Incorporating Palliative Care as Standard Practice in Heart Transplant Rejection Therapy

Abstract

<h3>Introduction</h3> Multidisciplinary teams are critical in the management of patients post transplantation. However, inclusion of palliative care modalities can be challenging and nebulous in the transplant community. Herein we describe a cardiac transplant recipient who received a unique outpatient palliative care consultation integrated into the care plan for acute antibody (AMR) rejection. <h3>Case Report</h3> A 70-year-old male patient with systolic heart failure, s/p heart transplantation postoperative course complicated by graft dysfunction requiring ECMO, plasmapheresis, and antithymocyte globulin. He was later diagnosed with AMR and treated with multiple rounds of therapeutic plasma exchange, Immunoglobulin therapy, and months of photopheresis. He unfortunately failed to thrive during AMR treatment and was hospitalized numerous times with complications to include infections, volume retention, dehydration, dysphagia, syncope, and mechanical falls with injury. He became debilitated and struggled with weakness, dyspnea requiring continuous oxygen, lethargy, and dependency on his family for assistance with daily activities. He reported poor quality of life and depression. Due to persistent AMR, there was consideration for re-attempting photopheresis. Palliative care was ultimately consulted to assist patient and family with goals of care discussion. Supported by palliative care and the medical team, the patient was able to define his quality-of-life standards and future goals. This included clarifying his values, fears, strengths, and spirituality. As a result of this approach, he opted to defer any further photopheresis or antirejection therapy. He requested to focus on reducing symptom burden, avoiding hospitalizations, and spending time with family. To date he has avoided hospital readmissions, reports significant reduction in symptom burden, and improved quality of life. <h3>Summary</h3> The World Health Organization (2020) reports that 40 million people are in need of palliative care and only 14% currently are receiving it. This case advocates for seamless integration of palliative care consults for patients undergoing treatment for refractory AMR. Moreover, this aligns the treatment plan with patient values furthering support of their families holistically. Ultimately this intervention will preserve quality and possibly extension of life.