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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
