Benefits and Harms of Continuous Intravenous Inotropic Support as Palliative Therapy: A Single-Institution, Retrospective Analysis.

Use of continuous intravenous inotropic support (CIIS) strictly as palliative therapy for patients with ACC/AHA Stage D (end-stage) Heart Failure (HF) has increased significantly. The harms of CIIS therapy may detract from its benefits. To describe benefits (improvement in NYHA functional class) and harms (infection, hospitalization, days-spent-in-hospital) of CIIS as palliative therapy. Methods: Retrospective analysis of patients with end-stage HF initiated on CIIS as palliative therapy at an urban, academic center in the United States between 2014-2016. Clinical outcomes were extracted, and data were analyzed using descriptive statistics. Seventy-five patients, 72% male, 69% African American/Black, with a mean age 64.5 years (SD = 14.5) met study criteria. Mean duration of CIIS was 6.5 months (SD = 7.7). Most patients (69.3%) experienced improvement in NYHA functional class from class IV to class III. Sixty-seven patients (89.3%) were hospitalized during their time on CIIS, with a mean of 2.7 hospitalizations per patient (SD = 3.3). One-third of patients (n = 25) required at least one intensive care unit (ICU) admission while on CIIS therapy. Eleven patients (14.7%) experienced catheter-related blood stream infection. Patients spent an average of 20.6% (SD = 22.8), approximately 40 days, of their time on CIIS admitted to the study institution. Patients on CIIS as palliative therapy report improvement in functional class, survive 6.5 months following initiation, but spend a significant number of days in the hospital. Prospective studies quantifying the symptomatic benefit and the direct and indirect harms of CIIS as palliative therapy are warranted.

Clinical Protocol for Left Ventricular Assist Device Deactivation at End of Life.

As patients live longer with left ventricular assist device (LVAD) support, many will either suffer an acute event or develop a gradual, progressive disease that results in a terminal prognosis. At the end-of-life, patients, and more often, their families, will be faced with the decision to deactivate the LVAD to allow natural death. The process of LVAD deactivation carries some distinct features that distinguish it from withdrawal of other forms of life-sustaining medical technology: multidisciplinary collaboration is paramount; prognosis after deactivation is short, typically minutes-hours; and premedication doses of symptom-focused medications are typically higher than other situations involving withdrawal of life-sustaining medical technologies given the precipitous decline in cardiac output following LVAD deactivation. In this Case Discussion, we introduce the complexity of planned in-hospital LVAD deactivation through a clinical case, share our detailed institutional checklist and order set for LVAD deactivation, and broach multidisciplinary clinical protocol development processes.