Most patients with LVAD as destination therapy die in the hospital

By Will Boggs MD

NEW YORK (Reuters Health) - Most patients with a left ventricular assist device (LVAD) as destination therapy (DT) end up dying in the hospital and without hospice enrollment, according to a new review of medical records.

"We were surprised to see that the vast majority of patients with DT-LVAD die in the hospital, and specifically, in the intensive care unit," Dr. Shannon M. Dunlay from Mayo Clinic in Rochester, Minnesota, told Reuters Health by email. "A much lower proportion of patients with heart failure but without an LVAD die in the hospital."

Originally used as bridge therapy to heart transplantation, LVADs are increasingly being used as destination therapy for patients with advanced heart failure who are not candidates for heart transplantation. Mortality for these patients is around 20% at one year, but little is known about the details and events preceding their death.

Dr. Dunlay's team examined electronic medical records of 89 patients who died with a DT-LVAD. They classified patients into four end-of-life trajectories:

*Early - those who died very early after LVAD;

*Persistent - those who continued to struggle with organ failure from the time of LVAD until death

*Terminal - those who derived benefit from their LVAD but later declined as a result of a serious complication or the development of a new terminal condition

*Acute - those who experienced an improvement after LVAD therapy but then suffered an unexpected, acute event that led to an abrupt decline and death within 14 days.

More than three quarters of these patients (77.6%) died in the hospital, including 20.2% who died during the initial LVAD implantation hospitalization.

Most of those who died in hospital (87.7%) died in an intensive care unit, the researchers report in Circulation: Heart Failure, online October 6.

Just under half (46.3%) of patients had a palliative care consultation within a month before death. The median time from consultation to death was nine days, and the median number of visits per patient in the last month of life was four.

Only 13 patients (15.3%) enrolled in hospice (median, 11 days before death), including four patients who had cancer, two patients with stroke, two with heart failure, and five with multiorgan failure.

Three in five patients had their LVAD deactivated before death, mostly in the hospital. Most patients (42/47, 89.4%) died within one hour of activation, and all 12 patients who had their LVAD deactivated during their initial hospitalization died within one hour of LVAD deactivation.

In-hospital death rates ranged from 100% of those with an early course to 76.5% of those with a persistent course, 74.2% of those with an acute course, and 63.2% of those with a terminal clinical course.

Based on the available data, the authors estimate that, among all patients undergoing DT-LVAD, about 10% would experience early deaths, 20% would experience a persistent course, 30% a terminal course, and 40% an acute clinical course.

Earlier reports of patients with heart failure without LVAD suggest in-hospital death rates of 22.4% to 35.2% and hospice enrollment rates of 38.1% to 42.2%.

"In my experience, both patients and clinicians are open to involving palliative care specialists; however, sometimes we aren't sure of the right time to do so," Dr. Dunlay said. "We have not yet defined the optimal role for palliative care specialists in the long-term care of patients with DT-LVAD. Many of us believe that long-term involvement from palliative care specialists may be helpful, but we need additional studies to determine if that is the case."

"This study is a first look at the end-of-life care for patients dying with a DT-LVAD," she said. "These data show that individuals with DT-LVAD die differently than other individuals with heart failure. We need additional studies to understand these differences and to determine how we can provide optimal end-of-life care to individuals with DT-LVAD."

Dr. Winifred Teuteberg from the University of Pittsburgh School of Medicine, Pennsylvania, who coauthored an accompanying editorial, told Reuters Health by email, "I was most surprised that 15% of the patients who died were enrolled in hospice. Hospice management is challenging for VAD patients due to the complex nature of the technology. Many hospice agencies do not feel comfortable caring for patients on a VAD. I actually thought this number was high (especially since such a large proportion of patients died somewhat unexpectedly). We have a much smaller proportion of our patients enrolled in hospice at the time of death."

"I would like physicians and other allied health providers who care for patients with VADs to recognize that, although VAD technology is improving, by definition, patients with VADs as destination therapy will die with their device," she said. "They need to recognize that the decline may be gradual and anticipated or more precipitous, necessitating careful advance care planning and access to palliative care services during as many touchpoints as possible throughout the course of VAD therapy."

Dr. Colleen K. McIlvennan from the University of Colorado School of Medicine in Aurora said, "There has been significant progress in incorporating palliative care specialists into the DT-LVAD population; however, there remain questions about the ideal timing to involve them and how to integrate them as part of team-based care."

"I think the way forward is to build upon the strengths of both palliative and cardiology specialties to provide comprehensive care to patients," she told Reuters Health by email. "This includes introducing palliative care specialists early in the decision-making process so they are viewed as part of the team that provides care while the patient is supported with an LVAD."

"Additionally, hospice can play a critical role for patients who chose to die outside the hospital," said Dr. McIlvennan, who was not involved in the study. "Continued partnership with local hospice agencies is imperative in order for patients, caregivers, and providers to feel comfortable with the transition of a patient with an LVAD to a hospice setting."

Dr. Lisa A. Kitko from The Pennsylvania State University, University Park, Pennsylvania, who recently reviewed patients' decision-making processes and expectations of LVAD pre- and post-implantation, told Reuters Health by email, "As detailed by the authors a very small percentage of the patients were able to participate in end-of-life (EOL) decisions. Involving the family in goals of care and EOL wishes during times of stability is critical as in the vast majority of cases, the family will be making decisions for the patient at the EOL."

"Alternate delivery models of palliative care such as in the outpatient setting, may improve rates of palliative care and more importantly the amount of time patients and families receive services and the benefits from comprehensive palliative care services (the median time of palliative care consult to death in this study was 9 days)," she said.

"Additional training of palliative care and hospice staff in caring for DT-LVADs at the EOL in various settings is critical," Dr. Kitko concluded. "Future work is needed to investigate the use of palliative care services early in the post implant period."

SOURCE: https://bit.ly/2ePJyQv and https://bit.ly/2dOGUYE

Circ Heart Fail 2016.