LEFT VENTRICULAR ASSIST DEVICES WHERE DOES PALLIATIVE MEDICINE FIT?

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1 Glennan Center for Geriatrics and Gerontology LEFT VENTRICULAR ASSIST DEVICES WHERE DOES PALLIATIVE MEDICINE FIT? April 7, Marissa Galicia Castillo, MD Medical Director, Sentara Norfolk General Hospital Palliative Care Medicine Palliative Medicine Section MISSION: To integrate, coordinate and disseminate all age related endeavors at the Eastern Virginia Medical School. The Center s ultimate goals are to promote the health, wellbeing, independence, and quality of life of older adults; and to enhance the knowledge base and standards of practice in geriatrics and gerontology, through clinical practice, education, research, and advocacy on behalf of older adults and their caregivers. Glennan Center for Geriatrics and Gerontology Clinical Services Consultation Clinics Geriatric Assessment Memory Assessment Post Acute/Long Term Care Beth Sholom Harbor s Edge Assisted Living Memory Center Palliative Medicine Sentara Norfolk General Hospital Sentara Careplex Sentara Newtown Hospice Hospice and Palliative Care of Tidewater OBJECTIVES Discuss the ethical decisions related to the use of LVAD s in clinical decision making. Explore how palliative care and end of life discussions are relevant to the care of Patients with LVAD s. Share relevant patient care stories to utilize palliative care for this patient population. Describe the process for involving patients in palliative care. 1

specifically named ventilator, dialysis, ACLS did not mention LVAD specifically Palliative Medicine team consulted

2 Facts about Heart failure Reasons we will see more LVADs Mr. O 69 year old LVAD DT Initially did well, POD 5 major stroke ACP would not want to be kept alive by artificial means: specifically named ventilator, dialysis, ACLS did not mention LVAD specifically Palliative Medicine team consulted Family felt LVAD was a part of him did not want it turned off Comfort care with exception of LVAD After 2 months, died on his 70 th birthday Could anything have been done differently? 2

3 Today Mechanical Circulatory Devices Benefits Complications Palliative Medicine topics/topics/vad 3

4 Medicare Indications for Coverage Number of heart transplants 1. Preauthorization 2. Post cardiotomy (acute bridge to recovery) 3. Bridge to transplant 4. Destination Therapy 4

NYHA Functional Classification for Heart Failure Class Definition I Cardiac Disease. No physical limitation or symptoms with exertion. II Symptom-free at rest.

IV Unable to perform any activity without discomfort. Symptoms of angina, Dyspnea, and fatigue may be present at rest.

5 Advanced Heart Failure 5.7 million Americans 10 percent have advanced heart failure Conventional heart therapies and symptom management strategies no longer work Shortness of breath and other symptoms even at rest. NYHA Functional Classification for Heart Failure Class Definition I Cardiac Disease. No physical limitation or symptoms with exertion. II Symptom-free at rest. Slight limitation of activity due to fatigue, angina, Dyspnea which resolves with rest. III Symptom-free at rest. Significant limitation of activity due to fatigue, angina, Dyspnea. IV Unable to perform any activity without discomfort. Symptoms of angina, Dyspnea, and fatigue may be present at rest. NYHA, New York Heart Association ACC/AHA Staging System for Heart Failure Stage Definition A High risk for heart failure, no structural defect. Example, diabetes, hypertension B Structural defect causing asymptomatic ventricular dysfunction. Patient has never had clinical heart failure. Example, left ventricular hypertrophy, previous MI C Current or past symptoms of HF associated with structural abnormalities. Most HF patients fit in this group. D Refractory end-stage heart failure. These patients are candidates for heart transplant, specialized interventions or hospice. ACC, American College of Cardiology; AHA, American Heart Association; MI myocardial infarction; HF heart failure 5

Destination Therapy Bridge to Transplant 1 year 2 years Kirklin JK, Naftel DC,

6 N Engl J Med 2009;361: Survival Statistics 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Medical Management Destination Therapy Bridge to Transplant 1 year 2 years Kirklin JK, Naftel DC, Kormos RL, Stevenson LW, Pagani FD, et al. The Fourth INTERMACS Annual Report: 4,000 implants and counting. J Heart Lung Transplant 2012;31:

7 Complications Mechanical failure Infection Bleeding Strokes Death Before this next slide, write down the first thing you see. 7

8 Preparedness Planning Part of the checklist Focus on completion of Advance Care Planning Definition of Quality of Life Biggest fear Preparedness Planning What ifs Complications When would you feel you would want it turned off? Turning off the LVAD "A Failing Heart And The Downside Of Life Prolonging Technology" Full Essay The device kept him alive, but was the pain and suffering worth it? Health Affairs, August 3,

Ms. C 35 yo female s/p LVAD x 6 months after

placement Over next 2 years, progressive cognitive

9 Ms. C 35 yo female s/p LVAD x 6 months after postpartum cardiomyopathy Presents to ED with suicide attempt Cut her driveline What now? Mr. J 70 yo male DT Cognitive impairment after LVAD placement Over next 2 years, progressive cognitive decline Wife having more and more difficulty caring for him Now what? 9

GOALS Take Home Points Destination therapy is increasing DT support is a medical intervention that can be withheld or withdrawn when risks/burdens outweigh benefits Treatments Procedures Tests Take

Frequency and assessment of poor global outcome in patients with left ventricular assist devices.

10 GOALS Take Home Points Destination therapy is increasing DT support is a medical intervention that can be withheld or withdrawn when risks/burdens outweigh benefits Treatments Procedures Tests Take Home Points References Preparedness Planning is important Teams are key Communication, communication, communication Fendler TJ, Nassif ME, Kennedy KF, et al. Frequency and assessment of poor global outcome in patients with left ventricular assist devices. Scheduled to be presented at the American Heart Association Quality of Care and Outcomes Research 2015 Scientific Sessions [canceled], April 30, Baltimore, MD, April 30, Available at: Fendler TJ, Spertus JA, Gosch K, et al. Incidence and predictors of cognitive decline in patients with left ventricular assist devices. Scheduled to be presented at the American Heart Association Quality of Care and Outcomes Research 2015 Scientific Sessions [canceled], April 30, Baltimore, MD, April 30, Available at: Ottenberg, AL, Cook KE, Topazian RJ, Mueller LA, Mueller PS, Swetz KM. Choices for Patients Without a Choice, Circ Cardiovasc Qual Outcomes. 2014; 7: Swetz KM, Cook KE, Ottenberg AL, Chang N, Mueller PS. Clinicians attitudes regarding withdrawal of left ventricular assist devices in patients approaching the end of life, European Journal of Heart Failure, 2013; 15: Rady MY, Verheijde JL. Ethical Challenges with Deactivation of Durable Mechanical Circulatory Support at the End of Life: Left Ventricular Assist Devices and Total Artificial Hearts, Journal of ICU, 2015; 29: Swetz KM, Kamal AH, Matlock DD, Dose AM, Borkenhagen LS, Kimeu AK, Dunlay SM, Feely MA. Preparedness Planning Before Mechanical Circulatory Support: A How To Guide for Palliative Medicine Clinicians, 2014; 47(5):

Larry A. Allen, MD, MHS on behalf of the investigators, clinicians, patients, families, and funders. Colorado Program for Patient Centered Decisions

Larry A. Allen, MD, MHS on behalf of the investigators, clinicians, patients, families, and funders. Colorado Program for Patient Centered Decisions Effectiveness of a Shared Decision Making Intervention for Patients Offered a Destination Therapy Left Ventricular Assist Device for End-Stage Heart Failure: The DECIDE-LVAD Trial Larry A. Allen, MD, MHS