Utah Artificial Heart Program, and Intermountain Medical Center and Intermountain Healthcare, Salt Lake City, Utah 84107, USA.
J Heart Lung Transplant. 2010 Dec;29(12):1337-41. doi: 10.1016/j.healun.2010.07.001.
The use of left ventricular assist devices (LVADs) as destination therapy (DT) is increasing and has proven beneficial in prolonging survival and improving quality of life in select patients with end-stage heart failure. Nonetheless, end-of-life (EOL) issues are inevitable and how to approach them underreported.
Our DT data registry was queried for eligible patients, defined as those individuals who actively participated in EOL decision making. The process from early EOL discussion to palliation and death was reviewed. We recorded the causes leading to EOL discussion, time from EOL decision to withdrawal and from withdrawal to death, and location. Primary caregivers were surveyed to qualify their experience and identify themes relevant to this process.
Between 1999 and 2009, 92 DT LVADs were implanted in 69 patients. Twenty patients qualified for inclusion (mean length of support: 833 days). A decrease in quality of life from new/worsening comorbidities usually prompted EOL discussion. Eleven patients died at home, 8 in the hospital and 1 in a nursing home. Time from EOL decision to LVAD withdrawal ranged from <1 day to 2 weeks and from withdrawal until death was <20 minutes in all cases. Palliative care was provided to all patients. Ongoing assistance from the healthcare team facilitated closure and ensured comfort at EOL.
With expanding indications and improved technology, more DT LVADs will be implanted and for longer durations, and more patients will face EOL issues. A multidisciplinary team approach with protocols involving DT patients and their families in EOL decision making allows for continuity of care and ensures dignity and comfort at EOL.
左心室辅助装置（LVAD）作为终末期心力衰竭患者的终末期治疗（destination therapy，DT）的应用正在增加，并已被证明在延长生存时间和提高生活质量方面具有益处。然而，终末期（end-of-life，EOL）问题不可避免，如何处理这些问题的报道很少。
我们对 DT 数据登记处进行了查询，以确定符合条件的患者，这些患者被定义为积极参与 EOL 决策的患者。审查了从早期 EOL 讨论到姑息治疗和死亡的过程。我们记录了导致 EOL 讨论的原因、从 EOL 决定到撤机以及从撤机到死亡的时间以及地点。对主要护理人员进行了调查，以确定他们的经验并确定与该过程相关的主题。
1999 年至 2009 年，在 69 名患者中植入了 92 台 DT LVAD。20 名患者符合纳入标准（平均支持时间：833 天）。生活质量下降是由于新的/恶化的合并症，通常会引发 EOL 讨论。11 名患者在家中死亡，8 名在医院，1 名在养老院。从 EOL 决定到 LVAD 撤机的时间从<1 天到 2 周不等，从撤机到死亡的时间在所有情况下均<20 分钟。所有患者均接受姑息治疗。医疗团队的持续帮助促进了患者的安宁，并确保了 EOL 期间的舒适。
随着适应证的扩大和技术的进步，将植入更多的 DT LVAD，并持续更长时间，更多的患者将面临 EOL 问题。采用多学科团队方法，制定涉及 DT 患者及其家属的 EOL 决策的方案，可实现医疗护理的连续性，并确保 EOL 期间的尊严和舒适。
