Palliative Care For Patients With End-Stage CVD and Devices

This article was authored by James N. Kirkpatrick, MD, FACC, a member of ACC’s Geriatric Cardiology Section.

I was the lead author on a research letter recently published in JAMA Internal Medicine that was conducted by the ACC Geriatric Cardiology Section’s Palliative Care Working Group and was endorsed by the leadership of the ACC.

Although palliative care is not often considered in cardiovascular medicine until the very end of life, the respondents in our study held favorable views toward palliative care, and not just for patients with transcatheter aortic valve replacement (TAVR) and ventricular assist devices (VADs) who are nearing the end of life. Although palliative care was not reported to be routinely involved in formal care protocols, it was reported more often for patients with VAD than patients with TAVR.

Very few respondents reported that they had received formal palliative care education during their cardiovascular training programs.

We believe that, given the importance of palliative care in patients undergoing TAVR and VAD, and in light of the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) requirement that palliative care specialists must be involved in care teams for destination therapy VAD patients, cardiovascular clinicians should receive more training in palliative care. Ideally, this goal would be accomplished through formal education during cardiovascular training programs but also more dedicated programs at scientific sessions and on-line educational opportunities. To this latter end, the palliative care working group of the Geriatrics Section of the ACC will be holding two webinars this month, one on symptom management and the other on communication and advance care planning. Education efforts are especially important in light of the national shortage of palliative care clinicians.

Formal inclusion of palliative care in protocols directing the care of patients with implanted cardiac devices will become increasingly important, especially as more of these devices are implanted in elderly patients with multimorbidity. Incorporation of palliative care specialists in the care of patients undergoing TAVR, in particular, may be especially important and may be mandated by CMS or TJC, similar to the situation for patients undergoing VAD.

It is important to remember that, while palliative care clinicians can help with the transition to hospice, palliative care can be instituted alongside of life-prolonging interventions. Palliative care is not synonymous with hospice. Symptom management and advance care planning are important for patients with serious cardiovascular diseases at any stage of the treatment process. Cardiac devices are important parts of symptom relief, as well as life prolongation, but they can complicate the dying process (e.g., decisions about deactivation of VADs in the setting of end stage dementia or a diagnosis of intractable cancer). Palliative care can help to make this process less complicated.

Future studies should address the long-term impacts of palliative care for patients with TAVR and VAD, particularly on patient-centered outcomes. Novel ways to address the palliative care clinician shortage should be investigated, including training cardiovascular clinicians in "basic" or "primary" palliative care.

Read more about the results in an news story.

Register for a free webinar on Palliative Care Symptom Management for the Cardiovascular Clinician on Wednesday, June 15 at Noon ET.