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Paradigm Shift: End-of-Life Care with a Destination Therapy LVAD

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Linda Staley, NP
Mayo Clinic
Phoenix, AZ, USA

How does one handle end-of-life care with a Destination Therapy (DT) LVAD? Should it begin during the selection process, prior to advanced therapies being started or performed? How does the LVAD team ensure that the quality of life of the patient and family goals are realistic and being met? When is the right time and place to engage the hospice team for end-of-life care in a DT LVAD so that the patient and family are availed of the most support from the service? How do these questions get answered within your DT LVAD program and among your interdisciplinary team?

In 2014, the Joint Commission recognized the importance of the palliative care team as part of the VAD interdisciplinary team. The Joint Commission required program leaders to integrate the palliative care team within the program's core LVAD team. Incorporating the palliative care team within the VAD programs has resulted in enhanced support for the patient and family throughout the progression of life while on LVAD support. As technology continues to advance regarding mechanical support, and patients are living longer with advanced therapies to manage end-stage heart failure, it is crucial to have the palliative care team involved with the DT LVAD programs.

The palliative care team members can consult with patients and families prior to implant of the DT LVAD, promoting open discussions regarding the goals of LVAD patient care, and what quality of life means to the patient and family. This collaboration can help patients and families cope during the major decision-making process regarding the implant of the DT LVAD. The palliative care team also assists the patient and family in managing the quality-of-life issues associated with an advanced disease such as end-stage heart failure, and use of advanced therapies with DT LVAD.

The palliative care team integration with the core VAD team has provided patients and families a comprehensive assessment and treatment of the physical, psychosocial, and spiritual aspects of patient care prior to a DT LVAD being implanted. This teamwork continues throughout the progression of life while the patient is on the DT LVAD until end-of-life care is required. The development of a positive patient-and-caregiver relationship between the DT LVAD patient and the palliative care team over the years while a patient is on support can enhance the transition to end-of-life care when hospice services are required.

I have been an NP VAD Coordinator for more than 10 years in a busy Tertiary Care Transplant/VAD program in the Southwestern USA. In the beginning of our program, end-of-life care with an LVAD typically occurred in the hospital ICU setting. Consultation with our palliative hospice team for end-of-life care too often occurred only within the patient's last 24-48 hours of life. We also did not have many options available to individualize the end-of-life care for a patient with an LVAD to meet the patient and family goals and needs.

As a NP VAD Coordinator, I have seen a paradigm shift in the last 2-3 years regarding end-of-life care and the DT LVAD patient. The integration of the palliative care team within the interdisciplinary VAD team has allowed end-of-life care to be individualized, and to meet the needs of the patients and families with the DT LVAD. These conversations are occurring earlier and often prior to LVAD complications, progression of aging complications, or worsening heart failure occurring while on LVAD support. I have seen more VAD patients and families choose end-of- life care to be at home, with hospice assistance, and have observed these services being offered and started earlier. This shift may help to reduce the caregiver stress, burden, and burnout resulting from the challenges of end-of-life care.

It truly takes an interdisciplinary team to care for the DT LVAD patient and family, and to provide compassionate end-of-life care. I would like to leave you with the following questions -- "How is the palliative care team used within your LVAD program, and have you seen a paradigm shift regarding end-of-life care with an LVAD?" ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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