Preparedness Planning for Patients Receiving Left Ventricular Assist Device as Destination Therapy: How Best to Measure Change in Culture? (SA545-A)

Abstract

•Articulate recent CMS and ISHLT guidelines for care of patients receiving DT and what palliative care-specific issues are in those guidelines.•Define preparedness planning for patients who receive left ventricular assist device as destination therapy (DT) and describe four core elements.•Explore rates of advance directive completion and preparedness plan documentation prior to DT implementation, and describe contents of such advance directive documents and PM consultations. Left ventricular assist device as destination therapy (DT) can improve survival, functionality, and quality of life in patients with advanced heart failure. However, advance care planning (ACP) is crucial to promote outcomes consistent with patient’s goals, as patients will have DT until their death. Preparedness planning (PP) refers to our proposed approach to such ACP. To describe our initial, 5-year, single institution experience with PP and DT. Retrospective medical record review of 107 consecutive patients undergoing DT implantation between January 5, 2009, and August 19, 2013, with focus on advance directive (AD) content and palliative medicine (PM) consultation documentation (specifically seeking core elements of PP: device failure, post-DT quality of life, catastrophic complication, and comorbidity progression). Mean (±SD) patient age at DT implantation was 64.3 ±10.7 years, and 42 (43%) patients have since died. PM evaluated 86 (80.1%) patients preimplantation; 75 (87.2%) were able to complete PP preimplantation. Seventy-one (66.4%) patients had an AD at time of implantation, compared with 47% pre 2009 (p=0.01). Fifty-nine (68.6%) patients having PM consultation had an AD at implantation, while 12 (57%) patients without PM consultation had an AD (p=0.32). While PM consultation notes often documented core elements of PP, only 2 (2.8%) ADs specifically addressed LVADs, and no such document contained any of the core PP elements. Hospice utilization was rare (3/42 patients) and did not differ based on PM consultation or presence of an AD or PP. PM consultation and ACP are integral to comprehensive DT care. While completion/availability of ADs prior to DT implantation has improved with PP efforts, ADs still rarely address LVAD-specific issues, and hospice utilization remains rare. Ongoing efforts at optimizing PP processes and measuring quality improvement are warranted.