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Programmatic Palliative Care Consultations in Pediatric Heart Transplant Evaluations
Erika J Mejia1, Rui Xiao2, Jennifer K Walter3
1Divisions of Cardiology and Palliative Care, Ann & Robert Lurie Children's Hospital, Chicago, IL, USA. ermejia@luriechildrens.org.
Insights
Programmatic palliative care (PPC) in pediatric heart transplant evaluations did not increase hospital-free days but was linked to fewer invasive end-of-life treatments. This suggests PPC may reduce intensive interventions for children with heart failure.
Area of Science:
- Pediatric Cardiology
- Palliative Care
- Health Services Research
Background:
- Guidelines recommend palliative care integration for pediatric heart failure (HF) and life-limiting conditions.
- The impact of palliative care on patient-centered outcomes in pediatric HF is not well-understood.
- Heart transplantation is a critical intervention for end-stage pediatric heart disease.
Purpose of the Study:
- To assess the association of programmatic palliative care (PPC) implementation in pediatric heart transplant evaluations.
- To evaluate PPC's impact on hospital-free days (HFD) and end-of-life (EOL) treatment choices.
- To understand how PPC influences care intensity for pediatric heart transplant candidates.
Main Methods:
- Retrospective cohort study comparing patients evaluated before and after PPC implementation.
- Included 188 pediatric patients (<19 years) undergoing heart transplant evaluation (Feb 2012-Apr 2020).
- Compared outcomes between the pre-PPC era (Feb 2012-Dec 2015) and PPC era (Jan 2016-Apr 2020).
Main Results:
- PPC was not significantly associated with increased hospital-free days (IRR 0.94).
- PPC was associated with decreased mechanical ventilation use (OR 0.12, p=0.03) at EOL.
- PPC was associated with decreased ionotropic support use (OR 0.13, p=0.03) at EOL.
Conclusions:
- Programmatic palliative care integration in pediatric heart transplant evaluations may be associated with less invasive end-of-life care.
- PPC implementation did not negatively impact hospital-free days.
- Findings suggest PPC can help align EOL care with patient and family goals in pediatric cardiology.
Abstract:
Guidelines advocate for integrating palliative care into the management of heart failure (HF) and of children with life-limiting disease. The potential impact of palliative care integration into pediatric HF on patient-centered outcomes is poorly understood. The present study sought to assess the association of programmatic implementation of palliative care into the heart transplant evaluation process with hospital-free days (HFD) and end of life (EOL) treatment choices. The study included patients less than 19 years of age who underwent a heart transplant evaluation between February 2012 and April 2020 at a single center. Patients evaluated in the programmatic palliative care (PPC) era (January 2016-April 2020) were compared to patients evaluated in the pre-PPC era (February 2012-December 2015). The study included 188 patients, with 91 (48%) in the PPC era and 97 (52%) in the pre-PCC era. Children < 1 year of age at the time of the evaluation represented 32% of the cohort. 52% of patients had single ventricle physiology. PPC was not significantly associated with increased HFD (IRR 0.94 [95% CI 0.79-1.2]). PPC was however associated with intensity of EOL care with decreased mechanical ventilation (OR 0.12 [95% CI 0.02-0.789], p = 0.03) and decreased use of ionotropic support (OR 0.13 [95% CI 0.02-0.85], p =0.03). PPC in pediatric heart transplant evaluations may be associated with less invasive interventions at EOL.
