Venous thromboembolism is a common complication in cancer patients, particularly in advanced stages, where the presence of metastatic disease can increase the risk of thrombosis by approximately 20 times compared to early stages, with this risk being even higher in end-of-life patients. Despite its high prevalence, there are significant gaps in the evidence guiding venous thromboembolism management during this phase of illness. It presents a therapeutic challenge due to the high rates of thrombotic recurrence and hemorrhagic complications. Additionally, diagnosis is complicated by the nonspecific nature of symptoms and the need to avoid invasive or burdensome diagnostic tests that may compromise patient comfort. This manuscript, developed in collaboration between the Portuguese Study Group on Cancer and Thrombosis and the Portuguese Association for Palliative Care, reviews the main clinical and ethical challenges associated with the diagnosis, treatment, and prevention of venous thromboembolism in this specific population, aiming to support medical decision-making in often complex scenarios. The recommendations presented are based on the best available evidence, supplemented by the clinical experience of the authors and an ethical reflection focused on the patient. Criteria are provided to guide i) decisions on initiating, continuing or discontinuing anticoagulation; ii) the role of imaging in this context; iii) the indications for thromboprophylaxis. This synthesis aims to promote a more informed and consistent practice, with a focus on patient quality of life and dignity, while enhancing care quality and encouraging the application of these principles across different healthcare settings.

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