Home-Based Palliative Care Visits for DT-LVAD Patients

Purpose All DT-LVAD patients must receive a palliative care consultation prior to implant. No guidelines exist for post-LVAD palliative care follow up to help patients cope with increasing illness burden. We describe our institution's experience with our health system's home-based palliative care (HBPalC) program. Methods We performed a chart review of DT-LVAD implants at our institution. The MGB HBPalC Program is staffed by an MD Medical Director, 3 nurse practitioners and a social worker. All HBPalC clinicians are certified in palliative care. Patients referred to the program are seen at home. The NP performs an initial assessment and collaborates with the LVAD team in developing a comprehensive care plan, with special attention to symptom management, documentation of hopes and worries, anticipatory planning and recommendations to mitigate unnecessary hospitalizations. Follow up visits are scheduled based on clinical and psychosocial needs. Results In 2018-20, 4 LVAD patients were referred to the HBPalC Program. They were elderly, met the criteria for frailty, and could no longer travel to clinic. The HBPalC team, working closely with LVAD team, managed 3 patients’ symptoms and transitioned them to hospice when appropriate. These patients died peacefully at home or at a hospice residence and none presented to the ED or were hospitalized while enrolled in the HBPalC Program. The 4th patient presented to the emergency room with somnolence and was hypotensive and tachypneic. The HBPalC provider and VAD coordinator collaborated to support the patient's daughter through the difficult decision to deactivate the LVAD, easing anxiety for the patient and her family, as well as preventing a readmission. Conclusion HBPalC is a valuable resource that can help to minimize symptom burden for patients as well as support patients and their families with the complicated transition to hospice, allowing them to die in the location of their choosing, which is often at home. As the number of older adults receiving DT-LVADs grows, the need for closer collaboration between LVAD programs and HBPalC programs will also continue to grow. At our institution, we are exploring workflows to expand this collaboration and are additionally working to develop a Geriatric Cardiology Clinic to better assess for and manage geriatric syndromes pre-implant with the goal of further improving outcomes for this patient population.