Abstract 123: Attitudes and Availability of Palliative Care Within Institutions Providing Mechanical Circulatory Support Device Implantation: A National Survey
Authors: Swetz Keith M , Bakitas Marie A , Tucker Rodney O , Kavalieratos Dio , Dionne-Odom J. N , Palmore Jackie , Blood Peggy , Allen Kristen R , Bourgeois Claire , Mancarella Gisella A , Kono Alan T , Pamboukian Salpy V 
Published: March 2022

Objectives:
The 2013 International Society for Heart and Lung Transplantation (ISHLT) guidelines recommend, and the Centers for Medicare and Medicaid Services (CMS) conditions of participation mandate, inclusion of a palliative care (PC) specialist in care of patient who have received mechanical circulatory support devices (MCSD) as destination therapy. It is unclear to what extent MCSD care is consistent with these recommendations, or how that care is operationalized.

Methods:
We surveyed PC and MCSD coordinators/clinicians at Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) centers using Qualtrics™ web-based software, or via phone, to identify institutional PC and MCSD program characteristics and clinician attitudes about role and utilization of PC in this patient population. Using literature review, expert panel, and current MCSD guidelines, we developed 3 surveys: MCSD center institutional characteristics (15 items), PC program characteristics at those sites (23 items), and both MCSD and PC clinicians’ perceptions of the role of specialist and generalist PC (31 items). Cardiology clinicians answered an additional 7 items about their level of confidence performing PC tasks for patients with advanced cardiac disease.

Results:
Thirty-nine percent (55 of 140) of INTERMACS centers responded. More than half of MCSD programs were established by 2003; however, most PC programs were not established until 2007. MCSD programs (n=45) reported referring a mean of 78% of patients with MCSD to PC; more than 88% (39 of 44) had a formal protocol for referral, and virtually all reported positive working relationships between MCSD and PC clinicians. All respondents agreed with 2013 ISHLT guidelines for PC involvement during pre-implantation evaluation. Regarding end-of-life, nearly 32% (14 of 44) of institutions did not have a specific MCSD deactivation protocol; however 48% (21 of 44) of respondents “always” consulted with PC when a decision to deactivate was made. Cardiology respondents reported the lowest confidence levels in managing delirium, anxiety, and depression; however, 88% (14 of 16) reported discussing end-of-life preferences during MCSD evaluation.

Conclusion:
Although selection/respondent bias is an important limitation of these results, these respondents agreed with and reported enacting ISHLT and CMS recommendations for including PC in MCSD evaluation. Nevertheless, there was less consensus on clinicians’ roles and confidence levels with providing PC following MCSD implantation and at end-of-life versus during the pre-implantation period.

Clinical Implications:
Findings from this survey can enable cardiovascular clinicians to evaluate how PC involvement impacts care for patients with MCSD; however, metrics to evaluate patient and system outcomes are yet to be systematically developed and measured.