The role of palliative care in withdrawal of veno-arterial extracorporeal membrane oxygenation for cardiogenic shock

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GODFREY, Sarah | SAHOO, Aradhana | SANCHEZ, Joseph | FRIED, Justin | MASOUMI, Amirali | BRODIE, Daniel | TAKAYAMA, Hiroo | URIEL, Nir | TAKEDA, Koji | NAKAGAWA, Shunichi

CONTEXT: As the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) increases, decisions regarding withdrawal from VA-ECMO increase. OBJECTIVES: To evaluate the clinical characteristics of patients withdrawn from VA-ECMO and the role of palliative care consultation in the decision. METHODS: We retrospectively reviewed adult patients with cardiogenic shock requiring VA-ECMO at our institution withdrawn from VA-ECMO between January 1, 2014 and May 31, 2019. The relationship between clinical characteristics and palliative care visits was assessed and documented reasons for withdrawal were identified. RESULTS: Of 460 patients who received VA-ECMO, 91 deceased patients (19.8%) were included. Forty-two patients (44.8%) had a palliative care consultation. The median duration on VA-ECMO was 4.0 days (IQR 8.8), and it was significantly longer for patients with palliative care consultation than those without (8.8 days vs 2.0 days, p<0.001). Amongst those with palliative care consultation, those with early consultation (within 3 days) had significantly shorter duration of VA-ECMO compared with those with late consultation (7.6 days vs 13.5 days, t=2.022, p=0.008). Twenty-two (24.2%) had evidence of brain injury, which was significantly associated with patient age, number of comorbidities, duration of VA-ECMO, number of life-sustaining therapies, and number of palliative care visits (Wilks lambda 0.8925, DF 5,121, p = 0.016). Presence of brain injury was associated with fewer palliative care visits (t=2.82, p=0.006). CONCLUSION: Shorter duration of VA-ECMO support and presence of brain injury were associated with fewer palliative care visits. Decisions around withdrawal of VA ECMO support might be less complicated when patient's medical conditions deteriorate quickly or when neurological prognosis seems poor.

http://dx.doi.org/10.1016/j.jpainsymman.2020.10.027

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