brain death: culturally congruent palliative care (331)

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  • Vol. 39 No. 2 February 2010 Schedule with Abstracts 3634e5 pm

    Concurrent Sessions

    Palliative Care in Patients Treated with LeftVentricular Assist Device DestinationTherapy (LVAD-DT) (330)Keith Swetz, MD, Mayo Clinic, Rochester,MN, Monica Freeman, MSW LICSW, MayoClinic, Rochester, MN. Winifried Teuteberg,MD, University of Pittsburgh Medical Center,Pittsburgh, PA. Paul Mueller, MD MPH, MayoClinic, Rochester, MN.(All speakers have disclosed no relevant finan-cial relationships.)

    Objectives1. Recognize the indications for LVAD-DT in ad-

    vanced heart failure.2. Discuss ethical considerations and advanced

    care planning in patients treated with LVAD-DT.

    3. Discuss integration of palliative medicine inthe care of patients treated with LVAD-DTand palliative medicine providers in theLVAD multidisciplinary team.

    Left ventricular assist devices (LVAD) are uti-lized to provide cardiac support to patientswith advanced heart failure. While originally de-signed as bridge-to-transplant support for mori-bund patients until a heart for transplantationwas available, LVADs are increasingly beingused as destination therapy (LVAD-DT). LVAD-DT serves as permanent support to improvequality of life (QOL), enhance functional status,and improve survival in patients ineligible forcardiac transplantation. We will explore integra-tion of palliative medicine (PM) in the care ofpatients treated with LVAD-DT and how PM pro-viders can work within multidisciplinary teamscaring for these patients.Patients treated with LVAD-DT are medicallycomplex prior to device implantation, and areat high risk of catastrophic complications post-implantation. Complications may includestroke, infection, bleeding, pain, and neurologicand/or other end-organ dysfunction. QOL mayimprove with improved cardiac output; however,patients treated with LVAD-DT and their care-givers are often overwhelmed with financialand psychosocial constraints these devices im-pose. Caregivers and patients are at risk of burn-out and isolation due to limited community

    support outside of the tertiary facility.Objectives1. Identify key elements and four processes re-

    lated to culturally congruent care.2. Define brain death as a clinical, legal, and cul-

    tural construct.3. Use a case study to illustrate a culturally con-

    gruent approach for supporting families andhealthcare providers when the diagnosis isbrain death.

    Physical signs such as lack of pulse, absence ofbreathing, pallor, and rigor are observable, un-contested signs that death has occurred. How-ever, death may also be declared in the absenceof brain function, including the brain stem,known as brain death.When a patient has a severeneurological injury that may be consistent withbrain death, the use of mechanical ventilators,medications, and cardiopulmonary devices causethe patient to have a pulse and other signs of life,thus blurring the line between life and death.Brain death is a concept that is not easily under-stood and may not be culturally accepted.Goals of care regarding complications are oftenmurky and unexplored. Though patients may re-ceive informed consent and may have advanceddirectives, these documents often do not articu-late wishes in the case of complications, worsen-ing comorbid conditions, device failure, ordeteriorating quality of life. PM providers fre-quently broach these issues with patients andbuild rapport up front before complicationsoccur.We believe PM providers can facilitate timely dis-cussion and education even before LVAD-DT im-plantation, and follow patients longitudinally toimprove satisfaction and QOL. This workshopwill utilize case-based discussion and didacticsto help PM providers become comfortable andcompetent in caring for patients treated withLVAD-DT and in interacting with their multidis-ciplinary team.

    DomainPhysical Aspects of Care

    Brain Death: Culturally CongruentPalliative Care (331)Christine Westphal, APRN-BC ACHPN,Oakwood Healthcare System, Dearborn, MI.Stephanie Schim, PhD RN PHCNS-BC, WayneState University, Royal Oak, MI.(All speakers have disclosed no relevant finan-cial relationships.)

  • tual dimensions of patient care. This is based


    364 Schedule with Abstracts Vol. 39 No. 2 February 2010off of the generalist-specialist model set forthby Handzo and Koenig, but raises the level of ex-pected involvement of clinicians from a cursoryscreening of spiritual distress to a more involvedspiritual history. Though many clinicians havebecome quite adept at discussing spiritual mat-ters with their patients, still many hesitations, ob-jections, and outright disagreements still exist.Fortunately, several well-established instrumentsexist to guide even the most reluctant cliniciansSupporting families who are facing a brain deathdiagnosis presents the hospice and palliative careteam with unique challenges that can be metthrough an understanding of clinical, legal, andcultural constructs surrounding brain death andapplication of four processes that can be used toachieve culturally congruent care.

    DomainsAll Domains

    None of Your Darn Business!dTakinga Spiritual History while Preserving YourProfessional Boundaries, Your Rapport, andYour Pride (332)Tim Ford, MA MS CT. VCU Massey CancerCenter, Richmond, VA.(Ford has disclosed no relevant financialrelationships.)

    Objectives1. Distinguish between spiritual screening, spiri-

    tual history, and spiritual assessment.2. Compare and incorporate various tools for

    taking a spiritual history.3. Distinguish the ethical boundaries of explor-

    ing a patients faith, including mentally un-healthy beliefs, proselytization, and religiousdecision-making.

    Following on the recommendations of the Na-tional Consensus Project, a Consensus Confer-ence of spiritual leaders and palliative careprofessionals will publish a white paper this fallcalling all professionals to address the spiritualdimension of every patient. While this has obvi-ous implications for board-certified chaplains,it also has long-reaching implications for everyclinician working in healthcare, especially in pal-liative care and hospice.At the time of this proposal, the Consensus Con-ference white paper is still in draft form, but theyare likely to recommend that every professionalin palliative care and hospice address the spiri-(Baker has disclosed the following relevant fi-nancial relationships: Physician Partner forTexas Oncology.)

    Objectives1. Discuss basic principles of radiation oncology,

    with particular attention to principles that of-ten influence the spectrum of approachesused by radiation oncologists for patientsneeding palliative therapy.

    2. Identify specific radiotherapy methods andtechniques that are optimal for use in the hos-pice and palliative care settings.

    3. Identify specific strategies that allow mutuallysuccessful interactions between palliative careproviders and radiation oncologists.

    Available literature documents that the majorityof palliative care and hospice programs in NorthAmerica provide palliative care to patients withsymptomatic advanced cancers. Some of these pa-tients would be expected to be candidates forsymptom relief with palliative radiation therapy.However, only approximately one in four pro-grams actually provided palliative radiationin interviewing their patients for possible spiri-tual needs.While most of the ethical and sensitive religiousconsiderations of spiritual care will still rightfullyfall to the board-certified chaplains, there are stillissues that are the concern of any clinician work-ing within the spiritual dimensions of care.Understanding the ethical boundaries of prosely-tization extend beyond conversion to a formal re-ligion to include any coercion of a dominantworldview whether overt or simply by inferenceupon vulnerable populations. This does not, how-ever, preclude healthcare providers from claim-ing their own authority against religious orspiritual beliefs that are blatantly unhealthy,harmful, or even fatal. Handling these issueswith compassion andunderstanding also requiresa working knowledge of how religious and spiri-tual beliefs can influence importantmedical deci-sions, as seen in recent literature.

    DomainsSpiritual, Religious, and Existential Aspects ofCare; Ethical and Legal Aspects of Care

    "Palliative Radiation Oncology" or How toTeach a Radiation Oncologist to Do WhatYou Need Them to Do (333)Jerry Baker, MD, Texas Oncology, Fort Worth,

    Palliative Care in Patients Treated with Left Ventricular Assist Device Destination Therapy (LVAD-DT) (330)ObjectivesDomain

    Brain Death: Culturally Congruent Palliative Care (331)ObjectivesDomains

    None of Your Darn Business!-Taking a Spiritual History while Preserving Your Professional Boundaries, Your Rapport, and Your Pride (332)ObjectivesDomains



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