To Thin or not to Thin

       Working in the emergency room allowed numerous opportunities to learn about countless medications. One medication that was consistently present throughout my experience was warfarin also known as Coumadin or Jantoven. In my experience, I learned that this medication is very common among the elderly population due to its reliability, length of presence on the market, and the low cost (specifically for Medicare, but that is a different discussion). 

    The main ethical issue I found in patients who administer anticoagulants such as warfarin is when they should be discontinued. Is is ethical to be allowing a 92 year old who is a fall risk to still be taking a blood thinner? This was a common frustration noted among the providers I worked with in the ED. I cannot even begin to count how many patients had serious complications due to being on anticoagulant such as intercranial hemorrhages or the need for expensive reversal of the effects of the medications. 

     This medication acts specifically on Vitamin K dependent clotting factors (Kester 2012) and can be very problematic for the patients that use it. For example, patients who take this medication must strictly follow-up with a hematologist every two weeks in order to have an PT-INR test performed which assesses if their blood is clotting too quickly, not enough, or if they are therapeutic (Kester 2012).  In addition, warfarin's mechanism is also greatly affected by other factors such as other medications administered and by different foods. One study found that certain antibiotics increases the anticoagulant properties of warfarin (Ghaswalla 2012). 

    Should there be a cut off point where this medication should be discontinued? When would a daily aspirin suffice? Do no harm is prevalent here because you are stuck in making the best decision for the patient. In making this decision it is important to note why they are on the medication in the first place. If they are able to come off of the medication, it is still up to the patient to make their own choice and uphold their autonomy. This is an example of where beneficence and non-malfeasance are not entirely clear cut. By making one decision to discontinue warfarin to do what is best for the patient, it may come at the cost of doing some harm in the sense that they may suffer from a blood clot or other pathology. 

    Overall as future healthcare workers and providers, it is important to realize that there may be some grey area present when making these decisions. In this case, I think the best option would be to have a long decision making conversation with the patient and perhaps their families about the potential outcomes of continuing warfarin or removing it from the medication regimen. This would allow the patient to make a fully informed decision about how they would like to proceed.  

    

    

Kester, Mark, Kelly D. Karpa, Kent E. Vrana, 1 - Pharmacokinetics, Editor(s): Mark Kester, Kelly D. Karpa, Kent E. Vrana, Elsevier's Integrated Review Pharmacology (Second Edition) (Second Edition), W.B. Saunders, 2012, Pages 1-15, ISBN 9780323074452,https://doi.org/10.1016/B978-0-323-07445-2.00001-X

Ghaswalla PK, Harpe SE, Tassone D, Slattum PW. Warfarin-antibiotic interactions in older adults of an outpatient anticoagulation clinic. Am J Geriatr Pharmacother. 2012 Dec;10(6):352-60. doi: 10.1016/j.amjopharm.2012.09.006. Epub 2012 Oct 22. PMID: 23089199.