Tenge T, Schlieper D, Schallenburger M, Meier S, Schwartz J, Neukirchen M
Interdisziplinäres Zentrum für Palliativmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland.
Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland.
Anaesthesist. 2021 Dec;70(12):1044-1050. doi: 10.1007/s00101-021-00967-y. Epub 2021 Apr 30.
An increasing number of patients reach the final stage of heart failure with heart transplantation as the only curative treatment. Mechanical circulatory support, such as left ventricular assist devices (LVAD) are becoming increasingly more important at this stage of the disease. An LVAD improves the quality of life and prolongs the lifespan. The LVAD is used as a bridge to transplantation (BTT) for patients waiting for a donor heart or as a destination therapy (DT) with no transplantation intended; nevertheless, implantation is often associated with complications and the prognosis remains unfavorable in DT cases or after transition from BTT to DT. For patients the device may be a source of physical and psychological distress and can become a burden for families and caregivers. So far it remains unclear whether LVAD treatment is an indication for concurrent palliative care.
The aim of this study was to collect the current data on the influence of palliative care in LVAD patients and to identify possible formats of palliative care in clinical practice.
In May 2020, a systematic literature search was performed using the PICOS instrument in six different databases, i.e. PubMed, Cochrane library, Google scholar, Scopus, Web of Science and Journals@Ovid. We included quantitative and qualitative studies in English and German. Case reports, comments and pediatric studies were excluded.
A total of 21 publications from an initial number of 491 were included in this review. The integration of palliative care in the context of LVAD implantation increased the number of advance directives and documented surrogate decision makers. Studies found a positive influence of palliative care on the conditions and place of death, family involvement and symptom and pain management. Involvement in the decision-making process may improve patient selection for LVAD treatment and helps patients to make the decision on informed consent. Various formats for the integration of palliative medical concepts into LVAD treatment are reported. It is not clear when palliative care involvement should start; however, most articles support an early and continuous integration in the LVAD process. We have aggregated possible topics for palliative care consultations from a number of publications. Mutual teaching of both LVAD and palliative care teams is recommended. Integration of a dedicated LVAD palliative care specialist as part of the LVAD team can support care for patients as well as clinicians.
The role of palliative care in LVAD patients in clinical practice in the German-speaking area is not standardized. Early and continuous integration of palliative care into the course of LVAD treatment can improve the quality of care. Benefits for LVAD patients, caregivers and clinicians are described. For this purpose, recommendations as well as professional training for palliative care practitioners are useful. Further studies are needed to clarify the impact of palliative care in both DT and BTT patients.
越来越多的患者进入心力衰竭终末期，心脏移植是唯一的治愈性治疗方法。在疾病的这一阶段，机械循环支持，如左心室辅助装置（LVAD）正变得越来越重要。LVAD可改善生活质量并延长寿命。LVAD被用作等待供体心脏患者的移植桥梁（BTT），或作为不打算进行移植的目标治疗（DT）；然而，植入通常会伴有并发症，并且在DT病例中或从BTT过渡到DT后，预后仍然不佳。对于患者而言，该装置可能会带来身体和心理上的困扰，并可能成为家庭和护理人员的负担。到目前为止，尚不清楚LVAD治疗是否是同时进行姑息治疗的指征。
本研究的目的是收集关于姑息治疗对LVAD患者影响的当前数据，并确定临床实践中姑息治疗的可能形式。
2020年5月，使用PICOS工具在六个不同数据库，即PubMed、Cochrane图书馆、谷歌学术、Scopus、科学网和Ovid期刊上进行了系统的文献检索。我们纳入了英文和德文的定量和定性研究。排除了病例报告、评论和儿科研究。
本综述共纳入了最初491篇文献中的21篇。在LVAD植入背景下整合姑息治疗增加了预立医疗指示的数量，并记录了替代决策者。研究发现姑息治疗对死亡状况和地点、家庭参与以及症状和疼痛管理有积极影响。参与决策过程可能会改善LVAD治疗的患者选择，并帮助患者做出知情同意的决定。报告了将姑息医学概念整合到LVAD治疗中的各种形式。目前尚不清楚姑息治疗应何时开始介入；然而，大多数文章支持在LVAD过程中尽早并持续整合姑息治疗。我们从多篇文献中汇总了姑息治疗咨询可能涉及的主题。建议LVAD团队和姑息治疗团队相互学习。作为LVAD团队的一部分，引入一名专门的LVAD姑息治疗专家可以为患者和临床医生提供支持。
在德语区临床实践中，姑息治疗在LVAD患者中的作用尚未标准化。将姑息治疗尽早并持续整合到LVAD治疗过程中可以提高护理质量。描述了对LVAD患者、护理人员和临床医生的益处。为此，为姑息治疗从业者提供建议以及专业培训是有用的。需要进一步研究以阐明姑息治疗对DT和BTT患者的影响。
