Palliative care in cardiac transplantation: an evolving model

Abstract

It is currently estimated that 5.7 million Americans live with heart failure. Of these, less than 3000 will receive a heart transplant this year, according to the US Department of Health and Human Services Organ Procurement and Transplantation Network. With successful transplantation can come significant emotional and physical symptoms that are not always addressed. Although palliative care is an interdisciplinary subspecialty designed to alleviate multiple domains of suffering in serious illness, many mistakenly associate it solely with the end of life. Traditionally associated with cancer, research into the role of palliative care in other chronic illnesses and complex life-changing therapies such as solid organ transplantation remains scarce but is nonetheless developing. Here, we try to investigate a potential role for palliative care for heart transplant recipients. Early research thus far has demonstrated importance of early involvement of palliative care teams and the significant improvement of physical and emotional symptoms in the pre- and post-transplant period. Nevertheless, more research is warranted to determine the ideal timing of palliative care integration, the effects on health care resource utilization, and whether improving quality of life can affect morbidity and mortality. By understanding these critical elements and others we may be able to develop a model for the role of palliative care for heart transplant patients.

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

“…Aging, co‐morbid conditions, end‐organ damage, cognitive impairment, frailty and limited social support complicate heart failure management, and palliative care should address each of these components. End‐of‐life decision making is even more challenging for patients with advanced heart failure when heart transplantation or long‐term MCS have failed . The PAL‐HF (Palliative Care in Heart Failure) trial, a single‐centre study of 150 patients, showed that interdisciplinary palliative care intervention in advanced heart failure patients resulted in greater benefits in quality of life, anxiety, depression and spiritual wellbeing compared with usual care alone .…”

“…A comprehensive end‐of life plan of care for each patient should be available. This plan of care should be defined before MCS implantation or heart transplantation and revisited during the course of care …”

“…End-of-life decision making is even more challenging for patients with advanced heart failure when heart transplantation or long-term MCS have failed. 262 The PAL-HF (Palliative Care in Heart Failure) trial, a single-centre study of 150 patients, showed that interdisciplinary palliative care intervention in advanced heart failure patients resulted in greater benefits in quality of life, anxiety, depression and spiritual wellbeing compared with usual care alone. 263 The SWAP-HF (Social Worker-Aided Palliative Care Intervention in High-risk Patients with Heart Failure) trial showed that patients 256 at high risk for mortality from heart failure frequently overestimate their life expectancy and a structured social worker-led palliative care intervention enhances prognostic understanding and patient-physician communication regarding goals of care.…”

“…This plan of care should be defined before MCS implantation or heart transplantation and revisited during the course of care. 262 Patients with MCS as DT are particularly complex. A study at the Mayo Clinic on end-of-life care in long-term MCS patients showed that 78% of the patients who died were hospitalized, and of these, 88% died in the intensive care unit.…”

End-of-Life Care among US Adults with ESKD Who Were Waitlisted or Received a Kidney Transplant, 2005–2014

“…liver) describes their limited involvement in advance care planning (ACP) [6][7][8][9][10] and high burden of unmet palliative care needs. [11][12][13][14][15] Although results are mixed, 10,16 there is some evidence that patients preparing for these other types of solid organ transplant received more intensive patterns of end-of-life care than similar patients who had not been considered for transplant, even when their death was expected. 8 However, systematic differences in the selection process for kidney, as compared with other kinds of solid organ transplant, 17 and the availability of dialysis as an alternative form of organ replacement therapy for people with ESKD may contribute to distinctive patterns of end-of-life care for patients engaged in the kidney transplant process.…”