Is There A Right Time?: Challenges in Discontinuing Dobutamine and Norepinephrine in Advanced Heart Failure

Outcomes 1. Utilizing a case-based approach, participants will be able to understand and describe the challenges associated with use and discontinuation of palliative inotropes in end of life care. 2. Participants will identify key strategies that the cardiology and palliative community should routinely consider and implement surrounding palliative inotropes, as well as directions for future research and inquiry. Key Message Many patients with advanced heart failure are initiated and continued on inotrope therapy for palliative purposes despite lack of candidacy for advanced therapies. This case abstract draws attention to the lack of current guidelines in the cardiology or palliative care communities regarding endpoints to discontinue these medications or specific strategies for leading these conversations with patients and their loved ones. Background There is wide variability in use of palliative inotropes in end-stage heart failure (HF) partly due to lack of clarity in the literature. ACC/AHA guidelines recommend palliative inotropes for advanced HF patients "where consistent with the patient's goals of care"(1). What happens after that remains muddied: inotropes may be continued through the end of life or discontinued due to adverse effects or logistical and financial considerations (2). No comprehensive guidelines exist surrounding when to discontinue these medications and how to conduct conversations around this distressing topic. Case Mr. B was admitted to the ICU with end-stage HF and cardiogenic shock requiring dobutamine and eventually norepinephrine. Weaning was unsuccessful, and the patient was not a candidate for advanced therapies or home inotropes due to lack of support. When told that the current treatments were non-curative and ICU discharge was impossible, the patient asked his team to, in his words, "Pull the plug." However, when the nurse prepared to discontinue the infusions, he questioned, "What if we don't stop them now?" This happened repeatedly over several days, with the patient consenting to a comfortable death and then asking for more time, leading to confusion and distress among his family and hospital staff. An interdisciplinary approach was employed to support the patient, family, and providers. Ultimately, cardiology reiterated the medications were not indefinite, recommended weaning, and the patient died later that day. Conclusion A literature search for this case yielded technical inotrope weaning strategies (3) but no guidance for patients with wavering wishes or multiple infusions. This case highlights the importance of discussions regarding endpoints and time limited trials at the time of medication initiation. In cases of ambiguity, it is paramount to provide and act upon a clear recommendation. Future research should include specific indications for when to discontinue palliative inotropes. Keywords Managing Suffering and Distress / Disease specific management