A, Percentages of respondents who care for patients with a TAVR or VAD regarding institutional protocols that involve formal palliative care consultation before implantation of the device. B, Responses regarding palliative care consultation for patients under consideration for TAVR and VAD who were not deemed to be candidates for the devices.
James N. Kirkpatrick, Paul J. Hauptman, Keith M. Swetz, Elizabeth D. Blume, Kimberlee Gauvreau, Mathew Maurer, Sarah J. Goodlin. Palliative Care for Patients With End-Stage Cardiovascular Disease and DevicesA Report From the Palliative Care Working Group of the Geriatrics Section of the American College of Cardiology. JAMA Intern Med. 2016;176(7):1017–1019. doi:10.1001/jamainternmed.2016.2096
Palliative care has not traditionally been seen as applicable to patients who are candidates for device-based therapies, including transcatheter aortic valve replacement (TAVR) and ventricular assist devices (VADs). However, although improvements in technology, expertise at implanting devices, and patient selection have been made,1 these devices come with a risk of morbid complications that can be particularly deleterious in elderly patients with preexisting comorbidities and impaired baseline functional and/or cognitive status.2 Therefore, we designed a survey of clinicians (physicians, nurses, and advanced practice practitioners) to assess attitudes toward and current status of palliative care in the approach to patients undergoing TAVR and VAD implantation procedures.
A 44-item survey, approved by the University of Pennsylvania Institutional Review Board and senior leadership of the American College of Cardiology, was sent to email addresses in American College of Cardiology membership files from November 1, 2014, to January 31, 2015. Participant consent was provided by choosing to take the survey. Potential respondents were asked to complete the survey if they cared for patients with a TAVR and/or VAD; owing to limitations in the membership file information, it was not possible to verify that the potential respondents cared for patients with a TAVR and/or VAD or to establish formal response rates.
Of 323 respondents, most were physicians (169 [52.3%]) practicing adult cardiology (277 [85.8%]). Practice location was mostly urban (176 [54.5%]) and academic (164 [50.8%]). Most respondents held favorable views toward palliative care, agreeing that palliative care consultations could be helpful (TAVR, 227 of 257 [88.3%]; VAD, 146 [83.4%]) (Table). Although 42.5% (116 of 273) and 51.3% (96 of 187) reported that advance directives were required in their institution or practice before implantation of a TAVR or VAD, respectively, a substantial minority of respondents indicated that they did not know about institutional practices requiring advance directives (TAVR, 76 of 273 [27.8%]; VAD, 41 of 187 [21.9%]), the existence of formal protocols involving palliative care consultation (Figure), or federal regulatory requirements for palliative care consultation before placement of a VAD (21.9% of respondents [41 of 187] were very familiar or familiar with them). More than half of the respondents (105 of 187 [56.1%]) who care for patients with VADs, but only 34.4% of those who care for patients with a TAVR (94 of 273) indicated that palliative care consultation was provided often or always for patients who were deemed ineligible to receive one of these devices. Most respondents (267 [82.6%]) indicated that they had some knowledge of palliative care, but only 44 (13.6%) characterized their knowledge as extensive; only 34 (10.5%) reported receiving formal instruction on palliative care during cardiovascular training.
To date, there remains a relative paucity of information about the attitudes toward and application of palliative care in patients under consideration for or who have undergone implantation of a TAVR or VAD, 2 expensive, life-prolonging, and potentially morbid procedures whose use is rapidly growing. Studies have demonstrated the utility of advance care planning tools in patients receiving a VAD3; however, while consensus statements and regulatory bodies have promoted palliative care involvement with patients receiving a VAD,4,5 evaluation and benchmarking of palliative care services provided to patients with end-stage cardiovascular disease has not been performed.6
In our study, respondents reported that palliative care is mostly initiated following an adverse event, and most institutions lack protocols to integrate it in TAVR or VAD processes. In general, palliative care was reported to be used more frequently in patients undergoing VAD than TAVR procedures.
This study has some limitations. 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.
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. 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.
Corresponding Author: James N. Kirkpatrick, MD, Division of Cardiology, Ethics Consultation Service, University of Washington, 1959 NE Pacific St, Seattle, WA 98125 (firstname.lastname@example.org).
Published Online: May 23, 2016. doi:10.1001/jamainternmed.2016.2096.
Author Contributions: Dr Kirkpatrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kirkpatrick, Hauptman, Swetz, Blume, Maurer, Goodlin.
Acquisition, analysis, or interpretation of data: Kirkpatrick, Hauptman, Swetz, Blume, Gauvreau, Maurer.
Drafting of the manuscript: Kirkpatrick, Hauptman.
Critical revision of the manuscript for important intellectual content: Hauptman, Swetz, Blume, Gauvreau, Maurer, Goodlin.
Statistical analysis: Gauvreau.
Administrative, technical, or material support: Kirkpatrick, Blume, Maurer.
Study supervision: Kirkpatrick, Hauptman.
Conflict of Interest Disclosures: None reported.
Additional Contributions: Richard A. Josephson, MD, Harrington Heart & Vascular Institute, Division of Cardiovascular Medicine, University Hospitals Health System, Craig Alpert, MD, Division of Cardiology, University of Michigan, and Jorge Brenes-Salazar, MD, Mayo Clinic, participated in conception and design, interpretation of the data, and crafting of the manuscript or revising it for important intellectual content. They were not compensated for their contributions.