Background In the UK, patients with severe heart failure suitable for heart transplantation may be managed with a life-sustaining LVAD as a bridge to transplant. Many will not undergo transplantation, due to lack of donor organs or clinical deterioration rendering them unfit for surgery. These patients are at risk of LVAD-related complications and will die with their device in situ. We describe the end of life for this patient group.
Method Retrospective case note review of 40 deceased patients who underwent LVAD implantation between 2010 and 2016 at a single UK centre.
Results Within this cohort, mean age at death was 57 years, with a median interval between LVAD implantation and death of 18 months(range 6–76). Death was described as sudden in 17 patients; this group commonly died at home(65%).
Serious LVAD-associated complications were seen in 35 patients (87.5%), namely VAD thrombus (30%), intracerebral bleed (30%), GI bleed (27.5%) or driveline infection (25%). These complications were often fatal. This group had frequent (median 5, range 0–35) and lengthy (median 57 days, range 0–267) hospital admissions to their specialist centre, which for the majority (87.5%) was not in their local area.
Where dying was identified and death expected (n=19), patients were most likely to die in hospital (84%), but transfer to local hospital (5%) or hospice (16%) was achieved for some. Anticipatory SC PRN medications were prescribed for 68% and symptom assessment undertaken in 84% of cases. Overall, preferred place of death was documented for 12 patients and achieved in 10/12 cases.
Conclusion The last days of life for patients with LVAD support, were commonly spent in hospital following active management of a LVAD-related complication. Early specialist palliative care input is recommended to improve quality of end of life care, support exploration of future care wishes and consideration of practical device management.
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