Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure

Treatment options in end-stage heart failure: where to go from here?

Chronic heart failure is a major healthcare problem associated with high morbidity and mortality. Despite significant progress in treatment strategies, the prognosis of heart failure patients remains poor. The golden standard treatment for heart failure is heart transplantation after failure of medical therapy, surgery and/or cardiac resynchronisation therapy. In order to improve patients’ outcome and quality of life, new emerging treatment modalities are currently being investigated, including mechanical cardiac support devices, of which the left ventricular assist device is the most promising treatment option. Structured care for heart failure patients according to the most recent international heart failure guidelines may further contribute to optimal decision-making. This article will review the conventional and novel treatment modalities of heart failure

Physical conditioning and mental stress reduction - a randomised trial in patients undergoing cardiac surgery

<p>Abstract</p> <p>Background</p> <p>Preoperative anxiety and physical unfitness have been shown to have adverse effects on recovery from cardiac surgery. This study involving cardiac surgery patients was primarily aimed at assessing the feasibility of delivering physical conditioning and stress reduction programs within the public hospital setting. Secondary aims were to evaluate the effect of these programs on quality of life (QOL), rates of postoperative atrial fibrillation (AF) and length of stay (LOS) in hospital.</p> <p>Methods</p> <p>Elective patients scheduled for coronary artery bypass graft and/or valve surgery at a public hospital in Melbourne, Australia were enrolled. Patients were randomized to receive either holistic therapy (HT) or usual care (UC). HT consisted of a series of light physical exercise sessions together with a mental stress reduction program administered in an outpatient setting for the first two weeks after placement on the waiting list for surgery. A self-administered SF-36 questionnaire was used to measure QOL and hospital records to collect data on LOS and rate of postoperative AF.</p> <p>Results</p> <p>The study population comprised 117 patients of whom 60 received HT and 57 received UC. Both programs were able to be delivered within the hospital setting but ongoing therapy beyond the two week duration of the program was not carried out due to long waiting periods and insufficient resources. HT, as delivered in this study, compared to UC did not result in significant changes in QOL, LOS or AF incidence.</p> <p>Conclusions</p> <p>Preoperative holistic therapy can be delivered in the hospital setting, although two weeks is insufficient to provide benefits beyond usual care on QOL, LOS or postoperative AF. Further research is now required to determine whether a similar program of longer duration, or targeted to high risk patients can provide measurable benefits.</p> <p>Trial registration</p> <p>This trial was conducted as part of a larger study and according to the principles contained in the CONSORT statement 2001.</p

A wellness program for cardiac surgery improves clinical outcomes

Objective: To evaluate the efficacy of an Integrative Cardiac Wellness Program (ICWP) for cardiothoracic surgery patients on postoperative recovery, bleeding risk, satisfaction and participation in rehabilitation programs. Design: An open label study whereby ICWP participants were compared to a historical control group that received usual care at the same hospital. Methods: Patients enrolled at pre-admission clinics took metabolic supplements (CoQ10, magnesium orotate, alpha lipoic acid, omega 3 fatty acids) three times daily from enrolment until surgery and for 4 weeks afterwards. Between postoperative days 3-7, patients received individualised health education from a naturopath followed by a phone call post-discharge. The control group consisted of elective cardiothoracic patients receiving usual care prior to the ICWP commencing. Data was collected from medical records, a survey and interviews. Results: Data from 922 patients were analysed. ICWP participants (n= 337) were well matched with controls (n= 585) for age, gender and history of hypertension, hypercholesterolaemia, diabetes and smoking.Multivariate analysis found that CABG ICWP patients had a relative reduction of 42% for postoperative inotrope (cardiac stimulants) support compared to controls (p&lt;. 0.001). Similarly, the ICWP valve surgery patients had 40% relative reduction in the incidence of postoperative inotrope support compared to controls (p= 0.02).There was no significant difference between the treatment and control groups in the incidence of serious bleeding events, defined as return to theatre due to haemorrhage or blood transfusion requirements.ICWP patients gave positive feedback of their experience and there was a 46% increase in attendance at rehabilitation programs compared to controls (p= 0.033). Conclusions: The ICWP is safe, improves postoperative heart function, is well accepted by patients and has long-term patient benefits by improving attendance at rehabilitation