Quality of Life Outcomes of Patients Receiving Palliative, Long-Term Continuous Intravenous Inotropic Support

Abstract

Long-term, continuous intravenous inotropic support (CIIS) is frequently initiated for palliation of symptoms related to advanced heart failure (AHF) in patients who are not eligible for heart transplantation or mechanical circulatory support (MCS). Although the use of CIIS has increased in prevalence over the past decade, robust data regarding quality of life (QOL) outcomes in these patients are lacking. We wished to describe healthcare utilization and QOL outcomes in patients on palliative CIIS. Retrospective analysis of inpatients followed by the AHF service at MedStar Washington Hospital Center who were started on palliative CIIS between 2014 and 2016. Patients were excluded if they were being worked up for transplantation or MCS at the time of initiation. EHR were queried to obtain patient demographics, duration of CIIS, readmissions and emergency room encounters, transfer to an intensive care unit (ICU), code status at the time of initiation, documented goals of care discussions, palliative care consultation, and hospice referral. Data was analyzed using descriptive statistics. We identified 72 patients that fit the criteria for the study with a median of 106 days on CIIS (range 4-726 days). 68 patients (94%) began CIIS as full code and 5 (6%) as do not resuscitate/do not intubate (DNR/DNI). Fifty percent of those starting as full code changed to DNR/DNI and 22% remained full code until death. There was an average of 2.4 +/- 2.4 hospital readmissions, 0.7 +/- 1.2 ER visits, and 22.5 +/- 22.7 hospital days (range 0-126 days) during CIIS. Thirty three percent of patients admitted to the hospital were transferred to the ICU at least once. Ninety five percent of patients had documented goals of care discussions and 69% had a palliative care consult; however, only 58% were referred to hospice. Patients in this cohort had high healthcare utilization. Although the majority of patients on CIIS had documented goals of care, we observed significant variation in palliative care and hospice involvement. This data may assist clinicians with educating and setting expectations for patients when initiation of CIIS is considered. Future studies should assess symptom benefit of CIIS, associated risks including central line infection and implanted cardioverter-defibrillator shocks, and explore barriers to hospice enrollment.