Devon Neale Geriatrics and Palliative Medicine UNM SOM
Slide 2
Objectives To review the differences between hospice and
palliative care services To discuss the management of symptoms
commonly experienced by heart failure patients at end of life To
address important issues in advance care planning for patients with
heart failure
Slide 3
Hospice care vs. Palliative care Hospice: A health care benefit
Medicare benefit (Part A) since 1983; many private insurances have
a hospice benefit Two MDs certify prognosis < 6 months if
disease runs its usual course Focus is on comfort and relief of
suffering, not life prolongation Interdisciplinary team provides
care It is not a place; primarily home-based
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The Old Model of Palliative Care Medicare Hospice Benefit Life
Prolonging Care
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What is Palliative Care? Palliative care as defined by WHO: An
approach that improves the quality of life of patients and their
families facing the problems associated with life threatening
illness, through prevention of and relief of suffering by means of
early identification and impeccable assessment and treatment of
pain and other problems, physical, psychological and spiritual
www.capc.org
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Hospice care vs. Palliative care Palliative care Can be
provided in conjunction with life prolonging treatment (no need to
choose between treatment plans) Does not take the place of curative
care! No prognostic requirement; no age requirement; not limited to
any specific diagnosis; not just actively dying Primarily
hospital-based The goal is not to hasten nor prolong death
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New Model of Palliative Care Palliative Care Bereavement
Hospice Care Life Prolonging Care
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Why is PC important in the management of HF? HF is very common:
#1 cause hospitalizations in Medicare population A leading cause of
death in US High symptom burden: Pain, dyspnea, fatigue, edema,
depression Physical function scores 2SD below average Symptoms are
treatable
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Palliative Care in HF Management In general, PC has been
demonstrated to improve patient outcomes: Symptom management
Quality of life Satisfaction with care palliative care can be
integrated with conventional HF care that emphasizes
life-prolonging treatment. This duality of care should be
considered a normal approach to patients with HF* *Hauptman and
Havranek, Arch Intern Med 2005
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Key elements of PC for HF Discussing prognosis and treatment
options Eliciting patients goals of care Supporting advance care
planning Team-based approach to symptom management Physical
Psychological Emotional Spiritual Existential Caregiver
support
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Cardiac Medications As indicated: Ace-inhibitor Beta-blocker
Diuretic Spironolactone ALLEVIATE SYMPTOMS AND IMPROVE QoL
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Prognostication in HF Very difficult: we are unable to predict
timing of exacerbations or sudden cardiac death (up to 50% of
patients) In general, clinicians tend to overestimate life
expectancy (by a factor of 5.3)* Increased duration of
patient-physician relationship, less accurate prognostication
*Christakis and Lamont, BMJ 2000
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Why is prognostication important?
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Allows patients to: Identify priorities based on life
expectancy Make informed decisions about their care Complete
advance directives and designate a PoA Attend to legal and
financial matters Focus on life closure and legacy issues Emphasize
participation in pleasurable activities
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General Statistics New diagnosis of HF in the community:* 1yr
mortality: 24% 2yr mortality: 37% 6yr mortality: 75% 50% of HF
patients die within 5yrs of diagnosis One-year mortality after
first HF admission in elderly patient with comorbidities: 60%
*Senni et al, Arch Intern Med 1999, Ho et al, Circulation 1993
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Functional Capacity The most important predictor of mortality
in HF Decline in functional capacity is associated with high 3
month mortality* *Lunney JR, JAMA 2003
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Date of download: 11/13/2012 Copyright 2012 American Medical
Association. All rights reserved. From: Patterns of Functional
Decline at the End of Life JAMA. 2003;289(18):2387-2392.
doi:10.1001/jama.289.18.2387 Error bars indicate 95% confidence
intervals. Figure Legend :
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NYHA class Symptoms1 year mortality with optimal treatment INo
symptoms5-10% IISymptoms with ordinary activity 5-10% IIIMarked
limitation of physical activity 10-15% IVSymptoms at
rest30-40%
Slide 19
Prognostication in HF Poor prognostic factors: Ischemic
etiology Recent cardiac hospitalization High BUN, cr > 1.4,
Na
Resources: Fast facts:
http://www.eperc.mcw.eduhttp://www.eperc.mcw.edu Brief answers to
>200 palliative questions / topics Heart Failure Society of
America: www.hfsa.orgwww.hfsa.org Information for clinicians and
patients/families Palliative Care for Patients with Heart Failure
Pantilat and Steimle, JAMA 2004 UNM Inpatient Palliative Care
Consult: x24868