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Maini M, Anderson KM, Seplowe M, Crowell NA, Pitcher C, Scally R, Weintraub WS, Najjar SS, Groninger H, Rao A. Disease-State Understanding and Experience of Patients Receiving Continuous Intravenous Inotropic Support as Palliative Therapy: A Multicenter Survey. J Palliat Med 2024. [PMID: 38564223 DOI: 10.1089/jpm.2023.0670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Background: The use of continuous intravenous inotropic support (CIIS) as palliative therapy in patients with advanced heart failure (HF) has increased over the past decade. CIIS improves New York Heart Association (NYHA) functional class but does not impact survival. Objective: The objective of this study was to examine patients' understanding of the therapeutic intent of CIIS, prognostic awareness, and quality of life with CIIS. Design: We conducted a prospective, cross-sectional, multicenter study of patients with advanced HF receiving CIIS as palliative therapy between 2020 and 2022. Settings/Subjects: An investigator-developed survey instrument was administered to outpatients on CIIS in the United States via telephone. Measurements: Survey data were analyzed using descriptive and inferential statistics. Results: Forty-eight patients, 63% male, 81% African American/Black, with a mean age of 68.9 (standard deviation 12.3) years, participated in this study. The majority of patients responded that they expected CIIS to make them feel better (79%) and increase longevity (75%), but few expected that CIIS would cure their HF (19%). Patients described their overall quality of life on CIIS as not better/worse (19%), somewhat better (46%), and significantly better (35%) and reported high treatment satisfaction (87% were at least somewhat satisfied). Conclusions: In this study, patients report improved quality of life with CIIS as palliative therapy. Patients on CIIS as palliative therapy expected increased survival on CIIS, which is incongruent with current evidence. Further studies on how we can improve care processes so that patients have accurate prognostic and disease-state awareness, and receive goal concordant care, are warranted.
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Affiliation(s)
- Mansi Maini
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Kelley M Anderson
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - Matthew Seplowe
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Nancy A Crowell
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - Clark Pitcher
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Scally
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - William S Weintraub
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samer S Najjar
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hunter Groninger
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Anirudh Rao
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA
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McPherson A, Nguyen C, Groninger H, Anderson KM, Henderson P, Rao A. Continuous Intravenous Inotropic Support for Advanced Heart Failure: Palliative Considerations. J Pain Palliat Care Pharmacother 2022; 36:59-67. [PMID: 35319327 DOI: 10.1080/15360288.2022.2050456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The global prevalence of heart failure (HF) is increasing. Advancements in guideline-directed medical and device therapy have resulted in improved survival. Thus, there are more patients living - and living longer - with advanced HF. Only a small proportion of these patients are deemed appropriate for advanced surgical intervention (mechanical circulatory support or heart transplantation), and even if offered, some may decline such interventions if not aligned with their overall goals and values. Therefore, a growing number of patients with advanced HF receive chronic intravenous inotropic support (CIIS) for palliation of symptoms. Despite increased use, clinical evidence supporting use of palliative inotropes remains limited. However, available data suggest improvements in functional class, health-related quality of life (HRQoL) indicators, symptom burden, hemodynamic parameters, and possibly rehospitalization. While initial concerns regarding increased mortality have been assuaged in the modern era of guideline-directed medical therapy, palliative inotropes are certainly not without burden. Risks of infection and medication-related adverse effects, need for routine laboratory monitoring, frequent dressing changes, and presence of a reliable caregiver must be carefully considered prior to initiation. This review addresses pharmacology, guideline recommendations, benefits and burdens, considerations related to hospice and end-of-life care, and future directions of CIIS in advanced HF care.
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Johnson MH, Bass C, Schroeder SE. The Fountain of Youth Will Not Last Forever: End of Life in Patients Receiving Mechanical Circulatory Support. AACN Adv Crit Care 2021; 32:452-460. [PMID: 34879128 DOI: 10.4037/aacnacc2021501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Health care providers face a unique set of decision-making, assessment, and equipment challenges at the end of life of patients supported with a left ventricular assist device. The aim for this article is to assist the multidisciplinary team in caring for patients with a left ventricular assist device in all phases of end-of-life care. This review includes common causes of death for patients with a left ventricular assist device, assessment at end of life, physiological and palliative care considerations, withdrawal of left ventricular assist device support, and equipment considerations.
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Affiliation(s)
- Mary H Johnson
- Mary H. Johnson is VAD Educator, The Christ Hospital, 2123 Auburn Avenue, Suite 115, Cincinnati, OH
| | - Colleen Bass
- Colleen Bass is Palliative Care Nurse Practitioner, The Christ Hospital, Cincinnati, Ohio
| | - Sarah E Schroeder
- Sarah E. Schroeder is VAD Nurse Practitioner and Program Manager, Bryan Heart, Lincoln, Nebraska
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Latimer A, Pope ND, McFarlin JM. "I Just Feel Like I Always Did": Inotropic Dependency at End of Life. Am J Hosp Palliat Care 2020; 37:497-502. [PMID: 31714150 DOI: 10.1177/1049909119886302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients not considered for mechanical circulatory support or heart transplant may be dependent on inotropic therapy at end of life. End-of-life conversations in advanced heart failure can be challenging for providers, but guidelines recommend frequent goals-of-care conversations when inotropes are used as a palliative treatment. The purpose of this study was to identify aspects of care pertinent for health-care professionals working with patients in end-stage heart failure who are receiving continuous inotropic support. METHODS Qualitative analysis was used to examine 3 audio-recorded semistructured interviews with 1 patient, her family, and her cardiologist. The selected patient was an older adult, diagnosed with advanced heart failure, and dependent on continuous inotropic therapy with no other advanced treatment options available. RESULTS The analysis revealed that (1) reliance on others, (2) contending with uncertainty, and (3) deciding when to discontinue inotropic support were identified as themes central to the patient's and provider's experience. CONCLUSION This study offers insight into how to best support and communicate with patients having advanced heart failure who are dependent on continuous inotropic therapy at end of life.
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Affiliation(s)
- Abigail Latimer
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Natalie D Pope
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Jessica M McFarlin
- Division of Palliative and Supportive Care, University of Kentucky, Lexington, KY, USA
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Groninger H, Rao A, Stewart D, Hofmeyer M. Weaning Continuous Cardiac Inotropes at End of Life: Case Studies and Institutional Clinical Guidelines. J Pain Symptom Manage 2020; 60:170-175. [PMID: 32142740 DOI: 10.1016/j.jpainsymman.2020.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Hunter Groninger
- Department of Medicine, Georgetown University Medical Center, Georgetown University, Washington, DC, USA; Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Anirudh Rao
- Department of Medicine, Georgetown University Medical Center, Georgetown University, Washington, DC, USA; Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Diana Stewart
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA; University of Maryland School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Mark Hofmeyer
- Advanced Heart Failure Program, MedStar Heart and Vascular Institute, Washington, DC, USA
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Burnside L, Whyte S, Cooper SG. Advanced Heart Failure Treatment Modalities and Hospice Care: The Need for High Level Care Coordination. Am J Hosp Palliat Care 2019; 36:812-814. [DOI: 10.1177/1049909119838250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Advanced heart failure therapies such as ventricular assist devices and home inotrope use are becoming more common. Technology advances as well as increased indications for use of such therapies is leading to a higher percentage of patients with end-stage heart failure receiving these therapies at end of life. We present a case of a young man with dilated cardiomyopathy who undergoes advanced cardiac care in the setting of progressively declining cardiac function. Our case outlines the importance of acute care, palliative care, and hospice services being coordinated prior to and during acute-care services to provide goal-concordant and expeditious care. With advancing medical therapies for heart disease, increased coordination and collaboration of services are needed, particularly between hospice and acute-care services.
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Affiliation(s)
- Lee Burnside
- Division of Gerontology and Geriatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Sharon Whyte
- Regional Center for Advanced Heart Failure, University of Washington School of Medicine, Seattle, WA, USA
| | - Stephanie G. Cooper
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Larry A. Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Shannon M. Dunlay
- Division of Cardiology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Haider J. Warraich
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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