Comprehensive care for mechanical circulatory support: a new frontier for synergy with palliative care.

Heart Failure (HF) is a chronic and progressive illness and is a leading cause of death in the United States. Patients with end-stage HF have limited therapeutic options and thus mechanical circulatory support (MCS) is increasingly being used to treat patients with end-stage disease. Between June 2006 and June 2010, 2680 adults in the United States received a Food and Drug Administration–approved durable MCS device as treatment for end-stage HF.1 Roughly 82% of patients receiving MCS were either listed for transplant at time of implant (bridge to transplant, BTT) or had at least a moderate probability of being listed for transplant at some point during MCS (bridge to candidacy), whereas 11% were implanted as destination therapy (DT). Currently, more than 98% of patients implanted with a durable MCS device receive a continuous-flow left ventricular assist device.1 The duration of MCS and survival is influenced by a number of factors, including timing of implant, strategy of support at time of implant, age of patient, and medical comorbidities. Within the INTERMACS [Interagency Registry for Mechanically Assisted Circulatory Support] registry, 87% of BTT patients have been transplanted or are still alive on MCS at 12 months compared with 67% of DT patients. By stratifying by type of device to account for the shift to continuous flow pumps that began in 2008, 12and 24-month actuarial survival for all patients receiving a primary continuous-flow left ventricular assist device as BTT is 83% and 75%, respectively, whereas 12-month actuarial survival for DT patients is 74%. Outcome data on patients supported by continuous-flow MCS past 2 years are limited. The combination of the increasing number of patients reaching the end stages of HF, the stable but inadequate number of available donor organs, and the continued improvements in MCS technology predicts that an increasing number of patients will be living longer on these devices. The challenges faced by patients and their caregivers in managing chronic illness on MCS are poorly characterized. Although quality-of-life scores, New York Heart Association functional class, and distance walked in 6 minutes are improved after left ventricular assist device implant,2,3 little is known about the long-term psychosocial impact of MCS on patients and their families. Although several comprehensive reviews have been written on the optimal relationship between palliative care and patients with HF,4–7 there is a paucity of literature on the value of palliative care services working in collaboration with the MCS team. The goals of this manuscript are to (1) clarify how palliative care may assist the MCS team caring for patients and their families; (2) review the impact of palliative care on outcomes among patients with other chronic diseases similar to HF; (3) review key points in the chronology of illness of MCS patients when palliative care might be beneficial; and (4) discuss communication techniques to help MCS patients and their families make decisions at key points over the course of their illness.