Pinkesh Bhuta, MD
●Internist at Gwinnett Physicians Group.
●Board Certification: American Board of internal Medicine
●Specialty and Treatments
–Hospice/Palliative Care
–Internal Medicine
Medical School:University of Florida
Fellowship:Shands Hospital
University of Florida
Residency:Shands Hospital
University of Florida
END OF LIFE DECISIONS:KEEP THE BUNNY GOING!PINKESH A. BHUTA M.D., M.P.H.
DISCLOSURE
NO CONFLICT OF INTEREST TO DECLARE
OBJECTIVES
Highlight the severity of illness in heart failure Identify the differences between palliative care and hospice Review indications of palliative care in cardiac diseases Introduce methods to initiate end of life conversations Discuss symptom management to alleviate suffering Highlight studies demonstrating value of palliative care in CHF Develop a comprehensive future care plan
END-STAGE HEART DISEASE
Leading cause of hospitalization in age 65 and older
Symptomatic CHF has a poor prognosis compared cancer, 1 year mortality of 45%
Underutilization of hospice and palliative care services
Prevalence >6 million & annual cost exceeding $39 billion
TRAJECTORY OF ILLNESS
CHALLENGES IN HEART FAILURE
• Lack of understanding disease prognosis• Somatic symptoms limiting communication• Feeling of powerlessness
PATIENTS
• Unpredictability in clinical trajectory• Hesitancy to discuss severity of illness• Dilemma in timing to discontinue aggressive
therapy
HEALTHCARE
• Escalating incidence of heart failure• Burgeoning costs of elderly HF patients• Resource limitations for aggressive therapy
SOCIETY
PALLIATIVE CARE MISCONCEPTIONS
Palliative Care can only be received at the end of life
Palliative Care does not allow follow-up with regular doctors
Palliative Care is not a tangible entity, but a philosophy of care
Palliative Care mandates suspension of curative therapies
CARE OPTIONS
• Approach to improve quality of life in patients with chronic illness
• Focus on patients & family needs
PALLIATIVE CARE
• Symptom management in illness of less than 6 month prognosis
• Based on patient prognosisHOSPICE
• Advanced directives, advanced care planning, hospice care
END OF LIFE CARE
Palliative Care
Patients in any stage of their disease
May receive in conjunction with curative treatments
Some diagnosis related treatment/meds covered
No time restriction Bereavement support
Hospice
Serious illness life exp. <6 months
Treatments aimed at relieving symptoms
Medicare covers diagnosis related meds & treatments
Length on meeting criteria Bereavement support
PALLIATIVE CARE GOALS
Symptom control Psychological supportCaregiver support End of life decision-making discussionsOpen communication regarding trajectory of illness Reduce hospital readmissions Ease transition to hospice care
INDICATIONS FOR PALLIATIVE CARE
NYHA CLASS III-IV UNEXPLAINED WEIGHT LOSS REFRACTORY ANGINA RECURRENT ICD SHOCKS SYMPTOMATIC & POOR
CANDIDATE OR DECLINES INVASIVE PROCEDURES
COMORBID ADVANCED KIDNEY AND/OR LIVER DISEASE
ANXIETY & DEPRESSION IMPACTING QOL
FREQUENT HOSPITALIZATIONS (>2 IN LAST 6 MONTHS)
FUNCTIONAL DECLINE
SUBSET OF CARDIAC PATIENTS
CHF•Advanced age, comorbidities, symptoms despite
optimal therapy
VALVULAR HEART DISEASE (AORTIC STENOSIS)•Partner B Trial(2010): TAVR preferred over medical
therapy in non-surgical candidates, but 3% mortality; >50% increased stroke/TIA risk
CORONARY ARTERY DISEASE•>75 with comorbid icm, ckd ≥3, lung disease•GRACE risk score: post ACS mortality in 6 months
CONGENTIAL HEART DISEASE•Severe progressive congenital heart disease
MODES OF DELIVERY OF PALLIATIVE CARE
HOSPITAL-BASED PROGRAMS
INPATIENT CARE UNITS
NURSING HOME COMMUNITY-BASED
PALLIATIVE CARE & HOSPICE TEAM
MEDICAL DIRECTORS
NURSE PRACTITIONERS
SPECIALTY TRAINED NURSES
PATIENT-CARE AIDES
CASE MANAGER &
SOCIAL WORKER
CHAPLAIN DREAM FOUNDATION
COORDINATOR
PRIMARY PALLIATIVE CARE
Hospitalizations occur at turning points in patients trajectory of illness
Focus on communicating prognosis and goals of care Aligning patients with their values and preferences Symptom management to relieve suffering Focus on helping patients & families avoiding unwanted
aggressive treatmentsGrief counseling and support for families and caregivers
BUILD Model Care Plan
BUILD Model example
Mr. L is 75 yo male with NYHA Class IV heart failure, dyspnea at rest, angina, continuous O2, Pacer & AICD, bed bound, total care, limited oral intake
You: Mrs. L you do a great job in caring for your husband. Can you tell me what condition you feel his heart is in?
Mrs. L: I notice his heart is getting weaker. You: Has his AICD fired recently? Mrs. L: Once in the last 2 months. It was painful for him You: What is your understanding about his pacemaker and AICD as
his heart weakens. Mrs. L: It will fire but what can I do, I can’t just let him have a heart
attack. I know he is not doing well, but if we turn off his pacemaker he will die, right?
You: The pacemaker will not fire, so we don’t need to turn it off. His AICD will only fire if he has an irregular rhythm. It will not be shocking a healthy heart, so even if it fires it will not improve the long-term condition of his heart. One option is to consider de-activating his defibrillator to avoid being shocked.
Mrs. L: I think that is a good idea. While I want him to live, I want him to be comfortable
SYMPTOM MANAGEMENT
Dyspnea Low dose opioids improve dyspnea and exercise tolerance Sublingual liquid Morphine for air hunger pain, breathlessness Anxiolytics help cease respiratory distress cycle
Physical Pain: 75 % of patients with advanced HF experience pain Non-pharmacologic therapy: PT, massage, acupuncture, ice, warm
compress Pharmacologic:
Nitrates and Ranolazine for anginaTylenol favored over NSAIDs to avoid fluid retentionOral opioids in moderate to severe pain Fentanyl patch & methadone can accumulate in the body
SYMPTOM MANAGEMENT
Depression: over 42% in NYHA Class IV CHF Initiate low dose SSRI with to improve mood & adherence
Vascular dementia Cognitive therapy for short-term memory and executive control
Constipation Bowel regimen with opioid use
Incontinence Excessive diuretics can lead to exhaustion and stress
Medication Reconciliation Eliminate statin in weight loss or muscle wasting to reduce myopathy Address risk-benefit ratio of anticoagulation in poor nutritional state Assess drug-drug interactions: less is more
PAL-HF STUDY
Primary Endpoints: 2 QOL measurements (KCCQ & FACIT-PAL)
Secondary Endpoints: depression & anxiety (HADS), hospitalizations, mortality
Clinically significant incremental improvement in primary endpoints and HADS
Rehospitalization and mortality not significant
Palliative care in advanced HF showed benefit for QOL, anxiety/depression, & spiritual well-being
“Not The Grim Reaper Service” The first US study to explore barriers to palliative care
referral in patients with advanced heart failure
Semi-structured interview of physicians, PA’s & NP’s from cardiology and primary care
1. Perceived needs of patients with HF 2. Experience with palliative care specialist3. Timing of palliative care referral 4. Perceived barriers to palliative care referral
HOSPICE VS. NON-HOSPICE SURVIVAL
Retrospective analysis 4493 patients with CHF or cancer
Statistically significant increase in mean survival CHF, lung, and pancreatic cancer
CHF mean survival: hospice cohort 402 days non-hospice cohort 321 days
Results conditional for expected mortality within 3 years
Suspected factors contributing to increased longevity
Reduce mortality risk through avoidance of invasive treatments
2. Improved monitoring and adherence to care
3. Psychosocial support
FUTURE CARE PLANNING GOALS
MEDICAL Improve edema Decrease angina Improve bp control Target ace-i & statin therapy Reduce risk of mi Reduce risk of sudden death
(icd implant)
PERSONAL Walk further, handle steps Active, avoid dyspnea Avoid dizziness & falls Avoid kidney disease & muscle
aches Avoid hospitalization Birth of my grandchild
FUTURE CARE PLANNING
Nominating POA or surrogate decision–maker if patient’s capacity is lost
Preferences for place of care as condition deteriorates
Preferences for treatments options and withdrawal of life-prolonging treatments eg.ICD deactivation
CPR preferences and likely outcome in current & future condition
TAKAWAY POINTS
Use non-acute setting to identify patient’s goals of care Timing of code status conversations Understand the spectrum of care from palliative care to
hospice Appreciate symptom management in illness progression Consult a palliative care specialist to assist with end-of-life
care
References
J Am Coll Cardiology . 2017 October 10; 70(15): 1919–1930. doi:10.1016/j.jacc.2017.08.036
J Geriatr Cardiol 2015; 12: 57−65. doi: 10.11909/j.issn.1671-5411.2015.01.007
Denvir MA, et al. Heart 2015;0:1–6. doi:10.1136/heartjnl-2014-306724
Conner, S, et al J Pain & Symptom management 2007; 33(3)
Rogers, J.G. et al J Am Coll Cardiology 2017; 70(3): 331-41
Dio, K et al J Am Heart Assoc. 2014;3:e000544 doi: 10.1161/JAHA.113.000544
Questions?