Extrahepatic portal vein thrombosis (EHPVT) is the leading cause of variceal hemorrhage in patients with healthy livers; however, in an era of dynamic imaging, the incidental discovery of EHPVT places a special burden on the surgeon to understand the surgical implications of the disease in this setting. During the period 1989 to 1995, 23 patients (12 males and 11 females) were found to have EHPVT. In 20 (87%), this was an unexpected finding on ultrasound (11 of 23), abdominal CT scan (9 of 23), or both (9 of 23). In two patients, the diagnosis was suspected and confirmed with angiography, whereas in the other, the lesion was discovered at surgery. Only seven (30%) had hemorrhage as a presenting complaint. More typically (61%), abdominal pain alone or pain with sepsis was the indication for evaluation. In 20 patients (87%), there was an identifiable etiology for the EHPVT. A total of 15 operations were performed on 12 patients (52%), in 7 (4, variceal hemorrhage, and 3, bowel ischemia) as a direct consequence of the EHPVT and in five, for conditions not directly related to the EHPVT. Three of the 23 patients (13%) died, two (17%) following surgery and one (9%) from advanced malignant disease. No patients with hemorrhage (seven), even those who required a shunt for decompression (three) or devascularization (one), died. We found that the diagnosis of EHPVT is usually not related to variceal hemorrhage, but rather, abdominal symptoms that serve as an indication for the imaging study. Three subsets of patients emerged: (1) those requiring no surgery (11 patients), (2) those requiring surgery related to hemorrhage (4 patients), and (3) those requiring surgery for conditions other than varices (8 patients). In any of these circumstances, mortality (13%) was related to the underlying disease process rather than EHPVT. Given the earlier recognition of EHPVT, the natural history of the disease has been altered, with outcome reflecting the underlying disease rather than the sequelae of portal hypertension.
•Describe two barriers to hospice referral for patients with LVADs.•Describe differences in referral patterns for inpatient and home hospice among patients with LVADs. Patients with LVADs have need for high-quality end-of-life care, including hospice services. It is not known how often patients with LVADs are referred to hospice, and what barriers to referral exist. To assess frequency of hospice referral for patients with LVADs, and barriers encountered by referring providers. Surveys were distributed to LVAD nurse coordinators and social workers who are members of the Society for Transplant Social Workers and the Mechanical Circulatory Support Collaborative on Yahoo Groups. Fifty-three providers responded: 10 social workers, 38 nurse coordinators, and 5 individuals serving in other capacities on LVAD teams. LVAD programs of all sizes were represented, including those implanting fewer than 5 LVADs annually (10%, 5/50) to those implanting greater than 40 LVADs annually (30%, 15/50). In the preceding 12 months, 53% (24/45) of respondents had not referred any patients to inpatient hospice, while 44% (20/45) had referred 3 or fewer patients. Referrals to home hospice were slightly more common, with 66% (30/45) having referred between 1 and 3 patients. Perceived barriers to hospice referral included LVAD clinician, patient/family, and hospice associated factors. When asked specifically about hospice-associated barriers, respondents cited lack of hospice staff training in LVAD management (56%, 25/45), lack of experience in caring for patients with LVADs (56%, 25/45), and cost (13%, 6/45). Referral to home hospice was more common than referral to inpatient hospice, and the number of patients referred to hospice programs was low. A number of barriers to hospice referral exist, with lack of education and training for hospice providers being cited most often.
Purpose of the review This review discusses the ethical issues raised by the increased use of devices to treat heart failure. Recent findings Recent guidelines and clinical trials describe the benefits of device therapy in advanced heart failure. Other studies and commentaries illustrate the potential for harm, both to the individual patient in the form of reduced quality of life and to society in the form of unbearable costs. Recent reports discuss the specific issues involved with deactivating different devices and document low rates of advanced care planning in relation to device management at the end of life. Summary More research, increased end-of-life education, renewed emphasis on advance directives, and a true multidisciplinary approach are needed to provide optimal care for heart failure patients in relation to device therapy.
