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Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as
Anirudh Rao1,2, Manavotam Singh3, Mansi Maini1
1Department of Medicine, Georgetown University School of Medicine, Washington, DC, United States.
Insights
Patients on chronic intravenous inotropic support (CIIS) as bridge therapy who do not receive surgery often transition to palliative care. These patients are less likely to receive hospice and more likely to die in the ICU.
Area of Science:
- Cardiology
- Palliative Care
- Medical Ethics
Background:
- Advanced heart failure (HF) patients often receive chronic intravenous inotropic support (CIIS) as a bridge to surgery.
- Some patients do not ultimately receive surgical intervention and transition to palliative care.
- Understanding reasons for this transition and end-of-life outcomes is crucial.
Purpose of the Study:
- To identify reasons why patients on CIIS as bridge therapy transition to palliative care.
- To compare end-of-life outcomes between patients transitioned from bridge therapy and those initially on CIIS for palliative therapy.
Main Methods:
- Retrospective cohort study of patients on CIIS (2010-2016).
- Data extracted from health records and multidisciplinary meeting minutes.
- Descriptive and inferential statistics used for analysis.
Main Results:
- 16% of patients on CIIS as bridge therapy did not receive surgery.
- Common "crossover" reasons: frailty (27%), cardiac arrest (13.5%), progressive non-cardiac illness (16.2%).
- Bridge patients were less likely to receive hospice (35% vs 69%) and more likely to die in the ICU (100% vs 42%) compared to palliative patients.
Conclusions:
- Patients on CIIS bridge therapy not receiving surgery transition to palliative care due to frailty or other serious illnesses.
- "Bridge to nowhere" patients receive less hospice care and have higher ICU mortality.
- This highlights a need for improved palliative care integration for these patients.
Background:
Many patients with advanced heart failure (HF) are administered chronic intravenous inotropic support (CIIS) as bridge to surgical therapy; some ultimately never receive surgery. We aimed to describe reasons patients "crossover" from CIIS as bridge therapy to palliative therapy, and compare end-of-life outcomes to patients initiated on CIIS as palliative therapy.
Methods:
Single-institution, retrospective cohort study of patients on CIIS as bridge or palliative therapy between 2010 and 2016; data obtained through review of health records and multi-disciplinary selection meeting minutes, was analyzed using descriptive and inferential statistics.
Results:
Of 246 patients discharged on CIIS as bridge therapy, 37 (16%) (male n = 28, 76%; African American n = 22, 60%) ultimately never received surgery. 67 matched patients on CIIS as palliative therapy were included for analysis (male n = 47, 70%; African American n = 47, 70%). The most common reasons for "crossover" from CIIS as bridge therapy to palliative therapy were frailty (n = 10, 27%), cardiac arrest (n = 5, 13.5%), and progressive non-cardiac illnesses (n = 6, 16.2%). A similar percentage of patients in the bridge (n = 28, 76%) and palliative (n = 48, 72%) groups died outside the hospital (P=0.66); however, fewer bridge patients received hospice care compared to the palliative group (35% vs 69%, P < 0.001). Comparing patients who died in the hospital, bridge patients (n = 9; 100%) were more likely to die in the intensive care unit than palliative patients (n = 8; 42%) (P < 0.001).
Conclusion:
Patients on CIIS as bridge therapy who do not ultimately receive surgical therapy "crossover" to palliative intention due to frailty, or development of or identification of serious illnesses. Nevertheless, these "bridge to nowhere" patients are less likely to receive palliative care or hospice and more likely to die in the intensive care unit than patients on CIIS as palliative therapy.
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