The heart failure bazaar negotiating the options

Larry Allen, MD, MHS ACC 2015

The Heart Failure Bazaar:

Negotiating the Options

The HF Bazaar

1. The options

2. The negotiation

– Clinical

– Patient

– Other

Two Classes of Rx Options/Decisions

1. Benefit >> Risk: When scientific evidence for benefit

strongly outweighs harm, behavioral support (e.g.

smoking cessation counseling) designed to describe,

justify, and recommend may be appropriate and

complementary to decision support.

2. Benefits ~ Risks: Shared decision making is most

easily applied to preference-sensitive decisions,

where both clinicians and patients agree that equipoise

exists, and decision support helps patients think

through, forecast, and deliberate their options.

GDMT for appropriate patients not really an “option” Adherence

Framework for Major Interventions Option Type Examples Considerations

1. Improve cardiac function

CABG, TAVR, CRT Surgical complication

(stroke, post-op shock)

2. Abort SCD only ICD Deactivation when goals of

care change

3. Adjunctive Rx for

decompensation

Inotropes

Temporary MCS (IABP)

Dialysis (CVVH)

Potential for dependence

4. Advanced Rx to replace

cardiac function

Durable LVAD

Transplantation

Exchange one disease for

another

5. Non-cardiac Screening studies

Joint replacement

Heart failure may color

typical risk/benefit

Framework for Major Interventions Option Type Examples Considerations

1. Improve cardiac function

CABG, TAVR, CRT Surgical complication

(stroke, post-op shock)

2. Abort SCD only ICD Deactivation when goals of

care change

3. Adjunctive Rx for

decompensation

Inotropes

Temporary MCS (IABP)

Dialysis (CVVH)

Potential for dependence

4. Advanced Rx to replace

cardiac function

Durable LVAD

Transplantation

Exchange one disease for

another

5. Non-cardiac Screening studies

Joint replacement

Heart failure may color

typical risk/benefit

Framework for Major Interventions Option Type Examples Considerations

1. Improve cardiac function

CABG, TAVR, CRT Surgical complication

(stroke, post-op shock)

2. Abort SCD only ICD Deactivation when goals of

care change

3. Adjunctive Rx for

decompensation

Inotropes

Temporary MCS (IABP)

Dialysis (CVVH)

Potential for dependence

4. Advanced Rx to replace

cardiac function

Durable LVAD

Transplantation

Exchange one disease for

another

5. Non-cardiac Screening studies

Joint replacement

Heart failure may color

typical risk/benefit

Framework for Major Interventions Option Type Examples Considerations

1. Improve cardiac function

CABG, TAVR, CRT Surgical complication

(stroke, post-op shock)

2. Abort SCD only ICD Deactivation when goals of

care change

3. Adjunctive Rx for

decompensation

Inotropes

Temporary MCS (IABP)

Dialysis (CVVH)

Potential for dependence

4. Advanced Rx to replace

cardiac function

Durable LVAD

Transplantation

Exchange one disease for

another

5. Non-cardiac Screening studies

Joint replacement

Heart failure may color

typical risk/benefit

Framework for Major Interventions Option Type Examples Considerations

1. Improve cardiac function

CABG, TAVR, CRT Surgical complication

(stroke, post-op shock)

2. Abort SCD only ICD Deactivation when goals of

care change

3. Adjunctive Rx for

decompensation

Inotropes

Temporary MCS (IABP)

Dialysis (CVVH)

Potential for dependence

4. Advanced Rx to replace

cardiac function

Durable LVAD

Transplantation

Exchange one disease for

another

5. Non-cardiac Screening studies

Joint replacement

Heart failure may color

typical risk/benefit

Rx

Op

tio

ns

Sta

ge

Stage D: Monumental Options, Big Decisions

Assumption of

significant risk

(and cost)

Paradigm shift to

potentially

shorter life for

improved quality

Transplantation Limited resource, $$$

MCS/LVAD (TAVR) Highly morbid, $$$

Inotrope infusion Often hastens death

Hospice

*Stage C Rx / GDMT is not a long-term option

McIlvennan, Magid, Ambardekar,

Matlock, Allen. CircHF 2014.

Complex Trade Offs

Alternatives can be difficult to describe

Weighing Options is Tough

REFLECTIVE

Utilitarian

“I thought about it

an awful lot”

Patient’s May See No Option . . .

REFLECTIVE

Utilitarian

“I thought about it

an awful lot”

AUTOMATIC

Self-preservation

“There was

no choice”

The Olympia Café 1978

• A Hobson’s choice: a ’free’ choice in which

only one option is offered. The choice is

therefore “take it or leave it”.

“Cheeseburger,

Cheeseburger,

Cheeseburger,

Pepsi!”

The Negotiation

Know your role

• Clinicians are responsible for defining the

range of medically appropriate options.

Balance Individualism v. Collectivism

• Clinicians represent individual patients but also

have greater responsibilites:

– Transplant: fixed resource committee

– LVAD etc: high cost ??? (coverage decisions)

Work backwards

• Early solicitation of values, goals, and

preferences focuses the options

Be Proactive, Not Reactive

• Routine: Annual HF review

– Modeled on wellness visit

1. Characterize clinical status and trajectory

2. Solicit main goals and general preferences

3. Review therapies (ensure OMT/GDMT)

4. Plan / advance care planning

5. Document

Decision Aids

Larry.Allen@ucdenver.edu