GOC Conversations About LVAD Deactivation in Destination Therapy and Bridge-to-Candidacy Decedents.

CONTEXT: Patients implanted with a left ventricular assist device (LVAD) as destination therapy (DT) or bridge-to-candidacy (BTC) have no established path off the device, making eventual deactivation likely. Documentation of goals-of-care (GOC) conversations addressing potential LVAD deactivation remains poorly described.

OBJECTIVE

To characterize the prevalence, timing, and clinical setting of documented GOC conversations addressing potential LVAD deactivation among DT and BTC decedents.

METHODS

Single-center, retrospective cohort study of DT and BTC LVAD patients who died between July 1, 2015-July 1, 2024 at a tertiary academic center with embedded palliative care. Clinical and death-related variables came from the Interagency Registry for Mechanically Assisted Circulatory Support. GOC conversations addressing potential deactivation were identified through structured electronic health record review using a keyword library.

RESULTS

Among 45 decedents, 35 (77.8%) had at least one documented deactivation conversation (79 total). Median time from first conversation to death was 20 days. Median time from implantation to first conversation was 566 days (IQR 52-1,659). Among first conversations, 40% occurred within 7 days of death; only 2 preceded implantation. Most were inpatient (87.3%) and authored by palliative care clinicians (78.5%). Palliative care was involved with 82.2% of patients, yet 10.8% had no documented deactivation conversation and 13.3% died in hospice.

CONCLUSIONS

Documented GOC conversations addressing potential LVAD deactivation were not universal and typically first occurred near death, despite broad palliative care availability and a median of 566 days on device. Conversations occurred primarily during acute decline, leaving limited opportunity for preparation earlier in the course of support.