Mayo Clinic Arizona and Arizona State University, Phoenix, Arizona.
Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
J Pain Symptom Manage. 2019 Feb;57(2):330-340.e4. doi: 10.1016/j.jpainsymman.2018.11.007. Epub 2018 Nov 15.
Destination therapy (DT) patients face significant challenges as they transition from chronic left ventricular assist device (LVAD) support to comfort-oriented care. Integration of palliative medicine (PM) into the multidisciplinary team is important to facilitate advanced care planning (ACP) and improve quality of life (QoL).
We evaluated the impact of a structured programmatic approach to the end-of-life (EOL) process in DT patients as measured by QoL surveys and the utilization of ACP.
We instituted a four prong intervention approach: 1) delineated the path from implant to EOL by defining specific stages, including a transitional phase where care limits were agreed upon, 2) standardized the role of PM, 3) held transitional care meetings to support shared decision-making, and 4) held multidisciplinary team debriefings to facilitate communication. Preintervention and postintervention outcomes were measured for patients/caregivers by using the QUAL-E/QUAL-E (family) QoL instrument. Wilcoxon signed-ranks test compared nonparametric variables.
All patients (n = 41)/caregivers (n = 28) reported improved QoL measures (patient P = 0.035/caregiver P = 0.046). Preparedness plans increased from 52% to 73% after implementation and advance directives increased from 71% to 83%. Fifty-nine percent of the patients completed an outpatient PM clinic visit; 51% completed/scheduled a second visit. Clinician outcomes improved including satisfaction with multidisciplinary team communication/expectations, ACP processes, and EOL management.
A programmatic approach that standardizes the role of PM and delineates the patient's path from implant to EOL improved quality outcomes and increased implementation of ACP. A defined communication process allowed the multidisciplinary team to have a clear patient management approach.
接受心脏移植手术的患者在从慢性左心室辅助装置（LVAD）支持过渡到舒适护理时面临重大挑战。姑息治疗（PM）融入多学科团队对于促进高级医疗计划（ACP）和提高生活质量（QoL）非常重要。
我们通过 QoL 调查和 ACP 使用评估 DT 患者临终过程中结构化程序方法的影响。
我们采用了四步干预方法：1）通过定义特定阶段（包括同意护理限制的过渡阶段）来划定从植入到临终的路径，2）规范 PM 的角色，3）召开过渡护理会议以支持共同决策，4）召开多学科团队汇报会以促进沟通。使用 QUAL-E/QUAL-E（家庭）QoL 仪器测量患者/照顾者的干预前后结果。采用 Wilcoxon 符号秩检验比较非参数变量。
所有患者（n=41）/照顾者（n=28）报告 QoL 测量值均有改善（患者 P=0.035/照顾者 P=0.046）。实施后准备计划从 52%增加到 73%，预立医疗指示从 71%增加到 83%。59%的患者完成了门诊 PM 诊所就诊；51%的患者完成/安排了第二次就诊。临床医生的结果得到改善，包括对多学科团队沟通/期望、ACP 流程和临终管理的满意度。
一种标准化 PM 角色并划定患者从植入到临终路径的程序方法改善了质量结果并增加了 ACP 的实施。明确的沟通流程使多学科团队能够有明确的患者管理方法。
