Mechanical Circulatory Support and End of Life Care. 10 th Annual Interdisciplinary Transplant Symposium 24 September 2015

Transcription

1 Mechanical Circulatory Support and End of Life Care 10 th Annual Interdisciplinary Transplant Symposium 24 September 2015

2 Nicole Huhn, APRN VAD Coordinator Center for Advanced Heart Failure & Transplant Maryann Steed, RN, MSN, CHPN Palliative Medicine Consult Service

3 Epidemiology Heart failure (HF) affects over 5 million Americans Over 250,000 people die annually from heart failure Advanced HF is associated with 50% 1-year mortality HF admissions are the cause for over 20% of all hospital admissions among persons > 65 years old In 2010, estimated healthcare cost associated with HF was $39.2 billion

4 Treatment of Advanced HF HF is a chronic, life-shortening illness that involves progressive decline in function and significant symptom burden Few therapeutic options exist for advanced HF Inotropes Mechanical Circulatory Support (MCS)/Ventricular Assist Device (VAD) Transplant Palliative care

5 What is a VAD? Mechanical circulatory support system that assists the pumping function of the left ventricle in patients with advanced heart failure Inflow cannula attached to apex of left ventricle Outflow cannula anastomosed to the ascending aorta Blood is circulated from the pump to the rest of the body A percutaneous driveline exits the abdomen and is connected to an external controller and power source

6 Pump Pump Battery Driveline Driveline Controller Battery HeartMate II LVAD Controller HeartWare HVAD

7 Benefits of Mechanical Support Restoration of hemodynamics Reduced mortality 90% one-year survival at HH 81% one-year survival nationwide Improved quality of life Less heart failure symptoms Improvement in end organ function Fewer hospital readmissions

8 Major Adverse Events VADs can be associated with worsening of previous conditions, new comorbidities or complications Bleeding Stroke Infection, sepsis Arrhythmias Renal failure Hepatic dysfunction Right heart failure

9 Indications for VAD Can be used for several reasons Bridge to Transplant (BTT) Destination Therapy (DT) Bridge to Recovery

10 Destination Therapy Refers to the implantation of a VAD for long-term use for patients ineligible for transplantation Evolving technologies are increasing the duration of time that circulatory support can be sustained Longest length of time on support with HeartMate II LVAD is over 11 years Over 21,000 implants worldwide with 7,000 patients currently on support HeartMate II LVAD is the only approved device for DT

11 Challenges of Destination Therapy Natural progression of disease and age present challenges unrelated to device Patient/family with poor understanding of life with a VAD Caregiver burden/fatigue No standardized approach or guidelines to address when to refer heart failure patients for hospice or palliative care Literature supports early palliative medicine involvement with HF and VAD patients Evidence of the evolution of VAD experience: palliative medicine consult now mandated as part of pre-vad evaluation

12 Challenges of Destination Therapy Emergence and prevalence of life-sustaining technologies have blurred the lines between natural death and otherwise Ethical struggle with device deactivation Stop pump due to device malfunction/failure Stop pump in face of other pathological process At end of life, VAD-related needs gradually shift from improving prognosis to decreasing suffering and distress

13 Palliative Medicine Interdisciplinary care that aims to relieve suffering and improve quality of life for patients with advanced illness and their families. It is offered simultaneously with all other appropriate medical treatment. Transplant Symposium 2015

14 Palliative Medicine Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Transplant Symposium 2015

15 Palliative Medicine s Place in the Course of Illness Life Prolonging Therapy Diagnosis of serious illness Palliative Medicine Medicare Hospice Benefit Death

16 Why Palliative Medicine? Patient centered care Improves quality of life Reduces overall costs At times, increases longevity Increases patient & family satisfaction Deemed a specialty by the American Board of Medical Specialties Transplant Symposium 2015

17 Domains of Palliative Medicine Spiritual Physical Social Emotional

18 Transplant Symposium 2015 What should I expect from a palliative consult?

19 Palliative Interventions Identifying patient & family values & priorities Articulating goals of care Determining and communicating prognosis Coordinating communication among caregivers Advance care planning Providing continuity across time and site of care Symptom management Transplant Symposium 2015

20 The Palliative Consult Process Make a friend Make a goal Make a plan Transplant Symposium 2015

21 Palliative Care vs. Hospice Care Palliative Care Any time along disease trajectory Can continue life prolonging treatments All PC is not hospice care Goal can remain curative or restorative Hospice Care Reserved for last 6 months of life Must forego life prolonging treatments All hospice care is PC Goal focuses on relieving symptoms and comfort Transplant Symposium 2015

22 Case Study: Mr. R. Mr. R is an 80 y/o man with PMH significant for: Ischemic CMP CAD s/p CABG 1996 MI Hyperlipidemia HTN DM Social history: Married for 36 years Predeceased by two children Retired gym teacher Atrial fibrillation Gallstones Diverticulosis Hip replacement 2010 Bilateral knee replacements

23 Case Study: Mr. R. Presented February 2013 w/ decompensated HF - worsening SOB x 6 months Initially followed in the infusion center with increasing frequency w/o significant symptom improvement Admitted to CCU for aggressive medical management w/ inotropes, diuresis Ultimately underwent HeartMate II implant as DT Stable post-op course Transitioned to HSC for ongoing rehab

24 Case Study: Mr. R. April- May 2013 Brief readmissions with symptomatic anemia Responsive to blood transfusions Changes in anticoagulation routine May May 2014 Stable with gradual improvement in energy and activity June-November 2014 Ongoing anemia, transfusions, progressive weakness, falls Ultimately off all anticoagulation

25 Case Study: Mr. R. November- December 2014 Renal dysfunction Worsening aortic valve dysfunction, low flow state Milrinone initiated to improve contractility, flow Lasix drip for aggressive diuresis Arrhythmias Ongoing symptomatic hypotension, low flow state Significant functional decline unable to participate with rehab

26 Case Study: Mr. R. Family meeting held with decision to shift to comfort-focused care - Plan to continue VAD support with intent to turn it off with onset of active dying Code status changed to DNR/DNI - ICD deactivated Patient and wife decided they wanted to be at home together After a brief stay at STR, he was discharged home

27 Case Study: Mr. R. February Readmitted after a fall at home resulting in hip fracture; not a surgical candidate - Pain control - Signed on for hospice services - Able to return home with around-the-clock help from hospice nurses and home health aides - Three days later, transition to active dying - Patient passed away the following day

28 Should all LVAD candidates receive a Palliative Medicine consult?

29 Should all LVAD candidates receive a Palliative Medicine consult? American College of Cardiology and AHA guidelines support the referral of all patients with heart failure for palliative care Help promote patient s expression of goals and preferences for care through enhanced communication between patient, family and health care providers enhances patient autonomy Opportunity to complete advance directives Despite desired goals, not everyone gets a good outcome potential for unexpected outcomes - fully explore preoperative risk and expected postoperative course before insertion Helps provide continuity over time Transplant Symposium 2015

30 Are patients appropriately prepared for living with a VAD? Is the informed consent process adequate?

31 Are patients appropriately prepared for living with a VAD? Is the informed consent process adequate? Requires honest dialogue between patient/family and team Difficult to predict risks or benefits as so much variability between patients Early palliative medicine consult enhances patient autonomy and ensures true informed consent occurs Discuss long-term implications Disease progression Caregiver illness or death Financial considerations End of life, device deactivation Appoint decision maker before VAD implant Arrange for potential VAD patients to meet a patient currently, or previously, on support

32 What VAD specific situations should be explored prior to implant?

33 What VAD specific situations should be explored prior to implant? What to do If VAD fails - catastrophic complications Multi-organ dysfunction or failure develops VAD no longer effective VAD becomes infected Need for hemodialysis, mechanical ventilation, artificial nutrition In the event of stroke, traumatic injury, terminal malignancy, dementia In the event of the loss of the caregiver In the event of the need for SNF Transplant Symposium 2015

34 Is it permissible to deactivate a VAD once present? Are there circumstances when deactivation should not be performed?

35 Is it permissible to deactivate VAD once present? Are there circumstances when deactivation should not be performed? Understand states in which patient would not want to be kept alive Advance care and preparedness planning may ameliorate moral tension by determining patients preferences and values regarding VAD at end of life Technology adds complexity to the determination of lethal pathophysiology and causation of death Is deactivation of a VAD is similar to discontinuing other biotech devices?

36 What unique characteristics are present at end of life for patients with a VAD?

37 What unique characteristics are present at end of life for a patient with LVAD? Medical advancements have lead to an increase in elderly patients living with heart failure who develop multiple comorbidities VAD requires self-care activities to live optimally with the device End of life issues eventually may become more of the focus than life prolonging therapies Turning off the VAD vs. allowing a natural death New types of EOL situations negotiated, terminated death EOL will happen VAD only shifts end of life trajectory May present acutely or over time Transplant Symposium 2015

38 Is it possible to try a VAD and deactivate if goals are not met?

39 Is it possible to try a VAD and deactivate if goals are not met? Time limited trials described in literature Requires open discussion to define specific goals, expectations to be achieved within a certain period of time Establish clear objective markers of improvement and deterioration Ultimately want to avoid indefinite exposure to treatment that may become too burdensome relative to benefits Not a standard practice at most centers