Case One - Phantom Shocks and Ongoing Trauma: Post-Traumatic Stress Disorder from an Implantable Cardioverter-Defibrillator
Background: Implantable Cardioverter-Defibrillators (ICDs) have a clear role in advanced heart failure patients whose goals of care include life-prolongation, given their proven mortality benefit. The psychological effects of living with an ICD are being increasingly recognized, including anxiety (13-38% prevalence), depression (18- 41%), and post-traumatic stress disorder (PTSD, 20%).
Case Two - Deciding Where to Deactivate: Taking a Total Artificial Heart to Inpatient Hospice
Background: With increasing prevalence of advanced heart failure and limited organ availability, mechanical circulatory support (MCS) utilization is increasing. As more patients receive MCS, novel approaches are needed to address unique end-of-life needs, including MCS deactivation. Currently, the TAH is used as a bridge-to-transplantation for patients with biventricular failure, but may be used as destination therapy similar to left ventricular assist devices in the future. While a portable TAH driver is under investigation, patients with TAH who become transplant ineligible may struggle to leave the hospital.
Case Three - Providing Care at the Leading Edge of End-Stage Heart Failure Therapy: Challenges and Opportunities in this Uncharted Territory
Copyright: 2013Continuing Education: No CME availableFormat: Available only as MP3 download
Background: Implantable Cardioverter-Defibrillators (ICDs) have a clear role in advanced heart failure patients whose goals of care include life-prolongation, given their prov...
Case Description: Mr. WC is a 69-year-old man with a left-ventricular assist device (LVAD) for advanced heart failure who was admitted to the hospital for recurrence of ventricular tachycardia and ICD-shocks. He had experienced several shocks in a single day. When Palliative Care was consulted to help with his anxiety, we found him sitting very still, avoiding any extraneous movements, and telling us about his fear of being shocked again. He reported that sometimes he woke at night feeling the ICD fire, and then found out in the morning that the device had not actually delivered a shock. He said he had a friend who had similar experiences prior to heart transplant, and he continued to wake at night like this even after ICD-removal. After working with our psychologist, he became a frequent-user of deep-breathing relaxation techniques and listening to music to ease anxiety. He found this more helpful than the alprazolam that was available as-needed. His wife participated using a routine of soothing activities if there was a threatened or actual shock. He also found prayer helpful, and appreciated visits with the chaplain. With these techniques and low-dose clonazepam, he worked his way up to moving more freely in his room and eventually walking in the hall, despite continued intermittent shocks.
Conclusion: Recognition of psychological symptoms related to ICDs, such as PTSD and phantom shocks, can guide treatment and improve quality of life for cardiac patients. This is an important opportunity for interprofessional/interdisciplinary collaboration between palliative care providers, mental health providers, and cardiologists.
Case Description: A 56-year-old man with severe multivessel coronary disease was transferred to a tertiary care center following cardiac arrest with severe heart failure. Percutaneous temporary MCS was placed due to progressive cardiogenic shock (ejection fraction 4%). As cardiac transplantation workup ensued, biventricular failure progressed necessitating total artificial heart (TAH) implantation. Postoperatively the patient suffered cerebral infarcts resulting in severe dysphagia and debility, and renal failure requiring hemodialysis. Palliative medicine (PM) was consulted on day 136 to address goals of care, subsequently the patient requested do-not-intubate status and stated his wishes to marry his long-time partner and to not die in hospital. Once transplant ineligible, the patient elected for supportive care and hospice. The inpatient PM team coordinated with a local hospice who accepted the patient to their inpatient unit for anticipated end-of-life care. PM worked to facilitate the patient’s wedding (in hospital), followed by transfer to inpatient hospice two days later. Ambulance transfer with hospital perfusionists and mid-level providers allowed for TAH management with alarms deactivated. Those providers educated the hospice team about the patient’s unique needs. Despite anticipated TAH deactivation, the patient died several hours after arrival at hospice before device deactivation. Conclusion: This case illustrates PM involvement fostering innovative approaches and expert support to allow MCS patients to reach their desired goals in complex situations.
Background: Until recently, continuous intravenous inotrope therapies, such as milrinone, were used only as "bridge therapies" until definitive treatment (such as heart transplantation or LVAD) could be implemented. Now, however, inotrope therapy is taking on an expanded role as "destination therapy" in the longer-term palliation of symptoms caused by refractory, end-stage heart failure, as reinforced by the just-released 2013 ACCF/AHA Guidelines for Management of Heart Failure. These guidelines state, “long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D heart failure.” The extension of these costly interventions into the hospice setting presents new dilemmas for patients, families, and practitioners.
Case Description: A patient with end-stage CHF, who was not a candidate for cardiac transplant or LVAD, elected for comfort-oriented care and was admitted to home hospice on continuous IV milrinone infusion with no plan for its discontinuation. We outline the benefits, burdens, and costs of this therapy, emphasizing its impact on the patient, caregivers, and members of the hospice team.
Conclusion: In response to requests to provide these complex and potentially long-term therapies, hospice providers will experience heightened tension between their dual roles as stewards of limited resources and as advocates for the well-being of their patients. These cases bring up multifaceted ethical considerations, including issues of justice (fair distribution of limited resources, concerns for equality of access to services) and beneficence (serving the best interests of patients by carefully weighing the burdens and benefits of therapy). We emphasize the real-world implications of these ethical considerations for hospices as they care for such patients. Finally, we recommend a multidisciplinary approach to advanced care planning in these situations, focused on patient-centered goals and time-limited trials for therapeutic success. Collaboration among cardiologists, palliative physicians, nurses, social workers, and ethicists will be essential to this task.