Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA.
Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA.
J Pain Symptom Manage. 2020 Nov;60(5):976-983.e1. doi: 10.1016/j.jpainsymman.2020.05.025. Epub 2020 May 25.
Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown.
To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life.
Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups.
Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life.
Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.
左心室辅助装置（LVAD）手术前的姑息治疗咨询（PreVAD）已被推荐，但它对目标一致治疗的影响尚不清楚。
描述 PreVAD 期间患者表达的独特不可接受的条件与生命末期实际提供的治疗之间的关系。
在 2014 年至 2019 年期间接受 PreVAD 的 308 名患者中，有 72 名患者在 2019 年 12 月 31 日前死亡。根据回答“是否有任何您认为无法接受的情况？”问题，患者被分为表达组（那些能够清楚表达不可接受条件的患者，n=58）和非表达组（那些无法表达的患者，n=14）。比较两组患者的死亡情况和临终关怀。
死亡时的平均年龄为 63.2 岁（SD±13.1），56 名患者（77.8%）为男性，LVAD 中位使用时间为 167.5 天（四分位间距 682）。与非表达组相比，表达组患者在 ICU 死亡的频率较低（33 名患者，57.9% vs. 13 名患者，92.9%；P=0.014），伦理学咨询的频率也较低（4 名患者，6.9% vs. 5 名患者，35.7%；P=0.011）。两组患者 LVAD 撤机的频率相似。在表达组中，PreVAD 中表达的不可接受条件似乎并未影响生命末期的决策。
在 LVAD 手术前明确表达自己不可接受条件的患者，在生命末期接受的伦理学咨询和强化护理较少，但这似乎并未影响 LVAD 撤机的决定。更重要的可能是围绕他们的不可接受条件进行讨论，而不是具体的表达条件。在 LVAD 手术前的常规姑息治疗咨询中，应包括不可接受条件的问题。
