End-of-life decision making and implementation in recipients of a destination left ventricular assist device.
BACKGROUND
The use of left ventricular assist devices (LVADs) as destination therapy (DT) is increasing and has proven beneficial in prolonging survival and improving quality of life in select patients with end-stage heart failure. Nonetheless, end-of-life (EOL) issues are inevitable and how to approach them underreported.


METHODS
Our DT data registry was queried for eligible patients, defined as those individuals who actively participated in EOL decision making. The process from early EOL discussion to palliation and death was reviewed. We recorded the causes leading to EOL discussion, time from EOL decision to withdrawal and from withdrawal to death, and location. Primary caregivers were surveyed to qualify their experience and identify themes relevant to this process.


RESULTS
Between 1999 and 2009, 92 DT LVADs were implanted in 69 patients. Twenty patients qualified for inclusion (mean length of support: 833 days). A decrease in quality of life from new/worsening comorbidities usually prompted EOL discussion. Eleven patients died at home, 8 in the hospital and 1 in a nursing home. Time from EOL decision to LVAD withdrawal ranged from <1 day to 2 weeks and from withdrawal until death was <20 minutes in all cases. Palliative care was provided to all patients. Ongoing assistance from the healthcare team facilitated closure and ensured comfort at EOL.


CONCLUSIONS
With expanding indications and improved technology, more DT LVADs will be implanted and for longer durations, and more patients will face EOL issues. A multidisciplinary team approach with protocols involving DT patients and their families in EOL decision making allows for continuity of care and ensures dignity and comfort at EOL.
Brush
Sally
S
Utah Artificial Heart Program, and Intermountain Medical Center and Intermountain Healthcare, Salt Lake City, Utah 84107, USA.
Budge
Deborah
D
Alharethi
Rami
R
McCormick
Ashley J
AJ
MacPherson
Jane E
JE
Reid
Bruce B
BB
Ledford
Ian D
ID
Smith
Hildegard K
HK
Stoker
Sandi
S
Clayson
Stephen E
SE
Doty
John R
JR
Caine
William T
WT
Drakos
Stavros
S
Kfoury
Abdallah G
AG
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017028:Caregivers / Q000523:psychology*; D015897:Comorbidity; D003657:Decision Making; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000601:surgery; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011368:Professional-Family Relations; D036301:Qualitative Research; D011788:Quality of Life; D013727:Terminal Care; D013997:Time Factors; D055815:Young Adult