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Difficulty: HardDisposition and Care Setting Transitions

A 78-year-old man is admitted to the hospital with acute decompensated heart failure. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 15% and stage 4 chronic kidney disease. This is his fourth admission for a heart failure exacerbation in the past six months. During this hospitalization, attempts to transition him from intravenous to oral diuretics resulted in symptomatic hypotension, worsening renal function, and severe dyspnea. He is currently maintained on a continuous intravenous milrinone infusion on the telemetry unit, which keeps his breathing comfortable at rest, though he experiences significant dyspnea when attempting to walk to the bathroom. The patient has been evaluated by the advanced heart failure team and is deemed ineligible for a left ventricular assist device (LVAD) or cardiac transplantation due to his advanced age and comorbidities. He is fully alert and oriented. During a family meeting, he clearly states, "I am tired of being in the hospital. I just want to go home and be comfortable. I do not want to be put on a breathing machine or shocked if my heart stops." He lives with his daughter, who is supportive and able to be present at home most of the day. Which of the following is the most appropriate disposition plan for this patient?

  1. Discharge home with a referral for home hospice care and continue the continuous intravenous milrinone infusionAnswer
  2. B
    Transfer to a long-term acute care hospital (LTACH) to attempt protocolized weaning of the intravenous milrinone infusion
  3. C
    Discharge home with standard home health services and transition to high-dose oral diuretic therapy
  4. D
    Transfer to an inpatient rehabilitation facility to improve physical conditioning and functional status before returning home
  5. E
    Request a psychiatry evaluation to assess decision-making capacity given his refusal of ongoing acute hospital care

Answer

Discharge home with a referral for home hospice care and continue the continuous intravenous milrinone infusion
The patient has end-stage heart failure, has exhausted advanced treatment options, and has clear goals of care focused on comfort and returning home. He is dependent on milrinone for symptom control, having failed weaning attempts. A common misconception is that patients requiring continuous intravenous infusions cannot be discharged home. However, continuous intravenous inotropes (such as milrinone or dobutamine) can be safely continued at home as palliative therapy under the management of a home hospice agency. This disposition perfectly aligns with his preference to return home, avoid further hospitalizations, and remain comfortable.

Step-by-Step Solution

1
Assess the patient's clinical status and prognosis.
The patient has end-stage (NYHA Class IV) heart failure, is ineligible for advanced therapies, and is dependent on a continuous milrinone infusion for symptom control.
Establishing the severity of illness and reversibility is necessary to determine the appropriate level of post-acute care.
2
Identify the patient's specific goals of care.
The patient desires a palliative approach, specifically requesting to return home, prioritize comfort, and avoid aggressive resuscitation (DNI/DNR).
Patient autonomy and stated goals dictate the direction of medical management and disposition planning.
3
Evaluate care settings that can safely accommodate the patient's medical needs while honoring his goals.
Standard home health cannot adequately manage actively dying patients on vasoactive drips, while LTACHs and rehab facilities conflict with his desire to go home and focus on comfort.
Matching the clinical requirements with facility capabilities prevents unsafe discharges and goal-discordant care.
4
Select the appropriate disposition.
Home hospice is selected, as hospice agencies can safely manage continuous palliative inotrope infusions (like milrinone) to alleviate dyspnea in the home setting.
Palliative inotropes are a standard, accepted therapy within hospice care for end-stage heart failure.

Key Concept

Disposition of end-stage heart failure patients to home hospice with the continuation of palliative continuous intravenous inotropes for symptom management.
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Topics

Disposition and Care Setting Transitions

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