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Physicians report lack of palliative care protocols, formal instruction for patients with TAVR, VADs

An analysis of survey data revealed many institutions lack protocols for the integration of palliative care in transcatheter aortic valve replacement and ventricular assist device processes, according to findings published in JAMA Internal Medicine.

Many physicians also lack formal instruction and extensive knowledge in palliative care, James N. Kirkpatrick, MD, director of the Echocardiography Laboratory at the University of Washington Medical Center and an associate professor of medicine, and colleagues, wrote on behalf of the Palliative Care Working Group of the Geriatrics Section of the American College of Cardiology (ACC).

“Palliative care has not traditionally been seen as applicable to patients who are candidates for device-based therapies, including transcatheter aortic valve replacement (TAVR) and ventricular assist devices (VADs),” they wrote. “However, although improvements in technology, expertise at implanting devices and patient selection have been made, these devices come with a risk of morbid complications that can be particularly deleterious in elderly patients with pre-existing comorbidities and impaired baseline functional and/or cognitive status.”

Kirkpatrick and colleagues assessed the responses to a 44-item survey sent to members of the ACC. They found most of the 323 respondents were physicians (52.3%) who practiced adult cardiology (85.8%) in either urban (54.5%) or academic (50.8%) settings.

They found most participants agreed palliative care consultations could be helpful in TAVR (88.3%) and VAD (83.4%) procedures. In addition, most respondents reported that their institution or practice required advance directives before implantation of TAVR (42.5%) or VAD (51.3%). However, the researchers also reported a large minority of participants did not know about institutional requirements for these directives regarding TAVR (27.8%) or VAD (21.9%).

In addition, 82.6% of participants indicated they had knowledge of palliative care, with 13.6% characterizing their knowledge as “extensive” and 10.5% reporting formal palliative care instruction.

“We observed a low rate of formal inclusion of palliative care consultation in institutional protocols, with higher use in patients receiving a VAD than a TAVR, and lack of specific knowledge about the protocols themselves,” Kirkpatrick and colleagues concluded. “These findings and the substantial workforce shortage in palliative care indicate a need for more research into barriers that limit provision of palliative care and for training opportunities for clinicians who care for patients (especially the elderly with comorbidities) undergoing implantation of TAVRs or VADs and, by extension, undergoing other high-risk cardiovascular procedures.” – by Chelsea Frajerman Pardes

Disclosure: The researchers report no relevant financial disclosures.