Division of Cardiovascular Surgery Using ECMO as Palliative Care for Patient with Post-cardiotomy End-Stage Heart Failure Da-Yang Chen1, Nien-Yi Wu2, Su-Chin Tsao2, Ching-Feng Tsai3, Kuei-Chuan Chan3, Jung-Ming Yu 4, Yi-Liang Wu2 and Tsung-Po Tsai2.   Department of Surgery1, Department of Cardiovascular Surgery2, Division of Cardiology3, Chung Shan Medical University Hospital and Department of Cardiovascular Surgery ,Tzu Chi Hospital4. TSA 2018.3.18 Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Division of Cardiovascular Surgery Purpose Once patients developed post-cardiotomy end- stage heart failure, the in-hospital mortality rate was around 60-80%. A palliative program to support patients and their family members facing the dying and the bereavement period is spiritually valuable -- J Thorac Cardiovasc Surg 2010;139:302 -- -- BMJ 2017;356:j367 -- Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Materials and Methods: Division of Cardiovascular Surgery Materials and Methods: Chung-Shan medical university hospital Jan. 2003-Dec. 2017 Inclusion criteria : Post-cardiotomy heart failure (NYHA Class IV) patient who use ECMO support over 5 days Expert palliative team provided spiritual support to patients and families More than 3 points of motor response in Glasgow Coma Scale Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Division of Cardiovascular Surgery Palliative team: Clinician(s) who achieved the qualification of palliative care (6+18) Experts of in-need medical divisions Palliative medical case manager : (3 palliative care nurses) communication bridge between clinician and patient and families mental support Extramural spiritual support resource Families and patient Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Palliative intervention: Division of Cardiovascular Surgery Palliative intervention: OP Team discussion and explanation of the treatment target to families Inform the patient and families of the possible complications of using ECMO Consult palliative medical case manager and other extramural spiritual resource Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

ECMO Supported Patients Division of Cardiovascular Surgery 1345 Cardiovascular Surgery Jan. 2003~DEC. 2017 56 ECMO Supported Patients 5 Could not weaned off ECMO in 5 days 6

Materials and Methods: Division of Cardiovascular Surgery : Materials and Methods: Operation Age Sex Pre-operative (GCS) Postoperative ECMO duration CABG 46 yr M E4M6V5 E3M5Vt 8d CABG+VAD 56 yr E2M4Vt 15d+ VAD 73d 72 yr E4M6Vt 9d VSD repair+ TVR 11 mo 13d MVR+TAP 82 yr F 50d Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Result: Mean ECMO duration: 19 days(8-50 days) M : F = 4 : 1 Division of Cardiovascular Surgery Result: Mean ECMO duration: 19 days(8-50 days) M : F = 4 : 1 All five patients didn’t remove ECMO until they fell unconscious again and became hemodynamically unstable One patient who gained consciousness but failed to wean off ECMO decided the inheritance and then loss consciousness later. Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Discussions: The dilemas in end-stage heart failure Division of Cardiovascular Surgery Discussions: The dilemas in end-stage heart failure Considerations in prognostication How to negotiate for potentially inappropriate intervention ? Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Dilemas in end-stage heart failure Division of Cardiovascular Surgery Dilemas in end-stage heart failure Patients and caregivers policymakers/society Healthcare team/physician －J Geriatr Cardiol 2015 Jan; 12(1) 57-65－ Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Division of Cardiovascular Surgery 40% of family members did not believe that doctors can accurately predict 0% survival 32% of family members stated that they would continue life-prolonging interventions even if the doctor stated that there was less than 1% chance of survival 18% stated that they would continue life-prolonging interventions even if the doctor stated that there was a 0% chance of survival － Chest 2009;136:110–117 － Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Considerations in prognostication: Division of Cardiovascular Surgery Considerations in prognostication: If there is reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment －Crit Care Med 2016; 44: 1769-1774 － Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

◎ ATS/AACN/ACCP/ESICM/SCCM: Division of Cardiovascular Surgery ◎  ATS/AACN/ACCP/ESICM/SCCM: Seven-step negotiation for potentially inappropriate intervention: 1) Enlist expert consultation 2) Give notice of the process to surrogates; 3) Obtain a second medical opinion 4) Perform review by an interdisciplinary hospital committee 5) transfer to alternate institution 6) extramural appeal 7) Implement －Crit Care Med 2016; 44: 1769-1774 － Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Division of Cardiovascular Surgery Conclusion: ECMO support is a valuable alternative to provide a short period of palliative / spiritual care for patients with post-cardiotomy end-stage heart failure and their family member through an interdisciplinary team approach. Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

Thank for your attention. Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan 15