June 1, 2011 For patients with severe heart failure, an implanted mechanical pump known as a Left Ventricular Assist Device (LVAD) can be a life-sustaining treatment. Even though the technology involves risks, few patients and their families tend to talk explicitly about the "what ifs" before surgery takes place. In the June issue of Mayo Clinic Proceedings, a team of Mayo Clinic researchers found that careful discussions at the bedside about patients' end-of-life preferences brought relief to families and eased subsequent medical care.
"Previous studies have looked at the ethics of LVAD surgery and the role of patient and family members when it comes to turning the device off," says lead author Keith Swetz, M.D., an internist and specialist in palliative medicine. "But these are complex patients and many things can happen. To our knowledge, this was the first study to investigate how to help patients and families to be proactive in decision-making before patients' quality of life is compromised."
The study looked at 19 patients dependent on LVAD as a long-term survival strategy rather than as a "bridge" to a heart transplant. Among them, 13 patients and their families discussed advanced care wishes with a palliative care team that included physicians and social workers. The study found the conversations provided guidance when adverse events occurred, such as when a patient fell after surgery and suffered brain damage. The study also found LVAD patients often presumed family members were aware of their end-of-life wishes, when, in fact, spouses and children were grateful to be guided in a conversation.
The study affirms the effectiveness of palliative care discussions before LVAD surgery, and provides guidelines for clinicians and hospitals about how to address end-of-life decision-making. "It can be a tough conversation for families to have but we found it didn't cause stress or loss of hope," Dr. Swetz says. "Instead, having the conversation brought relief and was ultimately reassuring for families and patients."
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