Abstract
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 Although the recommended nature and duration of this involvement are 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 Preventricular assist device (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. Although 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 Table 1 are based on expert opinion, reported experiences, and serious illness communication best practices.8–10 Although all domains should be addressed for patients contemplating DT-VAD therapy, other clinicians (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.
Suggested Conversation Domains and Sample Language
VAD, ventricular assist device.