Withdrawal of Temporary Mechanical Circulatory Support in Patients With Capacity

Carey, Matthew R.; Tong, Wendy; Godfrey, Sarah; Takeda, Koji; Nakagawa, Shunichi

doi:10.1016/j.jpainsymman.2021.10.007

Cited by 9 publications

(5 citation statements)

References 23 publications

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“…For patients in cardiogenic shock, palliative care physicians may be useful to understand expected outcomes with different therapies and to help patients understand their therapeutic options. In situations with a high degree of illness, when there are no viable options for bridging to other therapies, palliative care physicians can play a vital role for patients and families when discussing withdrawal of care and comfort measures [63,64].…”

Section: The Role Of Palliative Carementioning

confidence: 99%

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery

Oren

Zilinyi²,

Lotan³

et al. 2022

Current Opinion in Cardiology

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Purpose of reviewTemporary mechanical circulatory support (tMCS) has become central in the treatment of refractory cardiogenic shock and can be used to bridge patients to durable MCS, heart transplant or recovery. This review will discuss contemporary data regarding bridging strategies utilizing tMCS.Recent findingsThere has been significant growth in tMCS use recently, driven by increased familiarity with tMCS devices, and increased experience with both implantation and management. Identifying goals of therapy at the time of therapy initiation can facilitate better outcomes. The three primary goals are bridge to recovery, bridge to heart transplantation or bridge to durable left ventricular assist device. Bridging to recovery requires adequate treatment of underlying conditions and optimization of haemodynamics. Bridging to heart transplantation has become more frequent following changes to the heart allocation policy. Despite early concerns, patients bridge with tMCS, including ventricular-arterial extracorporeal membrane oxygenation, do not appear to have worse posttransplant outcomes. When bridging to durable mechanical circulatory support, tMCS can be used to enhance end-organ dysfunction and improve perioperative outcomes. In situations in which none of these goals are attainable, palliative care plays a critical role to identify patient wishes and assist with withdrawal of care when necessary.SummaryThe use of tMCS, as a bridge to recovery or heart replacement therapy in patients with refractory cardiogenic shock has grown significantly over the past decade. Multiple device choices are available and must be chosen appropriately to address the specific situation and the goals of therapy.

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Section: The Role Of Palliative Carementioning

confidence: 99%

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery

Oren

Zilinyi²,

Lotan³

et al. 2022

Current Opinion in Cardiology

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“…To our knowledge, this is the first study that describes why patients on CIIS as bridge therapy do not receive surgical therapy for advanced HF, effectively serving as a “bridge to nowhere.” This “bridge to nowhere” concept has been described for patients on extracorporeal membrane oxygenation or other temporary mechanical circulatory supports ( 6 ). Guidelines regarding the LVAD and HT evaluation processes provide a thorough framework for the medical and psychosocial evaluations that precede surgery ( 7 – 9 ).…”

Section: Discussionmentioning

confidence: 99%

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Rao

Singh

Maini

et al. 2022

Front. Cardiovasc. Med.

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BackgroundMany patients with advanced heart failure (HF) are administered chronic intravenous inotropic support (CIIS) as bridge to surgical therapy; some ultimately never receive surgery. We aimed to describe reasons patients “crossover” from CIIS as bridge therapy to palliative therapy, and compare end-of-life outcomes to patients initiated on CIIS as palliative therapy.MethodsSingle-institution, retrospective cohort study of patients on CIIS as bridge or palliative therapy between 2010 and 2016; data obtained through review of health records and multi-disciplinary selection meeting minutes, was analyzed using descriptive and inferential statistics.ResultsOf 246 patients discharged on CIIS as bridge therapy, 37 (16%) (male n = 28, 76%; African American n = 22, 60%) ultimately never received surgery. 67 matched patients on CIIS as palliative therapy were included for analysis (male n = 47, 70%; African American n = 47, 70%). The most common reasons for “crossover” from CIIS as bridge therapy to palliative therapy were frailty (n = 10, 27%), cardiac arrest (n = 5, 13.5%), and progressive non-cardiac illnesses (n = 6, 16.2%). A similar percentage of patients in the bridge (n = 28, 76%) and palliative (n = 48, 72%) groups died outside the hospital (P=0.66); however, fewer bridge patients received hospice care compared to the palliative group (35% vs 69%, P < 0.001). Comparing patients who died in the hospital, bridge patients (n = 9; 100%) were more likely to die in the intensive care unit than palliative patients (n = 8; 42%) (P < 0.001).ConclusionPatients on CIIS as bridge therapy who do not ultimately receive surgical therapy “crossover” to palliative intention due to frailty, or development of or identification of serious illnesses. Nevertheless, these “bridge to nowhere” patients are less likely to receive palliative care or hospice and more likely to die in the intensive care unit than patients on CIIS as palliative therapy.

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“…Therefore, centers that develop eCPR programs should also be required to develop mechanisms for navigating the likely rare, but possible, “bridge-to-nowhere” scenario. Healthcare institutions must prepare to address these complex cases in real time with early involvement of a multidisciplinary team that includes palliative care, psychiatry, and ethics consultants [ 49 ].…”

Section: Considerations In Uncertainty Of Ecpr Outcomesmentioning

confidence: 99%

Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations

et al. 2023

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Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals’ wishes.

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Withdrawal of Temporary Mechanical Circulatory Support in Patients With Capacity

Cited by 9 publications

References 23 publications

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations

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