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NURS 8114 Discussion: Framing a Practice Problem as a Critical Question With Measurable Outcomes

NURS 8114 Discussion: Framing a Practice Problem as a Critical Question With Measurable Outcomes

NURS 8114 Discussion Framing a Practice Problem as a Critical Question With Measurable Outcomes

Critical Question

Managing the end-of-life (EOL) journey with critically ill patients with implanted mechanical circulatory support (MCS) devices can be a complex process.  In the field of cardiothoracic surgery, there are numerous heart devices that are used to treat patients with heart failure, which can further complicate the EOL process.  In the last decade, these devices have improved dramatically, which has allowed advanced heart failure patients to live longer lives with fewer symptoms and improving quality of life (McIlvennan et al., 2019).  Over time, mechanical circulatory support (MCS) patients can develop complications that cause them to be admitted to the hospital or intensive care unit (ICU).  Given these patients’ complicated physiology and disease process, long-term sequelae may include injury to multiple organ systems, stroke, or GI bleeding (Pak et al., 2020).  These patients often stay in the ICU for many weeks or months, navigating clinical improvements and setbacks (Pak et al., 2020).  These experiences are physically and emotionally taxing on patients and families.  Technology allows ICU teams to keep these patients alive, often with tracheostomies in place, on ventilators, requiring intravenous vasopressors or inotropes, and continuous dialysis.

While the technology can extend patients’ lives, what is the answer when there is no longer quality of life?  Is there a process that can be implemented by the multidisciplinary team that can improve the dying process in this subset of critically ill patients?

Article One

Brush, S., Budge, D., Alharethi, R., McCormick, A. J., McPherson, J. E., Reid, B. B., Ledford, I. D., Smith, H. K., Stoker, S., Clayson, S. E., Doty, J. R., Caine, W. T., Drakos, S., & Kfoury, A. G. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist device. The Journal of Heart and Lung Transplantation29(12).

This article was published in 2010 but does a great job summarizing the concerns of improving technology and the implications at end of life for MCS patients.  For their study, the authors reviewed the Utah Artificial Heart Program registry of destination therapy (DT)

NURS 8114 Discussion Framing a Practice Problem as a Critical Question With Measurable Outcomes
NURS 8114 Discussion Framing a Practice Problem as a Critical Question With Measurable Outcomes

left ventricular assist device (LVAD) implants from 1999 to 2009 for end-of-life preparation.  For this study EOL preparation was defined as the patient making a decision to “stop mechanical circulatory support for whatever reason” (Brush et al., 2010).  The authors review the causes of EOL discussions, time from discussion to death, the location of the patient when death occurred, and queried the primary caregivers about the process to identify common themes.  Of the 92 DT LVADs placed at the medical center, 20 qualified for review per the study.  The most common reason for initiation of the EOL process was worsening quality of life and the addition of new comorbidities.  The conclusion of the study stated that as more MCS devices are implanted, and the patients are living longer, that more EOL discussions and processes will occur.  The authors suggested that implementing protocols specific to these issues may assist in creating a more comfortable environment for the patient (Brush et al., 2010).

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Article Two

Pak, E., Jones, C., & Mather, P. (2020). Ethical challenges in care of patients on mechanical circulatory support at end-of-life. Current Heart Failure Report17, 153–160. https://doi.org/10.1007/s11897-020-00460-4

This article offers insight into the potential ethical and legal concerns associated with EOL in MCS patients and a review of current studies around the topic of EOL in MCS patients.  Ethical concerns arrive at the issue of turning the pump off and the concerns it could be interpreted as euthanasia or physician-assisted death.  Current studies show common challenges in EOL care in MCS patients include lack of advance directive use, high rate of caregiver EOL decision making, and “high rates of death in the hospital and ICU settings” (Pak et al., 2020).  Studies have also shown that often there is not consensus within the multidisciplinary team about how best to approach EOL in the MCS patient.  The article concludes by suggesting the evidence supports the need for improvement in this process by creating protocols, implementing early advance care planning, and offering consistent support to patient caregivers (Pak et al., 2020).

Article Three

Dunlay, S. M., Strand, J. J., Wordingham, S. E., Stulak, J. M., Luckhardt, A. J., & Swetz, K. M. (2016). Dying with a left ventricular assist device as destination therapy. Circulation: Heart Failure9(10).

This article from the Mayo Clinic provides insight into the EOL process for DT-LVAD patients by reviewing 89 patients from their registry from 2007 through 2014.  The data showed that only 15% of patients were in enrolled in hospice prior to death and 78% of patients died in the hospital.  This data varies significantly from non-device heart failure patients, who commonly use hospice services and are able to die at home.  The authors suggest that more research should be done to determine why there is such a difference in EOL care for these patients and how EOL care for MCS patients can be optimized (Dunlay et al., 2016).

References

Brush, S., Budge, D., Alharethi, R., McCormick, A. J., McPherson, J. E., Reid, B. B., Ledford, I. D., Smith, H. K., Stoker, S., Clayson, S. E., Doty, J. R., Caine, W. T., Drakos, S., & Kfoury, A. G. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist device. The Journal of Heart and Lung Transplantation29(12).

Dunlay, S. M., Strand, J. J., Wordingham, S. E., Stulak, J. M., Luckhardt, A. J., & Swetz, K. M. (2016). Dying with a left ventricular assist device as destination therapy. Circulation: Heart Failure9(10).

McIlvennan, C. K., Grady, K. L., Matlock, D. D., Helmkamp, L. J., Abshire, M., & Allen, L. A. (2019). End of life for patients with left ventricular assist devices: Insights from INTERMACS. The Journal of Heart and Lung Transplantation38(4).

Pak, E., Jones, C., & Mather, P. (2020). Ethical challenges in care of patients on mechanical circulatory support at end-of-life. Current Heart Failure Report17, 153–160. https://doi.org/10.1007/s11897-020-00460-4