It is not easy to determine whether the use of anticoagulants in patients with far advanced and incurable disease is good palliative care or not. Most palliative care specialists will follow standard procedures in their units for the handling of thrombosis or pulmonary embolism. However, when the subject comes to discussion in international meetings, vast differences are found. Some palliative care professionals will reject the use of anticoagulants as life-prolonging but otherwise useless measures, and consider death from pulmonary embolism as part of the natural course of the malignant disease. Others will hold that anticoagulant therapy is necessary to relieve symptoms such as pain and swelling from deep vein thrombosis or prevent dyspnea from pulmonary embolism. In our palliative care unit in the University of Cologne, standard procedures for bedridden patients include regular application of low molecular-weight heparin.

Prevalence

There is no doubt that the incidence of deep vein thrombosis is high among cancer patients. Thromboembolic episodes were reported for approximately 15% of cancer patients. The incidence seems to be higher for pancreatic and gastric cancer and especially high for patients with lung cancer with an incidence of up to 30%. Pulmonary embolism and deep vein thrombosis have been found in even higher incidences in a large series of necropsies, and again cancer of the peritoneal cavity was correlated with particularly high incidences. Impediment of venous drainage from the lower limbs by these cancers has been proposed as the reason for these high incidences.