KellyAnn Light-McGroary, MD, FACC Cardiomyopathy Program and Palliative Med Program

University of Iowa Hospitals and Clinics ACC 2015

San Diego, Sunday, March 15th

I have no disclosures that are specifically relevant to this presentation.

Disclosures

To review the goals of mechanical circulatory

support

To discuss how patients and providers approach the decision

To outline the essential elements of preparedness planning/palliative consult in ACT and the impact on decision making.

Objectives

LVAD Candidate Pool

250,000-500,000 ESHF pts in terminal phase of disease (ACC Stage D = refractory to MM)

Mean survival 3.4 months

Inotrope dependent = up to 94% 1 yr mortality

80,000-150,000 pts/yr could benefit from HT

HT performed approximately 2,200/yr

LVAD as DT is available alternate

Lietz et al; J Card Surg 2010;25:462-471

Goals of MCS

Improve survival

Reduce hospitalizations

Improve quality of life

Improve likelihood of successful transplantation

What the medical team sees when deciding about MCS:

Medical team considerations:

Age

Co-morbid conditions

Anticipated survival

Risk scores

Bleeding risks

Social support

Right ventricle, right ventricle, right ventricle!

What is the right timing?

“Too Early” vs. “Too Late”

Sick enough to recognize the benefit

Well enough to minimize risks/burdens

What the patient often hears when deciding about MCS:

Patient approach:

Receive MCS and live

Decline MCS and die

Ideally, a patient would understand the exchange of end-stage HF problems for bleeding risks, infections, and/or stroke

Song, ISHLT 2012

Swetz, et al, Cardiology Research & Practice 2012

Preparedness Planning for Advanced Cardiac Therapies

How do we bring these two partners together?

Step 1: Goals of Care and Expectations

What are they hoping for, where are their values?

Can MCS or transplant actually help the achieve those goals?

GOC set the stage for the entire discussion; it is the foundation for many challenging issues.

Understanding goals of care can help manage expectations, ie “realistic hope”

Essential Elements of Preparedness Planning

Step 2: Advanced Care Planning and Identification

of Surrogate Decision Maker

What have they already done?

Consider Honoring Your Wishes, Five Wishes, etc (robust advanced care plans)

Include surrogate in discussions including responsibilities and how to approach this role

Normalize this as part of routine health care

Essential Elements of Preparedness Planning

Step 3: Preparedness Discussion for Patient and

Family

Discuss what to expect during the perioperative period including possible challenges and expectations for patients and providers.

Discuss long term benefits and complications including:

Infection

Bleeding issues

Ongoing HF/RV failure

Renal failure/dialysis

Discussion around device deactivation

Essential Elements of Preparedness Planning

1. Rizzieri et al. Philos Ethics Humanit Med 2008;3:20

2. Goodlin S. J Card Fail. 2004:54;200-9

Critical Step is discussing QOL and Care Trajectory after DT

Long term care and QOL considerations in DT patients

Caregiver misperceptions

Frequent clinic visits

Insurance/financial

Geographical limitations due to power source

Limited local resources

− Local medical community likely unprepared to care for DT patients

Caregiver burnout

EOL issues

− Inevitable

− Ethical aspects of withdrawing DT support

− Palliative care

These considerations emphasize

the need for a “preparedness

plan.”

At our institution, all VAD and

HT patients undergo palliative

medicine-facilitated

“preparedness planning”

Major components of “preparedness planning” for DT patients

Swetz et al; Mayo Clin Proc 2011;86:493-500

What does palliative medicine specifically offer to VAD patients?

Medical decision-making

Establish goals of care

Coordinate care

Manage symptoms

Psychosocial and spiritual support

Assure comfort, QOL and dignity

Prognosis

Ethics

Technical assistance

Active care of dying patients and loved ones

Bereavement support

Swetz et al; Mayo Clin Proc 2011;86:493-500

CP is a 64 y/o man with a history of an ischemic

cardiomyopathy/prior CABG, Stage D, NYHA Class IV.

In September presented in progressive biventricular failure.

Inotrope dependent by October but not thriving

Implanted in early November as DT HM2 VAD after palliative/preparedness planning consult.

Goals: live longer but most importantly be able to fish, go to grandson’s sporting events and stay out of hospital.

Case Presentation

After implant developed mesenteric ischemia felt to be

due to embolic event from VAD .

By December developed recurrent GI bleeds that were aggressive and difficult to control.

Multiple unsuccessful GI/IR procedures.

Multiple transfusions and hemodynamic instability.

Off anticoagulation he had stroke and VAD thrombosis. Full resolution of stroke with heparin.

Ongoing low level hemolysis.

Has been an inpatient 80% of the last 3-4 months.

Reactivated on the list as a 1A 2 weeks ago and transplanted 4 days ago

Case Presentation

What have his thoughts been about VAD?

Has it met expectations?

Did he feel prepared?

How have his symptoms been managed?

What is the impact on his family?

How is he suffering?

Case Presentation

Goals of Care are critical as the foundation of

deciding appropriateness of VAD and timing.

Ensuring that patients and surrogates understand ahead of time the possible decision points helps to create a road map for even the unexpected.

Managing expectations for the team and the patient/family can be successful through structured preparedness planning.

Summary