Mechanical circulatory support with left ventricular assist devices (LVADs) is, strongly, recommended as a therapeutic option in patients with advanced, stage D, heart failure [1,2]. Nowadays, a significant number of patients undergo LVAD implantation with annual survival rates equal to 80% and dramatically improved health-related quality of life [3]. Indeed, for the majority of these patients, this therapeutic option consists a destination therapy [4]. Corroborating the above mentioned data, according to Intermacs statistical report, 2345 patients had an LVAD implantation in the USA, during 2016, and approximately the half of them received these devices as destination therapy [4].
It is well known that patients with advanced heart failure are strongly eligible for palliative care services, included those with LVADs. Many scientific societies, such as the International Society of Heart and Lung Transplantation [2] and the European Society of Cardiology [1] recommend palliative care services for these patients, during the LVAD evaluation and the postoperative period. However, LVAD recipients consist a specific patient population with significant concerns regarding the providing palliative care [5]. Patients with an LVAD implant should take complex decisions, such as the place of death, the resuscitation options and the device deactivation. Indeed, end of life and hospice care face many barriers due to both the high healthcare cost and the lack of advanced staffing and equipment for advanced patient monitoring. Additionally, many LVAD patients need to obtain care at a tertiary hospital, which is inappropriate for high-quality secondary and tertiary palliative care [5-7].
Taking into account the above mentioned barriers and limitations to palliative care, advanced care directives are the core component of palliative care in LVAD patients on condition that advanced care planning start early in the disease process and prior to LVAD implantation [5]. Through advanced directives patients express their care preferences and decide on life sustaining treatments based on their own values and wishes. Additionally, clinicians assess patients’ values and preferences, adjust their management aiming to fully meet the individual patient wishes and needs and finally provide ethically permissible holistic care [5,6].
Although, LVAD patients are characterized by significantly low enrollment rates in palliative and hospice care services [8], clinicians, involving advanced care directives in their palliative care planning could ensure the optimal and high-quality palliation for LVAD recipients and their families, despite the significant barrier to palliative care for this patient group. Better integration of advanced care directives into the palliative care planning is needed and, simultaneously, this approach requires improved training of clinicians on the philosophy of heart failure patient palliative care.
References
- Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, et al. (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 18(8): 891-975. [Crossref]
- Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, et al. (2013) The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant 32(2): 157-187.
- McIlvennan CK, Magid KH, Ambardekar AV, Thompson JS, Matlock DD, et al. (2014) Clinical outcomes after continuous-flow left ventricular assist device: a systematic review. Circ Heart Fail 7(6): 1003-1013. [Crossref]
- Intermacs (2016) Intermacs Quartely Statistical Report 2016 Q4. http://www.uab.edu/medicine/intermacs/images/Federal_Quarterly_Report/Federal_Partners_Report_2016_Q4.pdf
- McIlvennan CK, Allen LA (2016) Palliative care in patients with heart failure. BMJ 353: i1010.
- Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM (2016) Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 13(1): 20-29.
- Ghashghaei R, Yousefzai R, Adler E (2016) Palliative Care in Heart Failure. Prog Cardiovasc Dis 58(4): 455-460.
- Dunlay SM, Strand JJ, Wordingham SE, Stulak JM, Luckhardt AJ, et al. (2016) Dying With a Left Ventricular Assist Device as Destination Therapy. Circ Heart Fail 9(10). [Crossref]
