Publications by authors named "Jane MacIver"

25 Publications

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The relational dynamics of caregivers of patients with a left ventricular assist device for destination-therapy: A qualitative investigation.

Heart Lung 2021 Feb 20;50(3):375-381. Epub 2021 Feb 20.

Scientist Ted Rogers Center for Heart Research and Peter Munk Cardiac Center, University, Health Network, 585 University Avenue, Toronto, M5G 2N2 Canada; Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 27 King's College Circle, Toronto, M5S 1A1 Canada.

Background: Caregivers are critical to the recovery and management of patients with destination-therapy left ventricular assist devices (DT-LVADs).

Objective: To explore the needs and impacts of caregiving for patients with DT-LVAD relative to the various relationships caregivers navigate from the shared perspectives of patients, caregivers, and healthcare providers.

Methods: Qualitative descriptive secondary analysis. Patients with a DT-LVAD (n = 3), caregivers (n = 2), and healthcare providers (n = 13) from all DT-LVAD programs in Ontario, Canada were invited to participate in semi-structured interviews. We used thematic analysis to identify, analyze, organize, describe, and report caregiver-related themes.

Results: Eighteen participants were interviewed. The needs and impact of caregiving for patients with DT-LVADs were characterized by connection with others (relational), and drastic and ongoing changes from normalcy within established and new relationships (dynamics).

Conclusions: DT-LVAD caregivers' unique needs may be a result of multi-leveled and compounding relational dynamics within and across established and new relationships. These could be considered to inform the content of targeted support strategies.
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http://dx.doi.org/10.1016/j.hrtlng.2021.01.008DOI Listing
February 2021

The "nurse as hero" discourse in the COVID-19 pandemic: A poststructural discourse analysis.

Int J Nurs Stud 2021 Jan 26;117:103887. Epub 2021 Jan 26.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario M5T1P8, Canada. Electronic address:

Background: Nurses have been labelled "heroes" by politicians, the mass media, and the general public to describe their commitment to providing front-line care to people with COVID-19, despite the risks of exposure and lack of clinical resources. Few studies have examined the implications of the hero discourse to nurses' professional, social, and political identities.

Objective: To critically examine the effects of the hero discourse on nurses who are contending with the ongoing COVID-19 crisis and to consider the political, social, cultural, and professional impact of this discourse on nursing work.

Methods: A poststructural discourse analysis, employing the theoretical ideas of truth, power, knowledge, subjectivity, and normalization, was conducted to explore the mass media's constructions of nurse as hero in the contexts of COVID-19. Media electronic databases were searched between March 1, 2020 to August 1, 2020 to locate newspaper and magazine articles, corporate advertisements, videos, social media postings, and institutional/corporate websites.

Setting: Data sources included English language media accounts that originated from Canada, the USA, and the UK.

Results: Three main elements of the hero discourse include: 1. Nurses as a "necessary sacrifice" - portraying nurses as selfless, sacrificing, and outstanding moral subjects for practicing on the front-line without adequate protective gear and other clinical resources; 2. Nurses as "model citizens" - positioning nurses as compliant, hardworking, and obedient subjects in contrast to harmful individuals and groups that ignore or resist COVID-19 public health measures. 3. Heroism itself as the reward for nurses - characterizing hero worship as a fitting reward for nurses who were unappreciated pre-pandemic, as opposed to supporting long-term policy change, and highlighting how heroism reconfigures nursing work from the mundane and ordinary to the exciting and impactful.

Conclusions: The hero discourse is not a neutral expression of appreciation and sentimentality, but rather a tool employed to accomplish multiple aims such as the normalization of nurses' exposure to risk, the enforcement of model citizenship, and the preservation of existing power relationships that limit the ability of front-line nurses to determine the conditions of their work. Our study has implications for approaching the collective political response of nursing in the ongoing COVID-19 crisis and formalizing the ongoing emotional, psychological, ethical, and practice supports of nurses as the pandemic continues.
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http://dx.doi.org/10.1016/j.ijnurstu.2021.103887DOI Listing
January 2021

Engaging Patients in Care (EPIC): A Framework for Heart Function and Heart Transplant-Specific Patient Engagement.

CJC Open 2019 Mar 29;1(2):43-46. Epub 2019 Mar 29.

Ted Rogers Center for Heart Research and Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.

ngaging atients n are (EPIC) is a local patient engagement initiative at the University Health Network for patients and families who have received care for heart failure, heart transplant, or mechanical circulatory support (left ventricular assist device). Patients and caregivers can engage at 4 different levels, including sharing, consulting, deliberating, and collaborating, depending on their knowledge, experience, and available time. The Engaging Patients In Care framework has 4 priority areas: Care Delivery and Policy, Patient Advocacy, Peer Support, and Research. We have identified key engagement barriers with a discussion of possible solutions. We hope this framework can be adapted as an evidentiary baseline for other heart failure and transplant institutions across Canada.
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http://dx.doi.org/10.1016/j.cjco.2019.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063628PMC
March 2019

Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life.

J Pain Symptom Manage 2020 05 19;59(5):1127-1146.e1. Epub 2019 Dec 19.

Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.12.357DOI Listing
May 2020

Advance care planning with chronically ill patients: A relational autonomy approach.

Nurs Ethics 2020 Mar 23;27(2):360-371. Epub 2019 May 23.

University of Toronto, Canada.

Advance care planning is a process that encourages people to identify their values, to reflect upon the meanings and consequences of serious illness, to define goals and preferences for future medical treatment and care, and to discuss these goals with family and health-care providers. Advance care planning is especially important for those who are chronically ill, as patients and their families face a variety of complex healthcare decisions. Participating in advance care planning has been associated with improved outcomes; yet, despite over 25 years of public awareness campaigns, research, and interventions developed to increase participation, advance care planning completion rates for people with chronic illnesses are no different than those in the general public (approximately 25%). Advance care planning has traditionally used an individualistic approach to autonomy, which puts forward an understanding of agents as independent, rational and self-interested persons. Because this individualistic approach has been largely unsuccessful in improving advance care planning uptake, a re-examination of the philosophical underpinnings of this practice and an exploration of alternative frameworks is warranted. In offering this exploration, we briefly outline two current perspectives on autonomy: the individualistic view and the relational view as articulated by feminist philosophers. Using a critical examination of the theoretical and empirical work on this topic, we argue that the individualistic view of autonomy does not sufficiently capture the relational and social complexities of the decision-making process of advance care planning. To offer a counterpoint, we examine the relational view of autonomy and suggest that this perspective is better aligned with the process of advance care planning. Specifically, we demonstrate that a relational model of autonomy is well suited to exploring advance care planning for four main reasons: (1) it recognizes the importance of relationships, (2) it reflects the fluctuating nature of autonomy in chronic illness, (3) it recognizes vulnerability, and (4) it is consonant with empirical work examining the advance care planning process.
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http://dx.doi.org/10.1177/0969733019848031DOI Listing
March 2020

Comparative effectiveness of the different components of care provided in heart failure clinics-protocol for a systematic review and network meta-analysis.

Syst Rev 2019 02 2;8(1):40. Epub 2019 Feb 2.

Institute of Health Policy, Management and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Heart failure (HF) is a complex chronic condition, leading to frequent hospitalization, decreased quality of life, and increased mortality. Current guidelines recommend that multidisciplinary care be provided in specialized HF clinics. A number of studies have demonstrated the effectiveness of these clinics; however, there is a wide range in the services provided across different clinics. This network meta-analysis will aim to identify the aspects of HF clinic care that are associated with the best outcomes: a reduction in mortality, hospitalization, and visits to emergency department (ED) and improvements to quality of life.

Methods: Relevant electronic databases will be systematically searched to identify eligible studies. Controlled trials and observational cohort studies of adult (≥ 18 years of age) patients will be eligible for inclusion if they evaluate at least one component of guideline-based HF clinic care and report all-cause or HF-related mortality, hospitalizations, or ED visits or health-related quality of life assessed after a minimum follow-up of 30 days. Both controlled trials and observational studies will be included to allow us to compare the efficacy of the interventions in an ideal context versus their effectiveness in the real world. Two reviewers will independently perform both title and abstract full-text screenings and data abstraction. Study quality will be assessed through a modified Cochrane risk of bias tool for randomized controlled trials (RCTs) or the ROBINS-I tool for observational studies. The strength of evidence will be assessed using a modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. Network meta-analysis methods will be applied to synthesize the evidence across included studies. To contrast findings between study designs, data from RCTs will be analyzed separately from non-randomized controlled trials and cohort studies. We will estimate both the probability that a particular component of care is the most effective and treatment effects for specified combinations of care.

Discussion: To our knowledge, this will be the first study to evaluate the comparative effectiveness of the different components of care offered in HF clinics. The findings from this systematic review will provide valuable insight about which components of HF clinic care are associated with improved outcomes, potentially informing clinical guidelines as well as the design of future care interventions in dedicated HF clinics.

Systematic Review Registration: PROSPERO CRD42017058003.
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http://dx.doi.org/10.1186/s13643-019-0953-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6359805PMC
February 2019

Utility of the Seattle Heart Failure Model for palliative care referral in advanced ambulatory heart failure.

BMJ Support Palliat Care 2018 Dec 6. Epub 2018 Dec 6.

Division of Cardiology, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada.

Background: Physicians face uncertainty when predicting death in heart failure (HF) leading to underutilisation of palliative care. To facilitate decision-making, we assessed the Seattle Heart Failure Model (SHFM) as a referral tool by evaluating its performance in predicting 1-year event-free survival from death, heart transplant (HTx), and ventricular assist device (VAD) implantation.

Methods: We retrospectively reviewed the charts of consecutive patients with advanced ambulatory HF with New York Heart Association Class III/IV HF and a left ventricular ejection fraction of ≤40% from 2000 to 2016. We evaluated SHFM's performance by using the Cox proportional hazards model, its discrimination using the c-statistic, its calibration by comparing the observed and predicted survival and its clinical utility by hypothetically assessing the proportion of patients adequately or inadequately referred to palliative care.

Results: We included 612 patients in our study. During the 1-year follow-up, there were 83 deaths, 4 HTx and 1 VAD. Although SHFM showed very good discrimination (c-statistic=0.71) and adequate calibration in medium to low-risk patients, it underestimated event-free survival by 12% in high-risk patients. SHFM's clinical utility was limited: 33% of eligible patients would have missed the opportunity for referral and only 27% of referred patients would have benefited.

Conclusion: Use of SHFM could result in a high proportion of referrals while capturing the majority of patients who may benefit from palliative care. Though this may be a more encompassing and safer alternative than current referral practices, it could lead to many early referrals.
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http://dx.doi.org/10.1136/bmjspcare-2018-001626DOI Listing
December 2018

The prognostic significance of frailty compared to peak oxygen consumption and B-type natriuretic peptide in patients with advanced heart failure.

Clin Transplant 2018 01 8;32(1). Epub 2018 Jan 8.

Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.

Frailty assessment has become an integral part of the evaluation of potential candidates for heart transplantation and ventricular assist device (HTx/VAD). The impact of frailty, as a heart failure risk factor or to identify those who will derive the greatest benefit with HTx/VAD remains unclear. The aim of this study was to evaluate the independent prognostic relevance of frailty assessment from peak oxygen consumption (peak VO ) or B-type natriuretic peptide (BNP) on mortality in patients referred for advanced heart failure therapies. Frailty was measured using modified Fried frailty criteria. In 201 consecutive patients, during a median follow-up of 17.5 months (IQR 11-29.2), there were 25 (12.4%) deaths. One-year survival was 100%, 94%, and 78% in nonfrail, prefrail, and frail patients, respectively (log rank P = .0001). Frailty was associated with a twofold increase risk of death (HR 2.01, P < .0001, 95% CI 1.42-2.84). When adjusted for BNP or peak VO , frailty was not associated with a significant risk of all-cause death. However, when peak VO is stratified into two categories (≥12 mL/kg/min vs <12 mL/kg/min), frailty was associated with increased mortality in patients with a lower peak VO (HR 1.72, P = .006).
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http://dx.doi.org/10.1111/ctr.13158DOI Listing
January 2018

A palliative approach for heart failure end-of-life care.

Curr Opin Cardiol 2018 03;33(2):202-207

Ted Rogers Center for Heart Research and the Peter Munk Cardiac Center, University Health Network.

Purpose Of Review: The current review discusses the integration of guideline and evidence-based palliative care into heart failure end-of-life (EOL) care.

Recent Findings: North American and European heart failure societies recommend the integration of palliative care into heart failure programs. Advance care planning, shared decision-making, routine measurement of symptoms and quality of life and specialist palliative care at heart failure EOL are identified as key components to an effective heart failure palliative care program. There is limited evidence to support the effectiveness of the individual elements. However, results from the palliative care in heart failure trial suggest an integrated heart failure palliative care program can significantly improve quality of life for heart failure patients at EOL.

Summary: Integration of a palliative approach to heart failure EOL care helps to ensure patients receive the care that is congruent with their values, wishes and preferences. Specialist palliative care referrals are limited to those who are truly at heart failure EOL.
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http://dx.doi.org/10.1097/HCO.0000000000000484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5811237PMC
March 2018

Long-term use of left ventricular assist devices: a report on clinical outcomes.

Can J Surg 2017 Aug;60(4):236-246

From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Raju), and the Advanced Heart Failure Program, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Raju, Maclver, Foroutan, Alba, Billia, Rao).

Background: The literature examining clinical outcomes and readmissions during extended (> 1 yr) left ventricular assist device (LVAD) support is scarce, particularly in the era of continuous-flow LVADs.

Methods: We completed a retrospective cohort study on consecutive LVAD patients from June 2006 to March 2015, focusing on those who received more than 1 year of total LVAD support time. Demographic characteristics, clinical outcomes and readmissions were analyzed using standard statistical methods. All readmissions were categorized as per the Interagency Registry for Mechanically Assisted Circulatory Support 2015 guidelines.

Results: Of the 103 patients who received LVADs during the study period, 37 received LVAD support for more than 1 year, with 18 receiving support for more than 2 years. Average support time was 786 ± 381 days, with total support time reaching 80 patient-years. During a median follow-up of 2 years, 27 patients died, with 1-year conditional survival of 74%. Median freedom from first readmission was 106 days (range 1-603 d), with an average length of stay of 6 days. Readmissions resulted in an average of 41 ± 76 days in hospital per patient. Reasons for readmission were major infection (24%), major bleeding (19%) and device malfunction/thrombus (13%). There were a total of 112 procedures completed during the readmissions, with 60% of procedures being done in 13% ( = 5) of patients.

Conclusion: Continuous-flow LVADs provide excellent long-term survival. The present study describes marked differences in reasons for readmissions between the general LVAD population and those supported for more than 1 year. Prolonged LVAD support resulted in decreased susceptibility to major bleeds and increased susceptibility to infection.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5529154PMC
http://dx.doi.org/10.1503/cjs.010016DOI Listing
August 2017

Barriers to Goals of Care Discussions With Patients Who Have Advanced Heart Failure: Results of a Multicenter Survey of Hospital-Based Cardiology Clinicians.

J Card Fail 2017 Nov 23;23(11):786-793. Epub 2017 Jun 23.

Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

Background: Conversations about goals of care in hospital are important to patients who have advanced heart failure (HF).

Methods: We conducted a multicenter survey of cardiology nurses, fellows, and cardiologists at 8 Canadian teaching hospitals. The primary outcome was the importance of barriers to goals-of-care discussions in hospital (1 = extremely unimportant; 7 = extremely important). We also elicited perspectives on roles of different practitioners in having these conversations.

Results: Questionnaires were returned by 770/1024 (75.2%) eligible clinicians. The most important perceived barriers were: family members' and patients' difficulty in accepting a poor prognosis (mean [SD] score 5.9 [1.1] and 5.7 [1.2], respectively), family members' and patients' lack of understanding about the limitations and harms of life-sustaining treatments (5.8 [1.1] and 5.7 [1.2], respectively), and lack of agreement among family members about goals of care (5.8 [1.2]). Interprofessional team members were viewed as having different but important roles in goals-of-care discussions.

Conclusions: Cardiology clinicians perceive family and patient-related factors as the most important barriers to goals-of-care discussions in hospital. Many members of the interprofessional team were viewed as having important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication about goals of care in advanced HF.
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http://dx.doi.org/10.1016/j.cardfail.2017.06.003DOI Listing
November 2017

Measuring quality of life in advanced heart failure.

Curr Opin Support Palliat Care 2017 03;11(1):12-16

aPeter Munk Cardiac Center bDepartment of Supportive Care, University Health Network cLawrence S. Bloomberg Faculty of Nursing dDepartment of Medicine eDepartment of Family and Community Medicine, University of Toronto, Toronto, Canada.

Purpose Of Review: Patients with Stage D heart failure can benefit from palliative care consultation to help them manage unpleasant symptoms and improve quality of life. Although guidelines describe how to manage symptoms, very little direction is provided on how to evaluate the effectiveness of those interventions.

Recent Findings: Numerous studies have used the measurement of symptoms, emotional distress, functional capacity and quality of life to evaluate the effectiveness of interventions in heart failure. There is limited evidence on the use of these instruments in heart failure palliative care. Four studies were identified that evaluate the effectiveness of palliative care consultation for patients with advanced heart failure. All four studies measured symptom severity, emotional distress, and quality of life. The application of appropriate instruments is discussed. Suggestions for scores that should trigger palliative care consultation are identified.

Summary: The routine administration of standardized instruments to measure symptom severity and quality of life may improve the assessment and management of patients with Stage D heart failure. Ongoing discussion and research is needed to determine if these instruments are the best tools to use with heart failure palliative care patients.
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http://dx.doi.org/10.1097/SPC.0000000000000250DOI Listing
March 2017

Barriers to goals of care discussions with hospitalized patients with advanced heart failure: feasibility and performance of a novel questionnaire.

ESC Heart Fail 2016 Dec 28;3(4):245-252. Epub 2016 Jun 28.

Department of MedicineMcMaster UniversityHamiltonOntarioCanada; Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonOntarioCanada.

Aims: Good end-of-life communication and decision-making are important to patients with advanced heart failure (HF) and their families, but their needs remain unmet. In this pilot study, we describe the feasibility and performance of a novel questionnaire aimed at identifying barriers and solutions to improve communication and decision-making about goals of care for hospitalized patients with advanced HF.

Methods: We distributed questionnaires to staff cardiologists, cardiology trainees, and cardiology nurses who provide care for HF patients at a Canadian teaching hospital. The questionnaire asked about the importance of various barriers to goals of care discussions. It also asked participants to rank their willingness to engage in goals of care discussions and their views on other clinicians could engage in such discussions.

Results: Of 76 clinicians, 44 (58%) completed the questionnaire (median completion time, 17 min). Individual survey questions had few missing responses (0% to 2%) for questions about barriers to goals of care discussions. There was appreciable discrimination of the importance of different barriers (mean scores 2.2 to 6.0 on a 7-point scale). Preliminary data suggest that clinicians perceive patient and family factors, such as difficulty accepting a poor prognosis, as the most important barriers preventing goals of care discussions.

Conclusions: In this pilot study, we have demonstrated the feasibility of a novel questionnaire to be used in a larger multi-centre study of end-of-life HF care. Essential information will be obtained to inform the design and evaluation of interventions that seek to improve communication and decision-making about goals of care with HF patients.
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http://dx.doi.org/10.1002/ehf2.12096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5107976PMC
December 2016

Patient perceptions of implantable cardioverter-defibrillator deactivation discussions: A qualitative study.

SAGE Open Med 2016 7;4:2050312116642693. Epub 2016 Apr 7.

Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada.

Background: There is a class I recommendation for implantable cardioverter-defibrillator deactivation discussions to occur between physicians and heart failure patients. Few studies have reported the patient's perspective on the timing of implantable cardioverter-defibrillator deactivation discussions.

Aim: To determine patient awareness, preferences and timing of implantable cardioverter-defibrillator deactivation discussions.

Design: Grounded theory was used to collect and analyze interview data from 25 heart failure patients with an implantable cardioverter-defibrillator.

Setting And Participants: Patients with an implantable cardioverter-defibrillator, from the Heart Function Clinic at University Health Network (Toronto, Canada).

Results: The sample (n = 25) was predominately male (76%) with an average age of 62 years. Patients identified three stages where they felt implantable cardioverter-defibrillator deactivation should be discussed: (1) prior to implantation, (2) with any significant deterioration but while they were of sound mind to engage in and communicate their preferences and (3) at end of life, where patients wished further review of their previously established preferences and decisions about implantable cardioverter-defibrillator deactivation. Most patients (n = 17, 68%) said they would consider deactivation, six (24%) were undecided and two (8%) were adamant they would never turn it off.

Conclusion: The patient preferences identified in this study support the need to include information on implantable cardioverter-defibrillator deactivation at implant, with change in clinical status and within broader discussions about end-of-life treatment preferences. Using this process to help patients determine and communicate their implantable cardioverter-defibrillator deactivation preferences may reduce the number of patients experiencing distressing implantable cardioverter-defibrillator shocks at end of life.
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http://dx.doi.org/10.1177/2050312116642693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830094PMC
April 2016

Readmissions Following Implantation of a Continuous-Flow Left Ventricular Assist Device.

J Card Surg 2016 May 12;31(5):361-4. Epub 2016 Apr 12.

Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Objective: The objective of this study is to review and analyze readmission data for patients who received a continuous flow left ventricular assist device (LVAD).

Methods: A retrospective review of 88 patients implanted with a continuous-flow LVAD between June 2006 and June 2014 was performed. Reason for readmission, frequency, length of stay, and procedures performed during each readmission were recorded. All patients were followed in our LVAD clinic and all readmissions were reported to our program.

Results: Sixty-seven patients (76%) were discharged following their hospitalization for LVAD implant. In these patients, indication for LVAD support consisted of bridge to transplant (78%) and destination therapy (22%). Total device support time was 30,482 days, with an average support time of 455 ± 376 days. Forty-two patients (63%) were readmitted at least once, with an average length of readmission stay of nine days (median = 6). There were 129 readmissions totaling 1264 hospital days. The main reason for readmission was infection (17%). Despite this relatively high readmission rate, patients spent 86% of their time outside the hospital.

Conclusion: Although common, LVAD readmissions can be appropriately managed with patients spending the majority of their support time at home. doi: 10.1111/jocs.12744 (J Card Surg 2016;31:361-364).
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http://dx.doi.org/10.1111/jocs.12744DOI Listing
May 2016

Using heart failure instruments to determine when to refer heart failure patients to palliative care.

J Palliat Care 2013 ;29(4):217-24

Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.

Aim: The purpose of this study was to determine whether the Edmonton Symptom Assessment Scale (ESAS) or the Palliative Performance Scale (PPS) are associated with traditionally used scores for heart failure patients -- specifically, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), an overall health visual analog scale (VAS), and the Seattle Heart Failure Model (SHFM). Furthermore, we sought to determine whether the PPS or the ESAS provided additional information on quality of life, symptom severity, or prognosis above that provided by the traditional scores for patients with heart failure.

Methods: We administered the ESAS, MLHFQ, VAS, PPS, and SHFM in a shuffled manner to 78 New York Heart Association Functional Classification (NYHA-FC) Ill-IV ambulatory heart failure patients. Pearson's r correlation was used to determine whether the scores from the ESAS and PPS correlated with the scores from the MLHFQ, VAS, and SHFM.

Results: The sample was predominately male (62.8 percent), mean age 60.1 +/- 13 years, with a diagnosis of idiopathic cardiomyopathy (45 percent). Moderate correlations were found between the ESAS and MLHFQ (r = 0.483, p < 0.01), the ESAS and VAS (r = -0.345, p < 0.01), the PPS and MLHFQ (r = -0.54, p < 0.01), and the PPS and VAS (r = 0.53, p < 0.01). There was no significant correlation between the PPS and SHFM.

Conclusion: The results of this study suggest that administration of the ESAS and PPS provides additional information on symptom severity and functional decline for patients with heart failure. Standardized administration of these scales may aid in the assessment and evaluation of heart failure patients.
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April 2014

Lost in translation: examining patient and physician perceptions of implantable cardioverter-defibrillator deactivation discussions.

Circ Heart Fail 2012 Sep;5(5):660-6

Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.112.967497DOI Listing
September 2012

Quality of life and left ventricular assist device support.

Circulation 2012 Aug;126(7):866-74

Divisions of Cardiology and Transplantation, Toronto General Hospital, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.111.040279DOI Listing
August 2012

Mechanical circulatory support as a bridge to transplant candidacy.

J Card Surg 2011 Sep 28;26(5):542-7. Epub 2011 Aug 28.

Heart Transplant Program, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.

Introduction: The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support.

Methods: From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group).

Results: Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m(2)), and 2 patients were dialysis-dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart-lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS).

Conclusions: MCS can successfully convert a large proportion of transplant-ineligible patients into acceptable candidates. 
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http://dx.doi.org/10.1111/j.1540-8191.2011.01310.xDOI Listing
September 2011

Quality of life for patients supported on a left ventricular assist device.

Expert Rev Med Devices 2011 May;8(3):325-37

Heart Transplant Program, Peter Munk Cardiac Center, Toronto General Hospital, 11C-1203, 585 University Ave., Toronto ON, M5G 2N2, Canada.

Left ventricular assist devices (LVADs) are mechanical pumps implanted into patients at risk of dying from Stage D heart failure. These devices not only increase survival time, they also significantly improve quality of life. Implantation of a LVAD improves hemodynamics and reduces congestion in both the pulmonary and peripheral vasculature. Improvements in forward blood flow are probably responsible for the significant reduction in the severity of dyspnea and fatigue postimplant. Quality of life is a subjective evaluation and includes aspects of physical, mental and social functioning. Quality of life is significantly improved after implantation of a LVAD, changes little over the duration of support and improves again following heart transplantation. Patients who are discharged home on support report significantly better quality of life than patients who remain in hospital. At home patients can resume physical, mental and social activities that were compromised preimplant. A significant decline in functional ability while on support may be a trigger for patients to initiate discussions regarding LVAD withdrawal. While the bulk of evidence was generated during the era of pulsatile support, preliminary information suggests similar results can be anticipated for patients supported on continuous-flow devices.
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http://dx.doi.org/10.1586/erd.11.9DOI Listing
May 2011

Mechanical circulatory support with the ABIOMED BVS 5000: the Toronto General Hospital experience.

Can J Cardiol 2010 Nov;26(9):467-70

Heart Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario.

Background: Acute hemodynamic collapse resulting in cardiogenic shock and impending end-organ failure is usually associated with certain death. The introduction of short-term mechanical circulatory support (MCS) devices offers potential therapy to these critically ill patients. The BVS 5000 device (ABIOMED Inc, USA) is widely used in the United States, but rarely in Canada, where device reimbursement remains a barrier.

Objective: To present the Toronto General Hospital's (Toronto, Ontario) initial five-year experience with this device to highlight the indications for use, common complications and overall success rates.

Methods And Results: The institutional MCS database from 2001 to 2006 was reviewed, and 18 patients who received 30 devices in a variety of configurations were identified. The most common support configuration consisted of biventricular support (n=12), followed by isolated left ventricular support (n=4) and isolated right ventricular support in two recipients of an implantable long-term left ventricular assist device. Overall survival to device explant or transplant was 55% (n=10), of which five (50%) were successfully discharged from the hospital. The overall survival from device implant to hospital discharge was 28% (five of 18). The most common cause of death was multisystem organ failure.

Conclusions: MCS with the ABIOMED BVS 5000 can successfully resuscitate critically ill patients; however, earlier institution of this device would avoid irreversible end-organ injury, and lead to higher rates of device explant and hospital discharge. Short-term MCS devices should be available in all cardiac surgical centres in Canada to permit stabilization and evaluation of the acutely ill cardiac patient and subsequent management in a heart transplant facility.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989351PMC
http://dx.doi.org/10.1016/s0828-282x(10)70449-9DOI Listing
November 2010

Choices: a study of preferences for end-of-life treatments in patients with advanced heart failure.

J Heart Lung Transplant 2008 Sep 26;27(9):1002-7. Epub 2008 Jul 26.

Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, Toronto, Ontario, Canada.

Background: The purpose of this study is to describe the treatment preferences of patients with heart failure among three distinct treatment options--optimal medical management, oral inotropes or left ventricular device (LVAD) support--to determine if there were differences in preferences between patients with mild heart failure (New York Heart Association [NYHA] Class II) and severe heart failure (NYHA Class IV), and also to determine whether quality of life, perceived severity of symptoms and overall health influenced treatment preferences.

Methods: We enrolled 91 patients who completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ); visual analog scales for depicting their perceived severity of overall health, dyspnea and fatigue; and a treatment trade-off tool.

Results: The most preferred treatment options were oral inotropes, LVAD and standard medical management. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patient preferences correlated poorly with MLHFQ, symptom and overall health scores. Although not statistically significant, there was a trend toward patients with worse quality of life and symptom scores preferring more aggressive treatment.

Conclusions: The results of our study identified two distinct groups of patients: one group preferring treatments that prolonged survival time and another group that favored strategies that improved quality of life but reduced survival time. Treatment preferences were independent of functional or symptom status, suggesting that preferences may be decided early in the course of illness.
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http://dx.doi.org/10.1016/j.healun.2008.06.002DOI Listing
September 2008

Pilot study of an Internet patient-physician communication tool for heart failure disease management.

World Hosp Health Serv 2006 ;42(3):32-8

Division of General Internal Medicine, University Health Network, Toronto, ON, Canada.

Background: Internet disease management has the promise of improving care in patients with heart failure but evidence supporting its use is limited. We have designed a Heart Failure Internet Communication Tool (HFICT), allowing patients to enter messages for clinicians, as well as their daily symptoms, weight, blood pressure and heart rate. Clinicians review the information on the same day and provide feedback.

Objective: This pilot study evaluated the feasibility and patients' acceptability of using the Internet to communicate with patients with symptomatic heart failure.

Methods: Patients with symptomatic heart failure were instructed how to use the Internet communication tool. The primary outcome measure was the proportion of patients who used the system regularly by entering information on average at least once per week for at least 3 months. Secondary outcomes measures included safety and maintainability of the tool. We also conducted a content analysis of a subset of the patient and clinician messages entered into the comments field.

Results: Between 3 May 1999 and 1 November 2002, 62 patients (mean age 48.7 years) were enrolled. At 3 months 58 patients were alive and without a heart transplant. Of those, 26 patients (45%; 95% Confidence Interval, 0.33-0.58) continued using the system at 3 months. In 97% of all entries by participants weight was included; 68% of entries included blood pressure; and 71% of entries included heart rate. In 3,386 entries out of all 5,098 patient entries (66%), comments were entered. Functions that were not used included the tracking of diuretics, medications and treatment goals. The tool appeared to be safe and maintainable. Workload estimates for clinicians for entering a response to each patient's entry ranged from less than a minute to 5 minutes or longer for a detailed response. Patients sent 3,386 comments to the Heart Function Clinic. Based on the content analysis of 100 patient entries, the following major categories of communication were identified: patient information; patient symptoms; patient questions regarding their condition; patient coordinating own care; social responses. The number of comments decreased over time for both patients and clinicians.

Conclusions: While the majority of patients discontinued use, 45% of the patients used the system and continued to use it on average for 1.5 years. An Internet tool is a feasible method of communication in a substantial proportion of patients with heart failure. Further study is required to determine whether clinical outcomes, such as quality of life or frequency of hospitalization, are improved.
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February 2007

Withdrawal of ventricular assist device support.

J Palliat Care 2005 ;21(3):151-6

Division of Cardiology, Toronto General Hospital, Ontario, Canada.

Objective: Ventricular assist devices (VAD) are mechanical pumps implanted into patients with advanced heart failure who are at risk of imminent death. VADs are a treatment and not a cure, and mortality on device support remains high. Recognizing the dire nature of the decisions for patients and families and the associated high mortality rates, we actively included processes for device withdrawal as part of our program mandate.

Methods: At Toronto General Hospital, from October 2001 to December 2004, 22 patients underwent implantation of a VAD. Seven patients died following device withdrawal.

Results: The average time spent on support prior to device withdrawal was seven days. In four of the seven cases, family members initiated discussions regarding device withdrawal. Family-initiated discussions were more likely to occur if patients were implanted electively, as a bridge to transplantation. Disagreements occurred between the ICU and the transplant teams regarding the timing of device withdrawal and responsibility for stopping the pump.

Discussion: Establishing a process for device withdrawal has been a key factor in the success of our VAD program. This process relies heavily on pre-implantation preparation, a strategy for resolving disagreements, and a process for withdrawing device support.
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February 2006

Pilot study of an Internet patient-physician communication tool for heart failure disease management.

J Med Internet Res 2005 Mar 26;7(1):e8. Epub 2005 Mar 26.

Division of General Internal Medicine, University Health Network, Toronto ON, Canada.

Background: Internet disease management has the promise of improving care in patients with heart failure but evidence supporting its use is limited. We have designed a Heart Failure Internet Communication Tool (HFICT), allowing patients to enter messages for clinicians, as well as their daily symptoms, weight, blood pressure and heart rate. Clinicians review the information on the same day and provide feedback.

Objective: This pilot study evaluated the feasibility and patients' acceptability of using the Internet to communicate with patients with symptomatic heart failure.

Methods: Patients with symptomatic heart failure were instructed how to use the Internet communication tool. The primary outcome measure was the proportion of patients who used the system regularly by entering information on average at least once per week for at least 3 months. Secondary outcomes measures included safety and maintainability of the tool. We also conducted a content analysis of a subset of the patient and clinician messages entered into the comments field.

Results: Between May 3, 1999 and November 1, 2002, 62 patients (mean age 48.7 years) were enrolled.. At 3 months 58 patients were alive and without a heart transplant. Of those, 26 patients (45%; 95% Confidence Interval, 0.33-0.58) continued using the system at 3 months. In 97% of all entries by participants weight was included; 68% of entries included blood pressure; and 71% of entries included heart rate. In 3386 entries out of all 5098 patient entries (66%), comments were entered. Functions that were not used included the tracking of diuretics, medications and treatment goals. The tool appeared to be safe and maintainable. Workload estimates for clinicians for entering a response to each patient's entry ranged from less than a minute to 5 minutes or longer for a detailed response. Patients sent 3386 comments to the Heart Function Clinic. Based on the content analysis of 100 patient entries, the following major categories of communication were identified: patient information; patient symptoms; patient questions regarding their condition; patient coordinating own care; social responses. The number of comments decreased over time for both patients and clinicians.

Conclusion: While the majority of patients discontinued use, 45% of the patients used the system and continued to use it on average for 1.5 years. An Internet tool is a feasible method of communication in a substantial proportion of patients with heart failure. Further study is required to determine whether clinical outcomes, such as quality of life or frequency of hospitalization, are improved.
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http://dx.doi.org/10.2196/jmir.7.1.e8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1550640PMC
March 2005