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Palliative Care and End-of-Life Issues in Patients Treated with Left Ventricular Assist Devices as Destination Therapy

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Abstract

Left ventricular assist devices as destination therapy (DT) improve quality of life for many patients with advanced heart failure. However, DT can be associated with risks such as infection, bleeding, and stroke, and may impose psychosocial strain on patients and caregivers. Furthermore, patients treated with DT eventually will die with their device in place whether death is related to the device or not. In response to these concerns, palliative medicine consultation has been suggested with standard DT care to improve focus on quality of life, symptom management, and end-of-life planning. This article reviews key issues associated with caring for patients with DT, including psychosocial, quality-of-life, caregiving, and ethical issues, and discusses end-of-life management of patients with DT, including practical considerations, but moreover, review topics regarding communication, symptom management, and provision of appropriate comfort care.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lietz K, Long JW, Kfoury AG, et al. Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection. Circulation. 2007;116:497–505.

    Article  PubMed  Google Scholar 

  2. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435–43.

    Article  PubMed  CAS  Google Scholar 

  3. Long JW, Healy AH, Rasmusson BY, et al. Improving outcomes with long-term “destination” therapy using left ventricular assist devices. J Thorac Cardiovasc Surg. 2008;135:1353–60.

    Article  PubMed  Google Scholar 

  4. Park SJ, Tector A, Piccioni W, et al. Left ventricular assist devices as destination therapy: a new look at survival. J Thorac Cardiovasc Surg. 2005;129:9–17.

    Article  PubMed  Google Scholar 

  5. •• Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241–51. According to the authors, patients receiving continuous-flow LVADs had improved 2-year survival compared to those using older pulsatile-flow LVADs.

    Article  PubMed  CAS  Google Scholar 

  6. Boilson B, Schirger J, Durham III J, et al. Transformation of LVAD destination therapy, “good to great”: ever increasing survival benefit. (Abstract 3662). Circulation. 2009;120:S844.

    Google Scholar 

  7. •• Rogers JG, Aaronson KD, Boyle AJ, et al. Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. J Am Coll Cardiol 2010;55:1826–34. According to the authors, patients receiving continuous-flow LVADs, including 374 as DT, noticed improvement in functional capacity and heart failure–related quality of life.

    Article  PubMed  Google Scholar 

  8. • Kirklin JK, Naftel DC, Kormos RL, et al. Third INTERMACS Annual report: the evolution of destination therapy in the United States. J Heart Lung Transplant 2011;30:115–23. This report of the most recent INTERMACS registry shows improved survival and reduced morbidity with continuous-flow LVADs.

    Article  PubMed  Google Scholar 

  9. • Stevenson LW, Pagani FD, Young JB, et al. INTERMACS profiles of advanced heart failure: the current picture. J Heart Lung Transplant 2009;28:535–41. This article provides a definition of patient characteristics to allow for better prediction of appropriate patients for LVAD.

    Article  PubMed  Google Scholar 

  10. Krumholz HM, Phillips RS, Hamel MB, et al. Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT project. Circulation. 1998;98:648–55.

    PubMed  CAS  Google Scholar 

  11. Lewis EF, Johnson PA, Johnson W, et al. Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant. 2001;20:1016–24.

    Article  PubMed  CAS  Google Scholar 

  12. Aranda JM, Rogers JG, Aronson KD, et al. Quality of life improvements are greater in destination therapy than bridge to transplant patients with a continuous flow left ventricular assist device. J Am Coll Cardiol. 2010;55:A22.E209.

    Article  Google Scholar 

  13. Starling RC. Improved quantity and quality of life: a winning combination to treat advanced heart failure. J Am Coll Cardiol. 2010;55:1835–6.

    Article  PubMed  Google Scholar 

  14. Spertus J, Peterson E, Conard MW, et al. Monitoring clinical changes in patients with heart failure: a comparison of methods. Am Heart J. 2005;150:707–15.

    Article  PubMed  Google Scholar 

  15. Hu FB, Stampfer MJ, Solomon C, et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med. 2001;134:96–105.

    PubMed  CAS  Google Scholar 

  16. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435–43.

    Article  PubMed  CAS  Google Scholar 

  17. Freeman M. Psychosocial assessment and discharge planning: importance of the social worker in the LVAD multidisciplinary team. In: Joyce D, Joyce L, Locke M, editors. Mechanical circulatory support: principles and applications. 1st ed: McGraw-Hill Professional; 2011 (in press).

  18. • Eshelman AK, Mason S, Nemeh H, Williams C. LVAD destination therapy: applying what we know about psychiatric evaluation and management from cardiac failure and transplant. Heart Fail Rev 2009;14:21–8. This article attempts to apply several aspects of psychosocial planning for cardiac transplant to evaluation and selection of LVAD patients.

    Article  PubMed  Google Scholar 

  19. Grady KL, Meyer PM, Dressler D, et al. Change in quality of life from after left ventricular assist device implantation to after heart transplantation. J Heart Lung Transplant. 2003;22:1254–67.

    Article  PubMed  Google Scholar 

  20. Shapiro PA, Levin HR, Oz MC. Left ventricular assist devices: psychosocial burden and implications for heart transplant programs. Gen Hosp Psychiatry. 1996;18:30S–5.

    Article  PubMed  CAS  Google Scholar 

  21. Petrucci R, Kushon D, Inkles R, et al. Cardiac ventricular support considerations for psychiatry. Psychosomatics. 1999;40:298–303.

    PubMed  CAS  Google Scholar 

  22. Grady KL, Meyer PM, Dressler D, et al. Longitudinal change in quality of life and impact on survival after left ventricular assist device implantation. Ann Thorac Surg. 2004;77:1321–7.

    Article  PubMed  Google Scholar 

  23. Casida JM, Peters RM, Magnan MA. Self-care demands of persons living with an implantable left-ventricular assist device. Res Theory Nurs Pract. 2009;23:279–93.

    Article  PubMed  Google Scholar 

  24. •• Swetz K, Freeman M, AbouEzzeddine O, et al. Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist devices as destination therapy. Mayo Clin Proc 2011;86:in press. This review of patients at a single institution that received palliative care consultation in addition to multidisciplinary team support discusses how advance care planning outcomes and complication management was improved by this intervention.

  25. Grady KL, Meyer P, Mattea A, et al. Improvement in quality of life outcomes 2 weeks after left ventricular assist device implantation. J Heart Lung Transplant. 2001;20:657–69.

    Article  PubMed  CAS  Google Scholar 

  26. Bunzel B, Laederach-Hofmann K, Wieselthaler G, et al. Mechanical circulatory support as a bridge to heart transplantation: what remains? Long-term emotional sequelae in patients and spouses. J Heart Lung Transplant. 2007;26:384–9.

    Article  PubMed  Google Scholar 

  27. Bunzel B, Laederach-Hofmann K, Wieselthaler GM, et al. Posttraumatic stress disorder after implantation of a mechanical assist device followed by heart transplantation: evaluation of patients and partners. Transplant Proc. 2005;37:1365–8.

    Article  PubMed  CAS  Google Scholar 

  28. •• Wilson SR, Givertz MM, Stewart GC, Mudge GH, Jr. Ventricular assist devices the challenges of outpatient management. J Am Coll Cardiol 2009;54:1647–59. The authors reviewed several unique outpatient issues encountered by patients with LVADs and discussed possible interventions to maximize quality of life.

    Article  PubMed  Google Scholar 

  29. • Zambroski CH, Combs P, Cronin SN, Pfeffer C. Edgar Allan Poe, “the pit and the pendulum,” and ventricular assist devices. Crit Care Nurse 2009;29:29–39. This essay explores how patients with LVADs are continuously aware of their device and how this can have psychological ramifications over time that may need to be addressed.

    Article  PubMed  Google Scholar 

  30. • Marcuccilli L, Casida JJ, Peters RM, Wright S. Sex and intimacy among patients with implantable left-ventricular assist devices. J Cardiovasc Nurs 2011. According to the authors, quality-of-life management after LVAD should consider sexual behavior as a part of patients’ normal desires, and efforts to improve this should be addressed.

  31. •• MacIver J, Ross HJ, Delgado DH, et al. Community support of patients with a left ventricular assist device: the Toronto General Hospital experience. Can J Cardiol 2009;25:e377–81. This is a retrospective case-based analysis of patients who received LVAD support that discusses keys to managing patients in the community.

    Article  PubMed  CAS  Google Scholar 

  32. Seemuth SC, Richenbacher WE. Education of the ventricular assist device patient’s community services. ASAIO J. 2001;47:596–601.

    Article  PubMed  CAS  Google Scholar 

  33. Dudzinski DM. Ethics guidelines for destination therapy. Ann Thorac Surg. 2006;81:1185–8.

    Article  PubMed  Google Scholar 

  34. •• Mueller P, Swetz K, Freeman M, et al. Ethical analysis of withdrawing ventricular assist device support. Mayo Clin Proc 2010;85:791–7. This is a case-based analysis and review of ethics literature reviewing principles that make withdrawal of LVAD support permissible.

    Article  PubMed  Google Scholar 

  35. Sulmasy DP. Within you/without you: biotechnology, ontology, and ethics. J Gen Intern Med. 2008;23 Suppl 1:69–72.

    Article  PubMed  Google Scholar 

  36. Pellegrino ED. Decisions to withdraw life-sustaining treatment: a moral algorithm. JAMA. 2000;283:1065–7.

    Article  PubMed  CAS  Google Scholar 

  37. Rhymes JA, McCullough LB, Luchi RJ, et al. Withdrawing very low-burden interventions in chronically ill patients. JAMA. 2000;283:1061–3.

    Article  PubMed  CAS  Google Scholar 

  38. Snyder L, Leffler C. Ethics manual: fifth edition. Ann Intern Med. 2005;142:560–82.

    PubMed  Google Scholar 

  39. Mueller PS, Hook CC, Hayes DL. Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clin Proc. 2003;78:959–63.

    Article  PubMed  Google Scholar 

  40. Gostin LO. Deciding life and death in the courtroom. From Quinlan to Cruzan, Glucksberg, and Vacco—a brief history and analysis of constitutional protection of the ‘right to die’. JAMA. 1997;278:1523–8.

    Article  PubMed  CAS  Google Scholar 

  41. Singer PA, Robertson G, Roy DJ. Bioethics for clinicians: 6. Advance care planning. CMAJ. 1996;155:1689–92.

    PubMed  CAS  Google Scholar 

  42. • Rizzieri AG, Verheijde JL, Rady MY, McGregor JL. Ethical challenges with the left ventricular assist device as a destination therapy. Philos Ethics Humanit Med 2008;3:20. This is an analysis of many of the ethical and psychosocial issues faced by patients with LVAD.

    Article  PubMed  Google Scholar 

  43. • Swetz K, Mueller P, Ottenberg A, et al. The use of advance directives among patients with left ventricular assist devices. Hosp Pract (Minneap) 2011;39:78–84. This retrospective study of 68 patients with LVADs demonstrated only 47% of patients had formal advance directives.

    Article  Google Scholar 

  44. Swetz K, Freeman M, Mueller P, Park S. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant. 2010;29:1081. Epub 2010 May 26.

    Article  PubMed  Google Scholar 

  45. Bramstedt KA, Wenger NS. When withdrawal of life-sustaining care does more than allow death to take its course: the dilemma of left ventricular assist devices. J Heart Lung Transplant. 2001;20:544–8.

    Article  PubMed  CAS  Google Scholar 

  46. Wiegand DLM, Kalowes PG. Withdrawal of cardiac medications and devices. AACN Adv Crit Care. 2007;18:415–25.

    Article  PubMed  Google Scholar 

  47. Landzaat LH, Sinclair CT, Rosielle DA. Continuous-flow left ventricular assist device. N Engl J Med. 2010;362:1149. author reply 1149.

    Article  PubMed  CAS  Google Scholar 

  48. MacIver J, Ross HJ. Withdrawal of ventricular assist device support. J Palliat Care. 2005;21:151–6.

    PubMed  Google Scholar 

  49. Von Gunten C, Weissman D. Symptom control for ventilator withdrawal in the dying patient, 2nd edition. Fast Facts and Concepts. July 2005; 34. Available at: http://www.eperc.mcw.edu/fastfact/ff_034.htm.

  50. Campbell ML. How to withdraw mechanical ventilation: a systematic review of the literature. AACN Adv Crit Care. 2007;18:397–403. quiz 344–395.

    Article  PubMed  Google Scholar 

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Disclosures

Dr. Keith M. Swetz has received honoraria from the Society for Hospital Medicine, Penn State University, and Boston Scientific, and has received travel expense compensation from the American College of Physicians, the Pulmonary Hypertension Association, and the Society of Hospital Medicine. Ms. A. L. Ottenberg: none; Ms. M. R. Freeman: none. Dr. Paul Mueller serves on the Boston Scientific Patient Safety Advisory Board and is an associate editor of JournalWatch.

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Swetz, K.M., Ottenberg, A.L., Freeman, M.R. et al. Palliative Care and End-of-Life Issues in Patients Treated with Left Ventricular Assist Devices as Destination Therapy. Curr Heart Fail Rep 8, 212–218 (2011). https://doi.org/10.1007/s11897-011-0060-x

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