Pre-Ventricular Assist Device Palliative Care Consultation: A Qualitative Analysis

Clinical Recommendations for Improving Palliative Nursing Care for Patients With a Left Ventricular Assist Device

Nurses who care for patients with a left ventricular assist device (LVAD) are highly skilled clinicians who manage unique technological demands and complex complications within this specialized patient population. There is a demonstrated need and benefit for palliative care for patients with a LVAD, yet palliative consults are often underused, and the quality of consultation for these patients is poorly understood. Rarely, if at all, do nurses receive formal training on how to navigate the palliative care needs of patients with a LVAD, which includes preparedness planning, caregiver support, device/body image acceptance, and end-of-life care. In addition, there is a need for literature to address specifically how nurses in their role and scope of practice can improve palliative care for patients with a LVAD. The purpose of this article was to present recommendations to equip palliative care nurses to best serve the needs of patients with a LVAD, wherein they can partner with and advance their colleagues in cardiology to improve their delivery of primary palliative care.

Integration of palliative care across the spectrum of heart failure care and therapies: considerations, contemporary data, and challenges

PURPOSE OF REVIEW

Heart failure (HF) is characterized by significant symptoms, compromised quality of life, frequent hospital admissions, and high mortality, and is therefore well suited to palliative care (PC) intervention. This review elaborates the current PC needs of patients with HF across the spectrum of disease, including patients who undergo advanced HF surgical therapies, and reviews the current data and future directions for PC integration in HF care.

RECENT FINDINGS

Patients with chronic HF, as well as those who are being evaluated for or who have undergone advanced HF surgical therapies such as left ventricular assist device or heart transplantation, have a number of PC needs, including decision-making, symptoms and quality of life, caregiver support, and end-of-life care. Available data primarily supports the use of PC interventions in chronic HF to improve quality of life and symptoms. PC skills and teams may also help address preparedness planning, adverse events, and psychosocial barriers in patients who have had HF surgeries, but more data are needed to determine association with outcomes.

SUMMARY

Patients with HF have tremendous PC needs across the spectrum of disease. Despite this, more data are needed to determine the optimal timing and structure of PC interventions in patients with chronic HF, left ventricular assist device, and heart transplantation. Future steps must be taken in clinical, research, and policy domains in order to optimize care.

Theory of Pivoting Uncertainties: Advance Care Planning Among Individuals Living With Mechanical Circulatory Support

BACKGROUND

Individuals living with mechanical circulatory support (MCS) devices are confronted with risks for catastrophic outcomes such as stroke and systemic infection. Considering these complexities, ongoing advance care planning (ACP) is important for shared decision making.

OBJECTIVE

The purpose of this study was to describe how experiences of the MCS trajectory informed decision making about ACP.

METHODS

All aspects of the research were guided by constructivist grounded theory. Focused conversations were conducted with a semistructured interview guide.

RESULTS

A total of 24 community-dwelling patients living with MCS were interviewed (33% female; mean age, 60.6 years; 50% White). Participants were implanted with MCS (average duration, 29.8 months; bridge to transplant, 58%). Reflected in the narratives were tensions between initial expectations of living with the device in contrast with the realities that emerged over time. A crucial finding was that ACP decision making pivoted around the growing awareness of uncertainties in the MCS trajectory. Yet, clinicians were perceived to be silent in initiating ACP, and their reticence was understood as a sign of encouragement to hold on to hope for a heart transplant. The complex and dynamic decision-making processes around ACP were organized into the theory of pivoting uncertainties.

CONCLUSIONS

In this sample, patients were ready to share their concerns about the uncertainties of living with MCS and waited for MCS clinicians to initiate ACP. The theory of pivoting uncertainties is useful for elucidating the ebb and flow of ACP and lending clinicians' guidance for opportunities to initiate these sensitive conversations.

Inpatient Specialist Palliative Care in Patients With Left Ventricular Assist Devices (LVAD): A Retrospective Case Series

Background

Repeat hospitalizations, complications, and psychosocial burdens are common in patients with left ventricular assist devices (LVAD). Specialist palliative care (sPC) involvement supports patients during decision-making until end-of-life. In the United States, guidelines recommend early specialist palliative care (esPC) involvement prior to implantation. Yet, data about sPC and esPC involvement in Europe are scarce.

Materials and Methods

This is a retrospective descriptive study of deceased LVAD patients who had received sPC during their LVAD-related admissions to two university hospitals in Duesseldorf, Germany and Basel, Switzerland from 2010 to 2021. The main objectives were to assess: To which extent have LVAD patients received sPC, how early is sPC involved? What are the characteristics of those, how did sPC take place and what are key challenges in end-of-life care?

Results

In total, 288 patients were implanted with a LVAD, including 31 who received sPC (11%). Twenty-two deceased LVAD patients (19 male) with sPC were included. Mean patient age at the time of implantation was 67 (range 49–79) years. Thirteen patients (59%) received LVAD as destination therapy, eight patients (36%) were implanted as bridge to transplantation (BTT), and one as an emergency LVAD after cardiogenic shock (5%). None of the eight BTT patients received a heart transplantation before dying. Most (n = 13) patients lived with their family and mean Eastern Cooperative Oncology Group (ECOG) performance status was three. Mean time between LVAD implantation and first sPC contact was 1.71 years, with a range of first sPC contact from 49 days prior to implantation to more than 6 years after. Two patients received esPC before implantation. In Duesseldorf, mean time between first sPC contact and in-hospital death was 10.2 (1–42) days. In Basel, patients died 16 (0.7–44) months after first sPC contact, only one died on the external sPC unit. Based on thorough examination of two case reports, we describe key challenges of sPC in LVAD patients including the necessity for sPC expertise, ethical and communicative issues as well as the available resources in this setting.

Conclusion

Despite unequivocal recommendations for sPC in LVAD patients, the integration of sPC for these patients is yet not well established.

Left Ventricular Assist Device: Indication, Timing, and Management

Left ventricular assist devices (LVADs) are indicated in inotrope-dependent heart failure (HF) patients with pure or predominant LV dysfunction. Survival benefit is less clear in ambulatory, advanced HF. Timing is crucial: early, unnecessary exposure to the risks of surgery, and device-related complications (infections, stroke, and bleeding) should be weighed against the probability of dying or developing irreversible right ventricular and/or end-organ dysfunction while deferring implant. The interplay between LVAD and heart transplantation depends largely on donor availability and allocation rules. Postoperatively, quality of life depends on patients' expectations and is influenced by complications. Patients' preferences, prognosis, and alternative options-including palliation-should be openly discussed and reviewed before and after the operation.

Perceptions of Bereaved Caregivers and Clinicians About End-of-Life Care for Patients With Destination Therapy Left Ventricular Assist Devices

Background Patients with left ventricular assist devices (LVADs) implanted as destination therapy may receive suboptimal preparation for and care at the end of life, but there is limited understanding of the reasons for these shortcomings. Exploring perceptions of individuals (caregivers and clinicians) who are closely involved in the end-of-life experience with patients with destination therapy LVADs can help identify key opportunities for improving care. Methods and Results We conducted semistructured qualitative interviews with 7 bereaved caregivers of patients with destination therapy LVADs and 10 interdisciplinary LVAD clinicians. Interviews explored perceptions of preparing for end of life, communicating about end of life, and providing and receiving end-of-life care, and were analyzed using a 2-step team-based inductive approach to coding and analysis. Six themes pertaining to end-of-life experiences were derived: (1) timing end-of-life discussions in the setting of unpredictable illness trajectories, (2) prioritizing end-of-life preparation and decision-making, (3) communicating uncertainty while providing support and hope, (4) lack of consensus on responsibility for end-of-life discussions, (5) perception of the LVAD team as invincible, and (6) divergent perceptions of LVAD withdrawal. Conclusions This study revealed 6 unique aspects of end-of-life care for patients with destination therapy LVADs as reported by clinicians and caregivers. Themes coalesced around communication, team-based care, and challenges unique to patients with LVADs at end of life. Programmatic changes may address some aspects, including training clinicians in LVAD-specific communication skills. Other aspects, such as standardizing the role of the palliative care team and developing practical interventions that enable timely advance care planning during LVAD care, will require multifaceted interventions.

Trends and Predictors of Palliative Care Consultation Among Patients Admitted for LVAD: A Retrospective Analysis From the Nationwide Inpatient Sample Database From 2006-2014

BACKGROUND

Left ventricular assist devices (LVADs) are an essential part of advanced heart failure (HF) management, either as a bridge to transplantation or destination therapy. Patients with advanced HF have a poor prognosis and may benefit from palliative care consultation (PCC). However, there is scarce data regarding the trends and predictors of PCC among patients undergoing LVAD implantation.

AIM

This study aims to assess the incidence, trends, and predictors of PCC in LVAD recipients using the United States Nationwide Inpatient Sample (NIS) database from 2006 until 2014.

METHODS

We conducted a weighted analysis on LVAD recipients during their index hospitalization. We compared those who had PCC with those who did not. We examined the trend in palliative care utilization and calculated adjusted odds ratios (aOR) to identify demographic, social, and hospital characteristics associated with PCC using multivariable logistic regression analysis.

RESULTS

We identified 20,675 admissions who had LVAD implantation, and of them 4% had PCC. PCC yearly rate increased from 0.6% to 7.2% (P < 0.001). DNR status (aOR 28.30), female sex (aOR 1.41), metastatic cancer (aOR: 3.53), Midwest location (aOR 1.33), and small-sized hospitals (aOR 2.52) were positive predictors for PCC along with in-hospital complications. Differently, Black (aOR 0.43) and Hispanic patients (aOR 0.25) were less likely to receive PCC.

CONCLUSION

There was an increasing trend for in-hospital PCC referral in LVAD admissions while the overall rate remained low. These findings suggest that integrative models to involve PCC early in advanced HF patients are needed to increase its generalized utilization.

"Talking Around It": A Qualitative Study Exploring Dyadic Congruence in Managing the Uncertainty of Living With a Ventricular Assist Device

BACKGROUND

Vital components of communicating goals of care and preferences include eliciting the patient and caregiver's definition of quality of life, understanding meaningful activities and relationships, and exploring wishes for care at the end of life. Although current literature suggests framing conversations regarding end of life through the lens of meaning and quality of life, there is limited literature exploring dyadic congruence surrounding these important constructs among patients with ventricular assist devices (VADs) and their caregivers.

OBJECTIVES

The purpose of this study was to explore congruence of VAD patient and caregiver perspectives regarding end of life, definitions of quality of life, and meaning in life while managing the uncertainty of living with a VAD.

METHODS

We used thematic analysis to analyze semistructured qualitative interviews of 10 patient-caregiver dyads 3 to 12 months after VAD implantation.

RESULTS

Three major themes were identified: (1) differing trajectories of uncertainty and worry, (2) a spectrum of end-of-life perspectives, and (3) enjoying everyday moments and independence. Overall, patients and caregivers had differing perspectives regarding uncertainty and end of life. Within-dyad congruence was most evident as dyads discussed definitions of meaning or quality of life.

CONCLUSIONS

Dyadic perspectives on end of life, meaning in life, and quality of life can inform how palliative care and VAD teams approach conversations about planning for the end of life. Findings from this study can inform future shared decision-making interventions for patients living with VADs and their caregivers.

Palliative Care Services in Patients Admitted With Cardiogenic Shock in the United States: Frequency and Predictors of 30-Day Readmission

BACKGROUND

Patients admitted with cardiogenic shock (CS) have high mortality rates, readmission rates, and healthcare costs. Palliative care services (PCS) may be underused, and the association with 30-day readmission and other predictive factors is unknown. We studied the frequency, etiologies, and predictors of 30-day readmission in CS admissions with and without PCS in the United States.

METHODS AND RESULTS

Using the 2017 Nationwide Readmissions Database, we identified admissions for (1) CS, (2) CS with PCS, and (3) CS without PCS. We compared differences in outcomes and predictors of readmission using multivariable logistic regression analysis accounting for survey design. Of 133,738 CS admissions nationally in 2017, 36.3% died inpatient. Among those who survived, 8.6% used PCS and 21% were readmitted within 30 days. Difference between CS with and without PCS groups included mortality (72.8% vs 27%), readmission rate (11.6% vs 21.9%), most frequent discharge destination (50.2% skilled nursing facilities vs 36.4% home), hospitalization cost per patient ($51,083 ± $2,629 vs $66,815 ± $1,729). The primary readmission diagnoses for both groups were heart failure (32.1% vs 24.4%). PCS use was associated with lower rates of readmission (odds ratio, 0.462; 95% confidence interval, 0.408-0.524; P < .001). Do-not-resuscitate status, private pay, self-pay, and cardiac arrest were negative predictors, and multiple comorbidities was a positive predictor of readmission.

CONCLUSIONS

The use of PCS in CS admissions remains low at 8.6% in 2017. PCS use was associated with lower 30-day readmission rates and hospitalization costs. PCS are associated with a decrease in future acute care service use for critically ill cardiac patients but underused for high-risk cardiac patients.

[Palliative care in patients with left ventricular assist devices: systematic review]

Hintergrund

Bei terminal herzinsuffizienten Patienten gewinnt die Implantation von Linksherzunterstützungssystemen (LVAD) als Therapieoption zunehmend an Bedeutung. Diese Systeme werden als Überbrückung bis zu einer Herztransplantation (BTT) oder als definitive Therapie (DT) eingesetzt. Sie können die Lebensqualität verbessern und die Lebenszeit verlängern. Trotzdem bleibt die Prognose besonders bei DT oder bei Wechsel von BTT zu DT mit Blick auf die Lebenszeit und auftretende Komplikationen ungünstig. Bisher ist ungeklärt, ob eine LVAD-Implantation eine Indikation für eine frühzeitige Integration von Palliativmedizin darstellt.

Ziel der Arbeit

Erfassung der aktuellen Studienlage über den Einfluss einer palliativmedizinischen Behandlung bei LVAD-Patienten.

Material und Methoden

Im Mai 2020 wurde eine systematische Literaturrecherche in 6 verschiedenen Datenbanken durchgeführt.

Ergebnisse

Von den 491 Treffern der Literaturrecherche wurden 21 Arbeiten in diese Übersichtsarbeit eingeschlossen. Durch die frühzeitige Integration der Palliativmedizin vor LVAD-Implantation erhöhte sich die Anzahl der Patienten mit vorausschauender Versorgungsplanung und Vorsorgeinstrumenten. Außerdem zeigte sich ein positiver Einfluss auf das familiäre Umfeld, das Symptommanagement und die Umstände des Versterbens. Es gibt verschiedene Formate für die Integration palliativmedizinischer Konzepte in die LVAD-Therapie.

Diskussion

Die frühzeitige und kontinuierliche Einbindung der Palliativmedizin im Verlauf einer LVAD-Therapie kann die Behandlungsqualität verbessern. Die Ausarbeitung von spezifischen Handlungsempfehlungen ist in Abhängigkeit vom Therapieziel (BTT oder DT) sinnvoll. Empfohlen werden Schulungen für Palliativmediziner und LVAD-Spezialisten.

Facilitating supportive care in cardiac intensive care units

PURPOSE OF REVIEW

The number of patients who die in the hospital in the Western world is high, and 20-30% of them are admitted to an ICU in the last month of life, including those in cardiac ICUs (CICUs) where invasive procedures are performed and mortality is high. Palliative consultation is provided in only a few cases. The ethical and decisional aspects associated with the advanced stages of illness are very rarely discussed.

RECENT FINDINGS

The epidemiological and clinical landscape of CICUs has changed in the last decade; the incidence of acute coronary syndromes has decreased, whereas noncardiovascular diseases, comorbidities, the patients' age and clinical and therapeutic complexity have increased. The use of advanced and invasive treatments, such as mechanical ventilation, mechanical circulatory support and renal replacement therapies, has increased. This evolution increases the possibility of developing a life-threatening clinical event.

SUMMARY

This review aimed to analyze the main epidemiological, clinical, ethical and training aspects that can facilitate the introduction of supportive/palliative care programs in the CICU to improve symptom management during the advanced/terminal stages of illness, and address such issues as advance care planning, withdrawing/withholding life-sustaining treatments, deactivation of implantable defibrillators and palliative sedation.

Association Between "Unacceptable Condition" Expressed in Palliative Care Consultation Before Left Ventricular Assist Device Implantation and Care Received at the End of Life

CONTEXT

Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown.

OBJECTIVES

To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life.

METHODS

Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups.

RESULTS

Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life.

CONCLUSION

Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.

Palliative Care Engagement for Pediatric Ventricular Assist Device Patients: A Single-Center Experience

Outcomes in pediatric patients with ventricular assist devices (VADs) for advanced heart failure (HF) are improving, but the risk of associated morbidity and mortality remains substantial. Few data exist on the involvement of pediatric palliative care (PPC) in this high-risk patient population. We aimed to characterize the extent of palliative care involvement in the care of patients requiring VAD placement at our institution. Single-center retrospective chart review analyzing all VAD patients at a large pediatric center over a 4 year period. Timing and extent of palliative care subspecialty involvement were analyzed. Between January 2014 and December 2017, 55 HF patients underwent VAD implantation at our institution. Pediatric palliative care utilization steadily increased over consecutive years (2014: <10% of patients, 2015: 20% of patients, 2016: 50% of patients, and 2017: 65% of patients) and occurred in 42% (n = 23) of all patients. Of these, 57% (n = 13) occurred before VAD placement while 43% (n = 10) occurred after implantation. Patients who died during their VAD implant hospitalization (24%, n = 13) were nearly twice as likely to have PPC involvement (62%) as those who reached transplant (38%). Of those who died, patients who had PPC involved in their care were more likely to limit resuscitation efforts before their death. Four patients had advanced directives in place before VAD implant, of which three had PPC consultation before device placement. Three families (5%) refused PPC involvement when offered. Pediatric palliative care utilization is increasing in VAD patients at our institution. Early PPC involvement occurred in the majority of patients and appears to lead to more frequent discussion of goals-of-care and advanced directives.

The right time for palliative care in heart failure: a review of critical moments for palliative care intervention

Heart failure (HF) is a progressive condition with high mortality and heavy symptom burden. Despite guideline recommendations, cardiologists refer to palliative care at rates much lower than other specialties and very late in the course of the disease, often in the final 3 days of life. One reason for delayed referral is that prognostication is challenging in patients with HF, making it unclear when and how the limited resources of specialist palliative care will be most beneficial. It might be more prudent to consider palliative care referrals at critical moments in the trajectory of patients with HF. These include: a) the development of poor prognostic signs in the outpatient setting; b) hospitalization or intensive care unit admission, and c) at the time of evaluation for certain procedures, such as left ventricular assist device placement and ablation for refractory ventricular arrhythmias, among others. In this review, we also summarize the results of clinical trials evaluating palliative interventions in these settings.