Introduction: For patients with end-stage heart failure, destination therapy ventricular assist devices (DT-VADs) can improve both quality and quantity of life (1-4). For a review of the practical aspects of this intervention, see Fast Fact #205. DT-VAD therapy is associated with significant morbidity and mortality risks (5). Consequently, the Centers for Medicare and Medicaid Services and the Joint Commission mandate palliative care involvement in the interdisciplinary care of all DT-VAD patients (6). While the recommended nature and duration of this involvement is not well-defined, palliative care teams often engage in planning conversations with patients being considered for a DT-VAD. This Fast Fact reviews best practices for such conversations.
The palliative care planning conversation Structured palliative care involvement in DT-VAD care can improve quality of life, advance directive completion, and clinician satisfaction with communication and end-of-life management (7). Pre-VAD planning conversations are meant to review goals and expectations, support shared decision-making, and engage in VAD-specific advance care planning. This type of advance care planning is sometimes referred to as ‘preparedness planning.’ It is used to review the risks and benefits of device therapy, elicit and deepen understanding of the underlying illness and therapeutic options, ensure adequate psychosocial support for successful VAD management, address existential concerns and coping, and engage in end-of-life planning. Preparedness planning is not meant to replace informed consent discussions the surgeon and cardiologist have with patients leading up to VAD placement. While the role of palliative care in DT-VAD evaluations varies by institution, the process of deepening a patient’s understanding of this specific medical intervention and ensuring this treatment aligns with their goals of care remains a central tenet of the planning conversation.
Clinical approach: The recommendations in the table below are based on expert opinion, reported experiences, and serious illness communication best practices (8-10). While all domains should be addressed for patients contemplating DT-VAD therapy, other clinicians (e.g., VAD coordinators, social workers, etc.) may be responsible for specific issues depending on the institution. Preparedness conversations should be documented in the medical record clearly and succinctly. Establishing a legal surrogate decision-maker should be an early clinical priority. Concerns about a patient’s understanding of the goals and risks of DT-VAD therapy, ambivalence about proceeding with VAD placement, and/or psychosocial complications should be communicated to the VAD multidisciplinary team.
Table: Suggested conversation domains and sample language
|Illness understanding and expectations (3,9,11,12)||What is your understanding of your heart failure? How have things been going lately with your health? (9,12)What have your clinicians told you about what to expect with your heart failure? Your treatment options? A VAD surgery?What is your understanding of what a VAD would provide in terms of survival and quality of life?What do you understand about what to expect if you cannot or choose not to receive a VAD?|
|Functional and psychosocial assessment(9,13)||What does a typical day look like for you? What are you able to do on a good day? On a bad day? What do you enjoy doing?Who do you consider part of your support system? Can they help with VAD care and medical follow-up?What have you been told about your caregiver’s responsibilities?Are there personal factors that you think will lead to the success of a VAD for you? Anything that might make having a VAD difficult?|
|Quality of life and coping(3,9,14,15)||What helps you live well despite your heart failure?What gives you strength and gets you through difficult times?What is the role of religion or spirituality in your life? (14)What are you worried about as you think about your health? (9)|
|Advance care planning (including priorities, trade-offs, end-of-life planning, review of advance directives)(9,12,14,15)||Who should make medical decisions for you if you cannot? How much do they know about your priorities and wishes? (9,12)What abilities are so critical that you cannot imagine living without them? (12)If you became sicker, how much would you be willing to go through for the possibility of more time? [Clarify with VAD-pertinent examples: dialysis, prolonged mechanical ventilation, long-term facility care, etc. If needed, help patients understand that at most institutions the VAD team will expect the patient to endure significant complications like dialysis and chronic mechanical ventilation for several weeks after placing a VAD.] (12)Are you aware that the VAD can be turned off if you were ever in a clinical situation in which your quality of life was not acceptable to you? (14)What would be most important if/when you are nearing the end of your life? (9)|
1. Rose EA, Moskowitz AJ, Packer M, et al. The REMATCH trial: rationale, design, and end points. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure. Ann Thorac Surg. 1999;67(3):723-730.
2. Starling RC, Naka Y, Boyle AJ, et al. Results of the post-U.S. Food and Drug Administration-approval study with a continuous flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2011;57(19):1890-1898.
3. Adams EE, Wrightson ML. Quality of life with an LVAD: A misunderstood concept. Heart Lung. 2018;47(3):177-183.
4. Chuzi S, Hale S, Arnold J, et al. Pre-Ventricular Assist Device Palliative Care Consultation: A Qualitative Analysis. J Pain Symptom Manage. 2019;57(1):100-107.
5. Kirklin JK, Pagani FD, Kormos RL, et al. Eighth annual INTERMACS report: Special focus on framing the impact of adverse events. J Heart Lung Transplant. 2017;36(10):1080-1086.
6. Jacques L, Jensen TS, Schafer J, Smith K, Casey M, Lotfi R. Decision memo for ventricular assist devices for bridge-to-transplant and destination therapy. Centers Medicare Medicaid Servivces. 2013:1-91.
7. Woodburn JL, Staley LL, Wordingham SE, et al. Destination Therapy: Standardizing the Role of Palliative Medicine and Delineating the DT-LVAD Journey. J Pain Symptom Manage. 2019;57(2):330-340.e334.
8. Swetz KM, Kamal AH, Matlock DD, et al. Preparedness planning before mechanical circulatory support: a “how-to” guide for palliative medicine clinicians. J Pain Symptom Manage. 2014;47(5):926-935.e926.
9. O’Connor NR, Moyer ME, Kirkpatrick JN. Scripted Nurse Visits: A Resource-Efficient Palliative Care Model for Ventricular Assist Devices. J Palliat Med. 2016;19(12):1312-1315.
10. Goldstein NE, May CW, Meier DE. Comprehensive care for mechanical circulatory support: a new frontier for synergy with palliative care. Circ Heart Fail. 2011;4(4):519-527.
11. Allen LA, McIlvennan CK, Thompson JS, et al. Effectiveness of an Intervention Supporting Shared Decision Making for Destination Therapy Left Ventricular Assist Device: The DECIDE-LVAD Randomized Clinical Trial. JAMA Intern Med. 2018;178(4):520-529.
12. Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003.
13. Ben Gal T, Jaarsma T. Self-care and communication issues at the end of life of recipients of a left-ventricular assist device as destination therapy. Curr Opin Support Palliat Care. 2013;7(1):29-35.
14. Nakagawa S, Yuzefpolskaya M, Colombo PC, Naka Y, Blinderman CD. Palliative Care Interventions before Left Ventricular Assist Device Implantation in Both Bridge to Transplant and Destination Therapy. J Palliat Med. 2017;20(9):977-983.
15. DeFilippis EM, Nakagawa S, Maurer MS, Topkara VK. Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. J Am Geriatr Soc. 2019;67(11):2410-2419.
Authors’ Affiliations: Medical College of Wisconsin, Milwaukee, WI.
Conflicts of Interest: None
Version History: First electronically published in November 2020; originally edited by Drew A. Rosielle MD
Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.
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