Palliative Care Assessment Sheet for Patient’s Being Evaluated
for Mechanical Circulatory Devices
(or Organ Transplantation)
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Patient Profile (MRN/DOB)
INTERMACS: Profiles for Patient Selection
Procedure(s) being considered:
Goals of Care/Expectations
o Why are you getting a MCD?
o Is this MCD a bridge to transplantation or destination therapy?
o What are your hoping for by getting a MCD?
Advanced Directives
o Living Will
o POST
o Other
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*Almost all patient’s being considered for a MCD or transplant will be a FULL CODE
Health Care Representative/ Health Care Power of Attorney:
Performance Status
Social Issues
o Who will be your support
o Who will be trained to care for the device
Spiritual / Religious considerations
Other Medical Conditions to Consider
Preparedness Plan (discuss with patient and surrogate)
o Catastrophic Complications Consideration
 Devastating neurological sequela
 Intractable GI bleed
 Intractable arrhythmia
 Uncorrectable coagulopathy
 Inability to wean from ventilator
 Renal failure resulting in need for long term HD
Device Malfunction
o As discussed by the MCS coordinators to ensure there is a preparedness for such issues
as battery backup/pump failure / etc.
Debilitative Comorbid Conditions / Progression of Existing Comorbidities
o Progressive Dementia
o New Malignancy
o Worsening Renal Failure
o Worsening Pulmonary Disease
Inadequate Quality of Life (This is not the same as Functional Capacity)
o Beliefs about when life would not be worth living
Left Ventricular Assist Device: A Decision Aid for Patients with Advanced Heart Failure
https://vimeo.com/270114526