Challenges In End-of-life Care In Left Ventricular Assist Device Patients With Neurocognitive Decline

Introduction Neurocognitive decline is common with advancing age in patients with durable left ventricular assist device (LVAD) as destination therapy (DT). Although LVADs can improve survival patients with Stage D Heart Failure, challenges exist in providing care to these patients as they develop advanced neurocognitive decline. We present a case series of LVAD patients who developed advanced neurocognitive decline after LVAD implantation surgery and challenges involved at their end of life (EOL). Methods We retrospectively reviewed patients with durable LVAD receiving longitudinal care at our institution between July 2017 and October 2021. We included patients with durable LVAD age 18 or older who had electronic health record (EHR) documentation by either neurology or psychiatry consultants of progressive neurocognitive decline (any underlying diagnosis). We excluded patients whose neurocognitive changes were attributable to acute delirium. Patient data extracted from the EHR included baseline demographics, cardiac history, LVAD implantation course/complications, and, when indicated, clinical details of about EOL care. Results Twenty patients met study criteria. Mean age at implantation was 63.9 (SD 6.02, range 51-75). Patients were mostly men (70%), African American (85%), with underlying non-ischemic cardiomyopathy (60%). Preexisting comorbidities like stroke, chronic kidney disease and diabetes were present in 40%, 55% and 60% respectively. Post-LVAD complications including stroke, GI bleed, infection, thrombosis occurred in 9 (45%), 10 (50%), 13 (65%) and 5 (25%) patients. Palliative care was consulted only in 11 (55%) patients and 8 out of those 11 (72%) had palliative care involved at least 6 months after the LVAD implantation. Behavioral health was consulted in 15 (75%) patients. VAD deactivation was planned only in 7 (35%) patients and only 10 patients (50%) had advance directive filled. Four (20%) patients required admission to nursing homes for custodial care. On average, patients spent 78 days in the hospital in the last year. Conclusions Progressive neurocognitive decline may significantly impact clinical courses for patients with durable LVAD. Earlier engagement regarding advance care planning and assessing goals of care, particularly with support from palliative care clinicians, may benefit patient, family, and primary teams. Neurocognitive decline is common with advancing age in patients with durable left ventricular assist device (LVAD) as destination therapy (DT). Although LVADs can improve survival patients with Stage D Heart Failure, challenges exist in providing care to these patients as they develop advanced neurocognitive decline. We present a case series of LVAD patients who developed advanced neurocognitive decline after LVAD implantation surgery and challenges involved at their end of life (EOL). We retrospectively reviewed patients with durable LVAD receiving longitudinal care at our institution between July 2017 and October 2021. We included patients with durable LVAD age 18 or older who had electronic health record (EHR) documentation by either neurology or psychiatry consultants of progressive neurocognitive decline (any underlying diagnosis). We excluded patients whose neurocognitive changes were attributable to acute delirium. Patient data extracted from the EHR included baseline demographics, cardiac history, LVAD implantation course/complications, and, when indicated, clinical details of about EOL care. Twenty patients met study criteria. Mean age at implantation was 63.9 (SD 6.02, range 51-75). Patients were mostly men (70%), African American (85%), with underlying non-ischemic cardiomyopathy (60%). Preexisting comorbidities like stroke, chronic kidney disease and diabetes were present in 40%, 55% and 60% respectively. Post-LVAD complications including stroke, GI bleed, infection, thrombosis occurred in 9 (45%), 10 (50%), 13 (65%) and 5 (25%) patients. Palliative care was consulted only in 11 (55%) patients and 8 out of those 11 (72%) had palliative care involved at least 6 months after the LVAD implantation. Behavioral health was consulted in 15 (75%) patients. VAD deactivation was planned only in 7 (35%) patients and only 10 patients (50%) had advance directive filled. Four (20%) patients required admission to nursing homes for custodial care. On average, patients spent 78 days in the hospital in the last year. Progressive neurocognitive decline may significantly impact clinical courses for patients with durable LVAD. Earlier engagement regarding advance care planning and assessing goals of care, particularly with support from palliative care clinicians, may benefit patient, family, and primary teams.