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.

Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution.

Background: When left ventricular assist device (LVAD) therapy no longer is able to achieve patients' desired quality of life, withdrawal of LVAD therapy (WLVAD) may be requested. Objectives: To evaluate factors associated with WLVAD, including the time taken before WLVAD. Setting/Subjects: Sixty-two patients who newly underwent initial LVAD therapy during January 1, 2010 and October 30, 2018 and subsequently underwent WLVAD by December 31, 2018 were divided into those who participated in the decision of WLVAD (defined as PT+, n = 14), and those who could not participate in the decision because of the medical reasons (defined as PT-, n = 48). Measurements: Time to WLVAD in PT+ and PT- was defined as WD_PT+ (days between patients' request and WLVAD) and WD_PT- (days between when patients became unable to express themselves and WLVAD), respectively. Circumstances around WLVAD, including location of death and use of palliative care (PC), were reviewed. Results: Mean age at WLVAD was 65.4 ± 10.1 years and 52 (83.9%) were men. Median days on LVAD support was 166.5 days (interquartile range = 838). The majority of WLVAD occurred in the intensive care unit (ICU) (83.6%) but less frequent in PT+ than in PT- (64.3% vs. 89.4%, p = 0.041). The median number of PC visits in the last month was higher in PT+ than in PT- (4.5 vs. 0.5, p = 0.005). The median WD_PT+ was 5.5 days and was significantly shorter in the ICU (1 day vs. 46 days, p = 0.013). The median WD_PT- was 5.5 days and tended to be shorter in the ICU (4 days vs. 13 days, p = 0.072). A multivariate analysis showed that male gender and ICU setting were both negatively associated with WD_PT- (p = 0.025 for men, p = 0.005 for ICU setting). Conclusions: The majority of WLVAD occurred in the ICU and required PC involvement. Time to WLVAD was shorter in the ICU. Requests for WLVAD directly made by patients, especially in a non-ICU setting, seemed to have posed more difficulty.

Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study.

BACKGROUND: Little is known about palliative care consultation (PCC) for patients with cardiogenic shock requiring short-term mechanical circulatory support (STMCS). OBJECTIVE: To describe the utilization of PCC in this population. DESIGN: Retrospective cohort study in a university medical center intensive care unit (ICU). SETTING/PARTICIPANTS: In total, 195 patients aged >18 years with cardiogenic shock requiring STMCS were included. The cohort was divided into three categories: no PCC, early PCC (within seven days of STMCS), and late PCC (eight or more days after STMCS). Follow-up occurred during the index hospitalization. RESULTS: Mean age was 59.3 ± 13.9 years; 67.9% were men. Mean follow-up period was 33.8 ± 37.7 days. Overall inpatient mortality was 52.3%. Ninety-four patients (48.2%) received PCC; 49 (25.1%) and 45 (23.1%) received early and late PCCs, respectively. STMCS duration, ICU stay after STMCS, and hospital stay after STMCS were significantly shorter in the no PCC group than the early PCC group (4 vs. 12 days, p < 0.001; 11 vs. 19 days, p = 0.004; and 16 vs. 19 days, p = 0.031; respectively). ICU stay after STMCS and hospital stay after STMCS were significantly shorter in the early PCC group than the late PCC group (19 vs. 38 days, p < 0.001; 19 vs. 49 days, p < 0.001; respectively). However, time from initial PCC to discharge was not significantly different between early and late PCC groups (18 vs. 31 days, p = 0.13). CONCLUSIONS: PCC was utilized in almost half of patients with cardiogenic shock requiring STMCS. PCC tends to occur toward the end of life regardless of the duration of STMCS. The optimal PCC timing remained unclear.