• Survey: Ask for Palliative Consult for VAD/TAVR Protocols and knowledge around end-of-life issues often lacking

    Palliative care has room to expand in the considerations around cardiovascular device placement and replacement, a clinician survey suggested.

    Among clinicians who answered an online survey, 88.3% agreed that palliative care consultations can be helpful for patients considering transcatheter aortic replacement (TAVR), and another 83.4% felt the same for ventricular assist devices (VADs), James N. Kirkpatrick, MD, of the University of Washington in Seattle, and colleagues found.

    And 56.1% reported often providing palliative care consultations for patients deemed ineligible for VAD placement, though only 34.4% of operators consulted accordingly with patients who couldn’t get TAVR, the researchers reported online in JAMA Internal Medicine.

    Most indicated that they had some knowledge of palliative care (82.6%), though only 13.6% claimed that knowledge to be extensive. Only 10.5% reported receiving any formal instruction on palliative care during cardiovascular training.

    A substantial number of clinicians said they did not know if their institutions required advance directives or had formal protocols for palliative care involving TAVR (27.8%) or VAD implantation (21.9%).

    A total of 323 respondents filled out the online survey between 2014 and 2015. Most were physicians practicing adult cardiology (85.8%).

    “We observed a low rate of formal inclusion of palliative care consultation in institutional protocols, with higher use in patients receiving a VAD than a TAVR, and lack of specific knowledge about the protocols themselves,” the investigators wrote.

    “These findings and the substantial workforce shortage in palliative care indicate a need for more research into barriers that limit provision of palliative care and for training opportunities for clinicians who care for patients (especially the elderly with comorbidities) undergoing implantation of TAVRs or VADs and, by extension, undergoing other high-risk cardiovascular procedures,” Kirkpatrick’s group concluded.

    Joanne Lynn, MD, of the Altarum Institute in Washington, noted that 2012 was the year that the American Heart Association released guidelines recommending that implantable cardioverter defibrillator (ICD) recipients know that turning the device off can be an option that aligns with other “overall goals of care.”

    “No longer did the clinicians sell their device as an unalloyed good,” she wrote in accompanying editorial. “We were coming to terms with the implacable fact of mortality and recognizing that some treatments caused more harm than good, perhaps especially when an ICD converted a peaceful dying into a cacophony of shocks and prolonged suffering.”

    Those issues were illustrated by an accompanying article in which Pamela Diaconis shared a story about her elderly father who had his entire ICD replaced, instead of the expected battery replacement. The option of forgoing intervention was never brought up by his cardiologists.

    Later on, that new device gave him two inappropriate shocks while he was “fully awake.”

    She noted that “this could have been avoided if, prior to any life extending procedures being performed on an 89-year-old man with minimal heart function, someone had asked about the kind of life – and death – my father wanted.”

    Diaconis finally had the device deactivated, letting her father pass away peacefully. “I would hate to think how his last minutes might have been spent with the defibrillator shocking him repeatedly as he was dying,” she wrote.

    According to Lynn, “Diaconis justifiably feels wronged by the care system that imposed unnecessary suffering on her father. Helping to support persons who must live with disabilities and illnesses in old age is part of our health care mission; and, as she recounts it, the replacement of the ICD was an error.”

    “We are doing better over time in recognizing the limits of our technologies. We should monitor progress and performance and, as warranted, celebrate our growing maturity in supporting patients who must deal with death,” the editorialist concluded.

    Among other limitations of the study, Kirkpatrick and colleagues acknowledged that “the modest number of responses and the relatively high rating of palliative care services among the respondents suggest that the findings may not be generalizable to the cardiovascular community at large.”


    Kirkpatrick, Lynn, and Diaconis reported no relevant conflicts of interest.


    JAMA Internal Medicine


    Kirkpatrick JN, et al “Palliative care for patients with end-stage cardiovascular disease and devices: a report from the palliative care working group of the geriatrics section of the american college of cardiology” JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2016.2096.


    JAMA Internal Medicine


    Lynn J “A maturing use of defibrillators” JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2016.1933.


    JAMA Internal Medicine


    Diaconis P “I wish someone had told us the risks and benefits of replacing my father’s defibrillator” JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2016.1926.


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