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Table 5 Platelet aggregation inhibitor case vignettes

From: Use of antithrombotics at the end of life: an in-depth chart review study

Platelet aggregation inhibitors
1. 86-year-old woman at home with heart failure, previous myocardial infarction, rectal blood loss and rheumatoid arthritis.
Carbasalate calcium 1dd 100 mg
Comedication: atenolol 1dd 100 mg, lisinopril 1dd 20 mg, loperamide 2dd 2 mg p.r.n., paracetamol 3dd 1000 mg, simvastatin 1dd 40 mg
She receives nitrofurantoin 4dd 50 mg for five days because of a urinary tract infection. A month later she develops a pneumonia for which she receives doxycycline 1dd 100 mg for a week. After three days amoxicillin/clavulanic acid 3dd 500/125 mg is started for five days because of clinical deterioration. With the patient and her daughter it is decided not to admit to the hospital in case of further deterioration. She gradually deteriorates, has difficulty to swallow the medication. Atenolol, lisinopril, loperamide and simvastatin are stopped. She receives haloperidol droplets if needed in case of agitation. She passes away after more than a month. The paracetamol and carbasalate calcium were continued until death.
2. 87-year-old man at home with leukemia. Previous myocardial infarction, prostate carcinoma and NIDDM.
Acetylsalicylic acid 1dd 80 mg
Comedication: citalopram 1dd 20 mg, diltiazem 1dd 300 mg, esomeprazole 1dd 40 mg, furosemide 1dd 40 mg
He gradually deteriorates. Oxazepam as needed 2dd 5 mg is started because of agitation two and half months before death. Two months later paracetamol suppository as needed 1000 mg and fentanyl 12 mcg/h transdermal is started because of pain. He is unable to swallow his medication and so all oral medication is stopped. Morphine s.c. as needed is started for pain and dyspnea. He passes away 6 days later.
3. 66-year-old man admitted to a hospice because of lung carcinoma with cerebral metastases. Previous history of intermittent claudication, colon carcinoma and benign prostate hypertrophy.
Carbasalate calcium 1dd 100 mg
Comedication at admission: dexamethasone 1dd 3 mg, esomeprazole 1dd 40 mg, macrogol/electrolytes 1dd 1 p.r.n., metformin 2dd 1000 mg, paracetamol 4dd 1000 mg p.r.n., spironolactone 1dd 25 mg
As needed midazolam and morphine s.c. is ordered in case of massive hemoptysis or brain herniation. After a week the dexamethasone is increased because of headache and nausea. Insulin is given in case of high blood glucose levels. Symptoms decrease and in a month the dexamethasone can be decreased to 1dd 1 mg. However, a few days later symptoms recur, dexamethasone is increased to 1dd 3 mg and after 2.5 weeks to 1dd 8 mg. A month later he further deteriorates. He receives morphine s.c. 5 mg as needed for dyspnea and pain and passes away two days later. All oral medication was continued until death.
  1. NIDDM non-insulin dependent diabetes mellitus, p.r.n. pro re nata (as needed), s.c. subcutaneous