Timing and Documentation of LVAD Deactivation Conversations in Destination Therapy

Key Message : Among DT LVAD patients, one quarter had no documented deactivation-specific GOC conversation, and 40% occurred within a week of death. Even with embedded palliative care, discussions were late or absent. Findings highlight the need for structured annual reviews and timely re-engagement at critical inflection points to ensure goal-concordant care.

Abstract:

Background:
Patients with destination therapy (DT) left ventricular assist devices (LVADs) live with persistent mortality risk despite improved survival, creating ongoing emotional and existential strain. Although advance care planning is recommended, little is known about deactivation-specific goals-of-care (GOC) conversations. We examined their timing and documentation to identify practice and system gaps.

Methods:
We conducted a retrospective review of all DT and bridge-to-candidacy LVAD patients who died at our institution between July 2015 and July 2024. During this period, our institution implanted 212 LVADs (range 12–37 annually, median 18/year), based on INTERMACS data. Using an iteratively developed keyword library, two reviewers independently identified documentation of LVAD deactivation conversations, defined as notes explicitly referencing deactivation, preparation for future deactivation, or deactivation planning (e.g., in the context of hospice enrollment). General GOC documentation without mention of LVAD was excluded. An EMR template for LVAD-related GOC documentation was introduced in 2022, while earlier records were free text.

Results:
Among 45 patients, 35 (78%) had at least one documented deactivation conversation (n=79). The first occurred a median of 566 days post-implant and 20 days before death; 40% occurred within 7 days of death, and only 6% pre-implant. One quarter of patients had no documented deactivation conversation. Most occurred inpatient (87%), were authored by palliative care clinicians (79%), and frequently documented by nurse practitioners (47%). Despite 82% receiving palliative consultation, only 13% died in hospice.

Conclusions:
This study is among the first to systematically examine deactivation-specific GOC conversations in DT LVAD patients. Even with embedded palliative care, documentation was often absent or late, particularly before introduction of an EMR template. Because documentation may not fully reflect all conversations, results should be interpreted cautiously. Findings underscore the importance of longitudinal palliative care follow-up, with re-engagement at key inflection points, to support adaptive coping and reduce illness-related distress.

References: 1. Yuzefpolskaya M, Schroeder SE, Houston BA, et al. The society of thoracic surgeons intermacs 2022 annual report: Focus on the 2018 heart transplant allocation system. Ann Thorac Surg. 2023;115(2):311-327.

2. Pak ES, Jones CA, Mather PJ. Ethical challenges in care of patients on mechanical circulatory support at end-of-life. Curr Heart Fail Rep. 2020;17(4):153-160.

3. Abdullah B, Gupta R, Anderson KM, et al. The role of palliative care for patients with left ventricular assist devices: A narrative review. Ann Palliat Med. 2024;13(3):598-606.

4. Salomon S, Frankel H, Chuang E, Eti S, Selwyn P. Implementing routine palliative care consultation before lvad implantation: A single center experience. J Pain Symptom Manage. 2018;55(5):1350-1355.

5. Verdoorn BP, Luckhardt AJ, Wordingham SE, Dunlay SM, Swetz KM. Palliative Medicine and Preparedness Planning for Patients Receiving Left Ventricular Assist Device as Destination Therapy—Challenges to Measuring Impact and Change in Institutional Culture. J Pain Symptom Manage. 2017;53(5):1095-1101. doi:10.1016/j.jpainsymman.2016.12.345. PMID: 28093312; PMCID: PMC5511781