Palliative Outcomes in Patients with Left Ventricular Assist Devices and Active Malignancies

Abstract

<h3>Purpose</h3> To describe palliative outcomes in patients with left ventricular assist devices (LVADs) diagnosed with cancer at or after LVAD implantation. <h3>Methods</h3> In this retrospective cohort study, an LVAD database was reviewed (2005 to 2021) to identify patients diagnosed with cancer at or after LVAD implantation. Variables included demographic data, hospice referrals, changes in code status, number of palliative consults, length of hospitalization in the last year of life and location of death. <h3>Results</h3> We identified 24 patients who had or were subsequently diagnosed with an active malignancy after LVAD implantation. The average age was 60 years, 54% were male and 79% were African Americans, and 54% were deceased. 67% of the patients had a cancer diagnosis after LVAD implantation (average 2.1 years after implantation). Primary cancer types included breast (29%), prostate, lymphoma, and renal cell (13% each), and colorectal, lung, thyroid or multiple myeloma in the remainder. Average number of hospitalizations in the last year of life was 3.25 (range 1-8). Mean hospital length of stay (LOS) in the last year of life was 50.5 days (range 2-211). Location of death included the hospital ICU (47%), hospital floor (20%), home (20%), nursing facility (7%) and the OR (7%). Primary cause of death was cancer complications in 60% and heart failure complications in 27%, with the remaining due to other causes. Palliative service was consulted for 58% of the patients at an average of 1.13 times in the last year of life, with the number of consults increasing with LOS to a maximum of 4 times in a 211 day stay. 63% of patients had their code states changed from full code to DNR/DNI or comfort care. Hospice was discussed with 33% of the patients but only 13% enrolled in hospice care. <h3>Conclusion</h3> There is limited data on palliative outcomes in heart failure patients with cancer at or after LVAD implantation. The findings from this study demonstrate that the majority of patients with dual diagnoses have a reduction in LVAD longevity due to a concomitant malignancy. Primary location of death in a high acuity setting and low utilization of hospice care in this subset of patients suggests that palliative care services should be involved early to facilitate goals of care discussions. Lastly, the prolonged average hospital stay indicates high utilization of care and cost yet a disproportionately low average of palliative consultations.