Hoping for a miracle: supporting patients in transplantation and cardiac assist programs

Palliative care in cardiac transplantation: an evolving model

It is currently estimated that 5.7 million Americans live with heart failure. Of these, less than 3000 will receive a heart transplant this year, according to the US Department of Health and Human Services Organ Procurement and Transplantation Network. With successful transplantation can come significant emotional and physical symptoms that are not always addressed. Although palliative care is an interdisciplinary subspecialty designed to alleviate multiple domains of suffering in serious illness, many mistakenly associate it solely with the end of life. Traditionally associated with cancer, research into the role of palliative care in other chronic illnesses and complex life-changing therapies such as solid organ transplantation remains scarce but is nonetheless developing. Here, we try to investigate a potential role for palliative care for heart transplant recipients. Early research thus far has demonstrated importance of early involvement of palliative care teams and the significant improvement of physical and emotional symptoms in the pre- and post-transplant period. Nevertheless, more research is warranted to determine the ideal timing of palliative care integration, the effects on health care resource utilization, and whether improving quality of life can affect morbidity and mortality. By understanding these critical elements and others we may be able to develop a model for the role of palliative care for heart transplant patients.

Palliative and end of life care in solid organ transplantation

Palliative care is an interprofessional approach that focuses on quality of life of patients who are facing life-threatening illness. Palliative care is consistently associated with improvements in advance care planning, patient and caregiver satisfaction, quality of life, symptom burden, and lower healthcare utilization. Most transplant patients have advanced chronic disease, significant symptom burden, and mortality awaiting transplant. Transplantation introduces new risks including perioperative death, organ rejection, infection, renal insufficiency, and malignancy. Numerous publications over the last decade identify that palliative care is well-suited to support these patients and their caregivers, yet access to palliative care and research within this population are lacking. This review describes palliative care and summarizes existing research supporting palliative intervention in advanced organ failure and transplant populations. A proposed model to provide palliative care in parallel with disease-directed therapy in a transplant program has the potential to improve symptom burden, quality of life, and healthcare utilization. Further studies are needed to elucidate specific benefits of palliative care for this population. In addition, there is a tremendous need for education, specifically for clinicians, patients, and families, to improve understanding of palliative care and its benefits for patients with advanced disease.

Integration of palliative care in end-stage liver disease and liver transplantation

BACKGROUND

Patients with end-stage liver disease (ESLD) have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life (QOL). This population traditionally has not had much attention within the palliative care community.

DISCUSSION

This article provides an evidence-based review of palliative care issues that patients with ESLD and those awaiting liver transplant face, including approaches to prognosis, symptom management, advance care planning, and end-of-life care.

CONCLUSION

Tremendous opportunity exists to integrate palliative medicine into the care of these patients.

Improving end-of-life care for ventricular assist devices (VAD) patients: paradox or protocol?*

When a person consents to have a ventricular assist device (VAD) implanted in one's heart, the intention is to extend life toward a new heart or toward more time. Complications may develop followed by frequent hospital admissions-most often in an intensive care unit (ICU) setting-rendering a transplant a distant reality and to discontinue the device means certain death. Emotional support for patient and family is critical. Regardless of the original goal for the device, palliative care provides assistance in communication, goal setting, and symptom management and yet its consultation is often more for brink-of-death care than end-of-life care provided at the time of diagnosis of a life-threatening disease such as heart failure. This study examined the recent deaths of hospitalized patients with VADs and the use of the palliative care service. Understanding the benefit and timing of palliative care for VAD patients-particularly in the ICU setting--may improve the end-of-life experience for patients, families, and healthcare providers.

Decision-making in the face of end-stage organ failure: high-risk transplantation and end-of-life care

PURPOSE OF REVIEW

Pediatric solid organ transplantation numbers have been increasing over the years. Research and the medical literature tends to focus on advancing the field and innovation - which often leads to higher risk and more complex procedures. How do we decide when it is too much - too much risk; too much uncertainty? Who makes that decision? Literature is scarce and usually focuses on end-of-life decision-making. This article does not purport to have the answers, but will highlight the depth and breadth of points that must be taken into consideration.

RECENT FINDINGS

There are many factors that contribute to the decision-making in the context of high-risk solid organ transplantation in children. Focus needs to include quality of life in the pediatric context, in addition to survival. End-of-life discussions should be included early in the process. Societal factors must be considered in an era of donor organ shortages. Shared decision-making should be the approach.

SUMMARY

The key guiding principle is to make a decision about what is best for a child requiring a high-risk transplant based not only on survival, but also on an acceptable quality of life on the background of optimal utilization of a scarce societal resource.