Table 3.

Specific Points to Cover at Key Times for Patients with MCS and Sample Communication Techniques for each Time Point. The table provides examples of the kinds of language that clinicians might use when having discussions with patients and caregivers. Adapted from references ^{41, 43, 47}. Portions adapted with permission from Wiegand DL, Kalowes PG. Withdrawal of cardiac medications and devices. AACNAdv Crit Care. 2007;18:415-425. Portions also adapted from Arch Intern Med. 2008;168:1733-1739, Copyright © 2008. American Medical Association. All rights reserved.

Time Point	Points to Cover in Conversations	Sample Phrases to Use
Patient Being Considered for Mechanical Circulatory Support	Assure patient understands other options, which include continued medical treatments (without implantation) ± hospice	“We want to make sure you understand all of your options. I'm going to outline three possible paths: use of MCS implantation, continued life-sustaining treatments without MCS, and a plan focusing solely on comfort.”
	Informed consent includes not only risks of procedure but possible complications of bleeding, infection, device failure, and stroke	“There are risks of putting the device in, but we should also talk about other complications that can happen after the device is implanted. Some of these relate to the device itself, and others relate to the medications we have to give you because of the device.”
	Discuss changes that may be necessary in terms of lifestyle and need for assistance from caregivers	“Let's talk some about what it will be like when you're home. Many patients and caregivers have questions about what it will be like in terms of day-to-day activities and what kinds of help they will need from their family and other kinds of caregivers.”
	Encourage advance care planning conversations, and in particular have patient appoint health care proxy (durable power of attorney for healthcare)	“Let's talk about who you would want to make decisions for you if at some point in your illness you become unable to make decisions for yourself. Have you had conversations about what kind of care you would want if you were permanently unable to recognize and interact with your loved ones?”
	Explain that device can be disabled at some point in future if patients so desires	“Sometimes patients want to know if they can stop MCS if at some point they feel like they've had enough. I want to assure you that you can. Let's talk some about that now, but what is most important is your just knowing that this is a future option.”
	Reassure patient of continued involvement by both MCS team and palliative care team	“We will remain available to assure that your symptoms are well controlled and help support you and your family.”
Follow-up appointments after device implanted	Assess physical, psychological, and spiritual needs. Refer to appropriate services when needed (e.g. social work, chaplain)	“I like to check in with patients at each visit to see how they are doing physically, emotionally, and spiritually. Tell me how you are doing.”
	Assess caregiver coping to patient's illness and MCS	“MCS has effects on both patients and their caregivers. Tell me how your loved ones are doing.”
Periods of Infection, Neurologic Events, or Device Failure	Same points as “follow-up appointments” above PLUS:
	Provide options for treatment which include both life-sustaining treatments as well as comfort oriented treatment only	“I think that we can help you get over this problem, but that doesn't mean that we have to necessarily continue every treatment that we are now doing. Would you like to talk more about other options?”
	Assess if goals of care have changed and assess if patient continues to benefit from MCS	“Let's take a moment to reassess your overall goals for your healthcare. What are your current thoughts about the pros and cons of the MCS system?”
Determination that Bridge to Transplant Patients are No Longer a Candidate for Cardiac Transplant	Explain to patient and caregiver why they are no longer a candidate for transplantation	“You have been under evaluation for heart transplantation. After speaking with your other physicians, we unfortunately do not have good news today. The cardiac transplant team has determined that you are not eligible for a transplant.” <Allow for silence.> “We'd like to review with you how the transplant team came to that decision and what it means for future treatment. Is it okay if I go ahead?”
	Acknowledge that this determination may have a significant psychological or emotional impact and allow for this to be expressed	“I know that this may be upsetting to hear. What are you feeling?”
	Determine how this does or does not change patient's decision making with regards to MCS	“How does the lack of transplantation as an option influence your thinking about MCS in your overall healthcare?”
	Assure continued emotional and psychological support and availability to discuss these needs on future visits	“This is a lot to discuss in one visit. I want to assure you that the entire team is here to support you and available should you want to discuss this further. I'll be sure to ask about how you're doing at our next visit as well.”
End of Life / Disabling MCS*	Assess goals of care and determine whether burdens of device now outweigh benefits	“The MCS system has served you well though it sounds like things may have been more difficult recently. Tell me your thoughts about how things have been going recently. Is MCS still helping you to have the kind of life you want? You may want to take some time to think about this - when you are ready let's talk about your feelings about continuing MCS.”
	Assess physical, psychological, and spiritual needs of patients and refer to appropriate services	“I know this can be a difficult time. Let's talk about your physical, emotional, and spiritual needs at this point. If there are things I can't help you with then perhaps we can refer you to someone who can.”
	Reassure patient of continued involvement by palliative care	“The palliative care team and the MCS team will remain available to assure that your symptoms are well controlled and help support you and your family. Your cardiologist and cardiac surgeons are still in charge of your care, but palliative care will continue to work along side them to help you in any way we can.”
	Assure patient and caregiver understand that disabling MCS will most likely be followed by rapid decline and death	“I know this is difficult to talk about, but I need to make sure you understand what stopping the MCS means. We will make sure you are comfortable at all times. After you have said your good-byes, we will give you medications to help you relax and sleep. We will then turn off the MCS and you will die soon thereafter.”
	Explain to patient, caregiver, and staff medications to be used and indication	“I'm going to give you some medications to make sure that you don't feel short of breath or anxious. It is important that you understand that the purpose of the medication is only to make sure you are comfortable after MCS is turned off.”
	Determine if patient / caregiver / family have said all they need to say to each other	“Are there any important tasks that are still undone? Have you said everything to your family and friends that you feel you need to? There are five things that many families may consider saying to each other at this stage of life: I forgive you, forgive me, thank you, I love you, and goodbye. I can write these things down and you can think through them later. Do you have questions about other important things to consider at this stage of your life?” [See reference 47]

^*At this stage of advanced disease, not all patients may be able to communicate with the clinician. Conversations should occur with the patient whenever possible (assuming he/she wants to be involved in them). The table is written as if the patient is able to communicate, though if he/she is unable, the conversation could occur with the caregiver or surrogate decision maker.