A View from the Bridge, Determining the Next Step in Cardiac Therapy

Outcomes

1. Participants will be able to provide support to patients in distress from loss of eligibility for advance cardiac therapy.

2. Participants will be able to collaborate with other specialties in transitioning care towards hospice, and mitigate potential symptoms.

Key Message

Palliative care physicians will need to revamp the approach of hospice and palliative care in cardiac failure with recent advancements. Decision to no longer pursue destination therapy while on the bridge, can be distressing for patients, their families and clinicians involved.

Abstract

Impella placement for management of cardiogenic shock is rapidly increasing. Impella 5.5 is approved by the FDA (I) for <14 days but too often, patients are on these devices longer as a bridge to destination therapy. Changes in eligibility can lead to distress in patients, families, and caregivers with palliative teams caught in the middle. A 46-year-old male was admitted for cardiogenic shock. He required inotropic support and bridge with Impella. He was unable to wean from Impella or inotrope support. He experienced multiple setbacks that impacted his eligibility for destination therapy. Palliative care was consulted after cardiology determined he was no longer eligible for destination therapy. A family meeting was held and based on his limited options he wanted to continue with Impella and remain a full code. In attempting to fulfill his wishes, cardiology re-evaluated his candidacy again and came to the same conclusion. Palliative care continued to follow and offered support. His updated goal was to get home, 2 hours away from the hospital to see his mother. While cardiology formulated a potential plan for impella removal, palliative care discussed hospice care in multiple meetings with the patient and his family on multiple occasions. Patient and family viewed the palliative care team as “bad news team.” He asked to no longer see the physicians but continued to receive support from social worker. After 11 weeks in the hospital, he was transferred to another local hospital where he had an LAVD placed and since been discharged home. When patients are walking the thin line of eligibility for a potentially lifesaving intervention, for some the path can be challenging emotionally and mentally especially when eligibility can change from a day-to-day basis. Palliative care teams could find themselves as the face of a worst option.

References

(I)Improved clinical outcomes associated with the Impella 5.5 compared to the Impella 5.0 in contemporary cardiogenic shock and heart failure patients Ramzy, Danny et al. The Journal of Heart and Lung Transplantation, Volume 42, Issue 5, 553 - 557