Open Access Open Badges Research article

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

Laura Sheard1*, Hayley Prout2, Dawn Dowding3, Simon Noble4, Ian Watt5, Anthony Maraveyas6 and Miriam Johnson7

Author Affiliations

1 Area 2, Health Sciences, Seebohm Rowntree Building, University of York, York, YO10 5DD, England

2 Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, Wales

3 School of Healthcare, University of Leeds, Leeds, England

4 Department of Palliative Medicine, Cardiff University, Cardiff, Wales

5 Health Sciences, University of York, York, England

6 Department of Academic Oncology, Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull, England

7 Hull York Medical School, University of Hull, Hull, England

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BMC Medical Ethics 2012, 13:22  doi:10.1186/1472-6939-13-22

Published: 4 September 2012



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.


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.


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.


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.

Venous thromboembolism; Heparin; Low-molecular-weight; Palliative care; Qualitative research; Ethics; Medical