Q000188:drug therapy; D036301:Qualitative Research; D006113:United Kingdom; D054556:Venous Thromboembolism / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control; D020246:Venous Thrombosis / Q000188:drug therapy; D000078329:Workforce
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight