Friday, December 11, 2009

Destination Therapy and Reversing Frailty


For those geriatric and palliative care practitioners who glossed over the recent NEJM publication of the Heartmate II trial as yet another esoteric, hyper-specialized trial should think twice. This trial could have significant implications for many geriatric and palliative care patients.

Issue #1 – disconnecting the Left Ventricular Assist Device (LVAD): On our palliative care service, I recently assisted with the care of a 74 year-old gentleman with one of these continuous flow LVADs. It was one of the most complicated goals-of-care discussions I have ever been involved with. From a cardiac standpoint, his heart/LVAD were doing extremely well. He did not have any signs of infection and his LVAD was maintaining great cardiac output. That said, He kept getting admitted with mild flare-ups of acute pancreatitis of unknown etiology, he didn’t want to get out of bed, and had an albumin of 2.8. Ultimately, he refused SNF, went home, failed rehab at home, stopped performing his ADLs, and transitioned to hospice. He then began requesting that they disconnect the LVAD. Because he wasn’t having any “problems” with his LVAD, there was reluctance to disconnect despite his near complete lack of function. Ultimately, the device nurse went to visit him at home and agreed that “he was done” and disconnected the LVAD. He died 5 minutes later. Earlier in the course of his illness, this same device nurse astutely noted “every destination LVAD will eventually require an end-of-life discussion.”

Issue # 2 – determining who would benefit from the LVAD: In the aftermath of this case, the cardiologists here in Colorado raised the question of whether they could predict, based on pre-procedure functioning, those who are too frail to benefit from an LVAD (yes, the cardiologists here in Colorado are far ahead of their field in considering geriatric and palliative care issues). In thinking about this further, I have realized a significant challenge. Defining a population unlikely to benefit from LVAD because of frailty (which makes perfect sense in decisions like colon or breast cancer screening) will be more difficult here as the frail will also be the population that stands to benefit the most. Indeed, patients in the trial improved a 6 minute walk from an average of 182 meters at baseline to 372 meters at 24 months – and these patients were sick (ineligible for transplant, failed medical management, at least 14 days of inotropes, etc.) Thus, LVADs appear to actually treat frailty...?

I write this post for a couple of reasons. First, I think the palliative care community needs to consider the unique challenges involved in disconnecting LVADs; while I think we are quite comfortable disconnecting ventilators and turning ICDs off, for some reason, LVADs feel different. Perhaps it is because this life-support is so directly tied to cardiac output. Perhaps the type of person who would accept an LVAD for destination therapy has a pre-disposition to defer end-of-life discussions. Second, some of the contributors to this blog are experts in using functional measures to predict outcomes and I would love to hear their thoughts on the use of 'frailty' to determine who might fail an LVAD.

6 comments:

Eric Widera said...

Great post Dan (Pallimed has a nice summary of the article for those who have not read it yet). I agree that for some reason LVAD withdrawal just feels different to me although I it took me some time to figure out why. If I try to rationalize this feeling I get nowhere - it really isn't any different than stopping a ventilator on someone who is ventilator dependent. Withdrawal of either ventilators or LVADs can result in an immediate death. I think the main difference is that I have a lot of experience with withdrawing people from ventilators and none with LVADs. I guess that highlights the importance of discussing the unique challenges of LVAD patients now.

Celeste said...

I recently had a case a level (or two or three) down from this. An elderly patient with metastatic cancer. We had entered the supportive/comfort care mode after several weeks of struggle with a rapidly declining performance status. The spouse was very concerned about the pacemaker (thankfully, NOT a pacemaker defibrillator) and wanted it turned off so that the process was not prolonged in any manner. The patient was in a waxing /waning delirium. The cardiologist initially refused. Finally, he agreed to send the technician over, but the technician, said that it was Medtronic's policy not to discontinue a device if it was "therapeutic" (i.e. if the patient paced on his own, they would turn it off; if he was dependent upon the pacemaker, they wouldn't. I as a physician could come turn it off.) I don't think it should be that difficult, and I feel strongly when the decision is made, why make it more emotionally difficult for the patient and the family (with an on-going fear that the device in the chest is keeping the patient here longer)? Apparently, it all comes down to legalities....not the patient.

New part of a advanced directive, "If I, in the course of my life, have acquired a device such as a pacemaker/defibrillator or LVAD that is stimulating any organ system to function, and if I am no longer able to make decisions for myself but it is agreed upon between my physician and my spouse/POA that said device might prolong a terminal state, said device should be turned off."

ken covinsky said...

Dan--I think you are correct that it would be very difficult to use frailty or functional criteria to predict who would benefit from a LVAD. In most of the situations where we use functional status as a prognostic measure, functional status will either not improve or continue to decline over time. In the case of LVAD, the underlying cause of the functional impairment is being treated. The data in the NEJM article seem to suggest that the functional improvement may sometimes be dramatic.

It seems it would be useful to know to how much of the baseline functioning is due to CHF and how much is due to other chronic disease. I would imagine that patients that have significant functional impairment unrelated to CHF would not do as well. The problem is that it is very hard to parse out in a particular patient how much each disease is contributing to their functional difficulties.

Hopefully, as this technology is disseminated, there will be studies that better identify who does well. It seems likely that non cardiovascular factors, including depression and cognitive functioning, will play an important role.

Marian Grant said...

I think this is an important area for the palliative care field to address. Regarding LVADs, they seem similar to me to pacers for complete heart block. I've had a patient request to his his pacer discontinued and, after an ethics consults, the MICU attending finally agreed. But the fact that the MICU attending, who is generally comfortable with discontinuing life support, found this so difficult confirms that many view such cardiac devices as being in a different life support category.

Dan Matlock said...

Ken, your comments were actually very helpful for our local cardiology group.

Eric, thanks for pointing out that Drew had written a post on LVADs the day prior to my post. It is a great review and I truly hadn't seen it.

Guy Micco said...

Hi All,

Lordy, I dislike a pedant; but I'm going to be a bit pedantic here.. sorry in advance... I'm saying nothing new in pointing out that words matter, and specifically here in hoping that the whole medical world will eschew the use of patients "failing" a treatment or therapy; as in "the patient failed rehab" or "the patient failed medical management." I know I have said something of this sort before - "the patient failed chemo," or the like - and I don't want to cast aspersions on anyone who does so; I just hope we can all remember that the patient isn't the one who 'fails.' If anything does so, it's the treatment that fails the patient.