Clinical evaluation underpins decisions about investigation and treatment
One of the main cognitive activities engaged in by clinicians was evaluation of the risks from the VTE, possible treatment options of the VTE and the underlying cancer – especially if this was extensive and likely to result in a poor prognosis for the patient. However, opinion was divided about the relative merits of each, and different conclusions regarding management plans were seen. Much of the risk/benefit balance considered was a clinical evaluation, related to the patient’s clinical condition (e.g. likelihood of VTE). However, GPs and palliative physicians were also more likely to take into account the contributory social issues, such as distance to the hospital, and the impact on dependants such as small children; these issues were carefully considered. Summaries of the scenarios referred to in this section can be found in Appendix B. Scenario summaries.
"“So on balance it’s about whether there’s a risk of bleeding into her brain tumour I suppose is something to consider but even that she has a confirmed PE it will be very difficult not to treat it but it is something that we have to let the patient and the family know that there is a risk of her bleeding into the tumour and potentially that will be very detrimental to her life expectancy if she does bleed into the tumour, her life expectancy is not very good anyway.” (Oncology registrar, England, ID17, scenario 5)"
"“He needs an urgent, urgent scan of his leg, mega urgent and I think these children are potentially vulnerable because he could die today. I think this is a mega priority case and basically he’s got a massive DVT until proved otherwise and he’s going to need to be anticoagulated and the big problem is the children and he should not be alone either because if he has a massive PE, he’ll die in front of the children when there’s nobody there.” (Palliative medicine consultant, Wales, ID10, scenario 2)"
Plans for investigation or treatment and their reasons
Interwoven with evaluations of the patient’s condition were plans regarding investigation and treatment and the rationale for that plan (coded as a reason). Although there were similar processes used with regard to weighing up patient risk and benefit, the plans made could vary between doctors. Most variation centred on whether to investigate or not, whether to anticoagulate or not, and if so which anticoagulant to use. The following two doctors from the same specialty, at the same training grade came to opposite conclusions.
"“There is the risk, somebody with brain mets, that if we gave the Clexane there is an increased risk of having a bleed in the brain but it’s not an absolute contraindication because there is nothing to say that on the scan there were signs of bleeding, so I think given that she’s now acutely unwell with confirmed bilateral pulmonary emboli, I would, from a best interest point of view, see treating those as a priority over the risk of the brain mets bleeding really.” (Palliative medicine registrar, Wales, ID8, scenario 5)"
"“I don’t think I would recommend anticoagulation really. I don’t think it’s likely to help her. I don’t think it will prolong her life probably. I don’t think it will particularly help her symptoms either… possibly make her bleed into her brain.” (Palliative medicine registrar, England, ID5, scenario 5)"
The scenarios generated differing opinions as to which anticoagulant to use. In all scenarios, if anticoagulation was planned, warfarin was more likely to be chosen by GPs than by oncologists or palliative physicians. All the palliative physicians and most of the oncologists planning to anticoagulate planned to use LMWH alone. A minority of oncologists planned to use initial LMWH followed by warfarin. Reasons for choosing LMWH included the ease of control of anticoagulation and knowledge that it is more effective in cancer.
"“In terms of how I would anticoagulate her, I would be inclined with this sort of patient to probably go with low molecular weight heparin rather than Warfarin, it’s just more controllable…” (Oncology consultant, England, ID14, scenario 1)"
"“and she’s got cancer and it’s been shown in multiple studies that patients with cancer undergoing treatment either do better or it’s safe to give them low molecular weight heparin” (Oncology consultant, England. ID 33, scenario 1)"
Again in scenario 2, GPs were more likely to think of using warfarin than the other doctors.
"“But if he refuses to go for investigation for his own self and he’s able to weigh up the information and come to an opinion and he has got a capacity to make that decision, from his point of view, I’ve got no choice but to start him on Warfarin” (Senior GP, England, ID28, scenario 2)"
In addition, some oncologists and palliative physicians specifically rejected warfarin as a choice because of the presence of liver metastases. No GP rejected warfarin in scenario 2.
"“He needs to be started on a low molecular weight heparin today and with his liver metastases I would thinking, forget warfarin and just keep him on a low molecular weight heparin indefinitely” (Palliative medicine consultant, England, ID4, scenario 2)"
However, in scenario 6, about a patient in the last few days of life, no doctor recommended warfarin, and the decision-making then centred on the potential benefits, burdens and practicalities of LMWH in this situation.
"“…avoid injections of Clexane which are in themselves unpleasant because they have to be subcutaneous, they can hurt, they can cause bruising, discomfort in the abdomen”. (Oncology registrar, England, ID19, scenario 6)"
"“The fact that his oral intake is variable and he’s having difficulty swallowing solids also complicates your choice of anticoagulation, he may not be able to swallow Warfarin” (Senior GP, England, ID 24, scenario 6)"
Throughout most scenarios, there was a strong emphasis on the importance of discussing patient wishes (nearly three quarters of respondents) as well as a willingness to take advice from other colleagues.
"“I mean I think that the patient’s first statement is, you know, “do whatever” but I actually think that it is really important that he is involved in the decisions here because he’s very much sort of towards end of life now and I wouldn’t recommend for readmission to hospital and acute treatment of the DVT” (Senior GP, Wales, ID1, scenario 6)"
"“So your first question to this patient is, how much do you want me to do? He’s not refusing all medical treatment because he’s having prescribed medicines, so it may well be that he will consider anticoagulation if a DVT was confirmed, so I would have that first discussion with the patient about whether he would want me to investigate or not because if he wasn’t going to accept any treatment, then clearly there would be no point in proceeding.” (Oncology consultant, Wales, ID12, scenario 6)"
"“I’m thinking this is really difficult and there is the children involved as well so that does make a difference about whether you would want the social work team to be involved and I’d probably speak to my consultant and maybe a surgeon. Just to find out how risky it is to put someone on a treatment dose of tinzaparine when they’ve had hepatic surgery two weeks ago” (Palliative registrar, England, ID3, scenario 2)."
The latter quote also demonstrates how the patient’s circumstances and the impact of management options may affect their dependants, are taken into account.