1. 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
Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

2. 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

3. Materials and Methods:
Division of Cardiovascular Surgery
Materials and Methods:
Chung-Shan medical university hospital
Jan 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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: －
Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

13. ◎ 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: －
Chung Shan Medical University Hospital , Department of Cardiovascular Surgery, Taichung, Taiwan

14. 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

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