Abstract
Goldstein NE, May CW, Meier DE: Comprehensive care for mechanical circulatory support: A new frontier for synergy with palliative care. Circ Heart Fail 2011;4:519–527.
Heart failure is a chronic and progressive illness and a leading cause of death in the United States. With limited therapeutic options, mechanical circulatory support (MCS) has been increasingly used to treat patients with end-stage heart failure, both as a bridge to transplantation (BTT) as well as destination therapy (DT). In this excellent article the authors discuss the use of MCS as well as palliative care in the management of these patients. Various topics are discussed, including what is palliative care, role of palliative care at key points in the clinical care of MCS patients, improving communication and decision-making in MCS patients, and discussion of goals of care. There are three great tables, Selected Joint Commission Requirements for MCS Programs and How Palliative Care Meets Standards, Techniques to Improve Communication With MCS Patients and Their Caregivers, and Specific Points to Cover at Key Times With MCS and Sample Communication Techniques for Each Time Period. This is a highly recommended article for all palliative care clinicians who will undoubtedly be involved with the care of MCS patients.
Byram EK: Upstream palliative care for the patients with a left ventricular assist device as destination therapy. Dimens Crit Care Nurs 2012;31:18–24.
Left ventricular assist devices (LVADs) used for destination therapy (DT) have proven to be beneficial for patients with heart failure who are eligible or are not candidates for a heart transplant. As this population grows, so will the need for palliative care. In this article the author provides a background on heart failure and LVADs, how the LVAD works, the LVAD as end-of-life therapy, the role of palliative care, ethical considerations for deactivation of LVAD therapy, the caregiver's burden, and an integrated multidisciplinary approach. This article is highly recommended for all palliative care clinicians.
Khazanie P, Rogers JG: Patient selection for left ventricular assist devices. Congest Heart Fail 2011;17:227–234.
As per the two preceding articles, mechanical circulatory support (MCS) is becoming increasingly frequent. In this article the authors discuss patient selection for one type of MCS, left ventricular assist devices. The article is thorough and covers defining treatment goals, indications for MCS, patient evaluation for LVADs, noncardiovascular criteria, and operative risk and risk scores predicting mortality after VADs. This article is highly recommended.
Killoran A, Biglan KM: Therapeutics in Huntington's disease. Curr Treat Options Neurol 2012 (published online ahead of print publication).
Huntington's disease (HD) is a debilitating neurologic disease for which there is no specific treatment. In this article the authors discuss the limited therapeutics available to manage the symptoms of HD. The only drug approved by the U.S. Food and Drug Administration (FDA) for treatment of HD is an antichoreic agent, tetrabenazine, but it is used sparingly because of concern regarding its propensity to cause depression and suicidality in the HD patient population, which is already at risk for such complications. Neuroleptics are still first-line treatments for chorea accompanied by comorbid depression and/or behavioral or psychotic symptoms, as is often the case. Psychiatric features, which have a significant impact on a patient's professional and personal life, often become the major focus of management. In addition to neuroleptics, commonly used medications include antidepressants, mood stabilizers, anxiolytics, and psychostimulants. In contrast, few treatment options are available for cognitive impairment in HD; this remains an important and largely unmet therapeutic need. HD patients typically lack insight into their disease manifestations, failing to recognize their need for treatment, and possibly even arguing against it. Multipurpose medications are employed to simplify the medication regimen, so as to facilitate compliance and not overwhelm the patient. For example, haloperidol can be prescribed for a patient with chorea, agitation, and anorexia, rather than targeting each symptom with a different drug. This approach also limits the potential for adverse effects, which can be difficult to distinguish from the features of the disease itself. As the disease progresses, palliative care can play a significant role in providing symptom management and support of patient and family in meeting goals of care.
Mentz RJ, Fiuzat M, Wojdyla DM, Chiswell K, Gheorghiade M, Fonarow GC, O'Connor CM: Clinical characteristics and outcomes of hospitalized heart failure patients with systolic dysfunction and chronic obstructive pulmonary disease: Findings from OPTIMIZE-HF. Eur J Heart Fail (published online ahead of print publication).
Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF) patients, yet the population is poorly characterized and associated with conflicting outcomes data. In this study the authors attempted to evaluate the clinical characteristics and outcomes of HF patients with systolic dysfunction and COPD in a large acute HF registry. OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) was a performance-improvement registry of patients hospitalized with HF (n=48,612), which included a pre-specified subgroup of patients (n=5,701) with 60- to 90-day follow-up. The authors performed a retrospective analysis of the clinical characteristics and outcomes (length of stay, and in-hospital and 60-day mortality) of patients with systolic dysfunction according to baseline COPD status. COPD was present in 25% of the patients. These patients had more comorbidities compared with patients without COPD, and were less likely to receive a beta-blocker or angiotensin-converting enzyme inhibitor during hospitalization and at discharge. COPD was associated with an increased median length of stay [five days (interquartile range 3-8) versus four days (interquartile range 3-7), P<0.0001] and increased in-hospital all-cause and noncardiovascular (CV) mortality, with rates of 4.5% versus 3.7% and 1.0% versus 0.6%, respectively, for the two endpoints, but similar 60-day mortality (6.2% versus 6.0%). After risk adjustment, the in-hospital non-CV mortality remained increased. The authors conclude that the presence of COPD in HF patients with systolic dysfunction is associated with an increased burden of comorbidities, lower use of evidence-based HF medications, longer hospitalizations, and increased in-hospital non-CV mortality, but similar postdischarge mortality.
Mack JW, Cronin A, Taback N, Huskamp HA, Keating NL, Malin JL, Earle CC, Weeks JC: End-of-life care discussions among patients with advanced cancer: A cohort study. Ann Intern Med 2012;156:204–210.
National guidelines recommend that physicians discuss end-of-life (EOL) care planning with patients with cancer whose life expectancy is less than one year. In this cohort study the authors attempted to evaluate the incidence of EOL care discussions for patients with stage IV lung or colorectal cancer and where, when, and with whom these discussions took place. Patients diagnosed with lung or colorectal cancer from 2003 to 2005 were involved in the study. Participants lived in northern California, Los Angeles County, North Carolina, Iowa, or Alabama or received care in 1 of 5 large HMOs or one of 15 Veterans Health Administration sites. Stage IV lung or colorectal cancer enrollees numbered 2155. Results demonstrated that 73% of patients had EOL care discussions identified by at least one source. Among the 1470 patients who died during follow-up, 87% had EOL care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up. Of the 1081 first EOL care discussions documented in records, 55% occurred in the hospital. Oncologists documented EOL care discussions with only 27% of their patients. Among 959 patients with documented EOL care discussions who died during follow-up, discussions took place a median of 33 days before death. The authors conclude that although most patients with stage IV lung or colorectal cancer discuss EOL care planning with physicians before death, many discussions occur during acute hospital care, with providers other than oncologists, and late in the course of illness.