Abstract P283: Palliative and End-Of-Life Care After Left Ventricular Assist Device-Associated Intracranial Hemorrhage

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Background: Intracranial hemorrhage (ICH) has a high mortality rate (up to 40% in some studies) with most deaths occurring after limitation of life-sustaining therapies. ICH is a feared complication of left ventricular assist device (LVADs) and challenges end-of-life decisions for patients, families, and health-care teams. Palliative care (PC) is considered essential for the management of patients who receive an LVAD, yet little is known about the end-of-life course of patients with LVAD-associated ICH. The goal of this single center study was to better understand the impact of PC involvement in post-ICH care in LVAD patients. Methods: We retrospectively identified all patients within our institutional LVAD database who experienced ICH between 2012 - 2018. Demographic, clinical, and outcome data were collected and analyzed using descriptive statistics. Results: Of the 283 patients who underwent LVAD placement, 32 (11%) experienced 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%), a median of 258 (110-526) days post-LVAD. PC was consulted in 23 (68%) cases (69% of IPHs, 75% of SDHs, and 64% of SAHs). The patients who received PC were younger (50.5 [16.5] vs 54.9 [17.1] years) and more neurologically impaired (mean GCS 12.8 [3.6] vs 13.2 [4.0]). Women were referred more frequently than men (80% vs 63%) and White patients more frequently than non-White (74% vs 63%). All patients were full code at the time of their ICH; following PC consult, code status was changed to DNR in 48%. Ten patients (29%) died during their hospitalization. Though most patients in the cohort were referred for PC, only one died on home hospice; the remaining patients died in the hospital setting, 7 (70%) in the intensive care unit (ICU). Conclusions: In this single-center study, the vast majority of LVAD patients who died from their ICH died in the hospital setting, and most in the ICU, despite high numbers of PC consultation. As prior studies have associated in-hospital death with worse end-of-life-care and more physical and emotional distress for terminal patients, the use of hospice services has been increasing in the stroke population. Further work is needed to provide better end-of-life options for LVAD patients following serious neurologic injuries.