End Stage Heart Failure in Hospice
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Transcript of End Stage Heart Failure in Hospice
Dana Kay, MSN, ACNP-BC
SHVI/CMC-Main
February 2013
ADVANCED HEART FAILURE
HEART FAILUREDEFINITION
• A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs ability of the ventricle to fill with or eject blood.
• Current patients with HF are older, have more comorbidities and take more medications than in the past. Wong et al 2011
ADVANCEDHEART FAILURE
• AHF affects 2.4% of adults
• 11% of those are > 80 years old
• Estimated costs reaching 44.6 billion by 2015
• Therapies slow but infrequently reverse progression
TIME TO INTERACT
Click icon to add picture
Any of you with heart failure patient on your service right now?
LEFT SIDED
(reduced cardiac output)
Systolic Dysfunction:
-decreased contractility
Diastolic Dysfunction:
-abnormal or restrictive ventricular filling
RIGHT SIDED
(fluid overload)
-Usually from LV failure
TYPES OF HEART FAILURE
Figure 2. Stages in the development of heart failure/recommended therapy by stage. FHx CM = family history of cardiomyopathy; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker. Reproduced with permission from the American College of Cardiology. [6]
Stage D – Refractory HF requiring specialized interventions (Class IV NYHA)
Marked symptoms at rest despite maximal medical therapyGOALS – appropriate measures under Stages A, B, COptions – compassionate end-of-life care/hospice, extraordinary measures including transplant, chronic inotropes, ventricular assist device, experimental surgery or drugs
WHAT IS THE MOST COMMON SYMPTOM IN STAGE D HEART FAILURE?
A. Dyspnea
B. Fatigue
C. Anorexia
D. All of the Above
• High risk cardiac surgery
• Percutaneous intervention
• Pacing device therapy
• Implantable defibrillator
• Positive inotropic agents
• Temporary mechanical circulatory support
• Renal replacement therapy
• Transplantation
• Ventricular assist device
MAJOR INTERVENTIONS TO IMPROVE CARDIAC FUNCTION
POTENTIAL BENEFITS OF SAID THERAPY
• Improves functional status
• Reduces symptoms
• Improves hemodynamics
• Improves echocardiographic parameters
• Improves QOL
SHARED DECISION MAKING
• Annual HF review with patients to include current/potential therapies for the anticipated and unanticipated events
• Review advanced care decisions on admission to the hospital
• Clinical milestones such as hospitalization, ICD shocks should trigger review of the advanced care plan with discussion of treatment options and preferences
Circulation 2012
SHARED DECISION MAKING
• Discussion should include range of anticipated outcomes and QOL
• Therapies that lead to dependence should be weighed carefully
• Referral to palliative team should be considered
Circulation 2012
BARRIERS TO SHARED DECISION MAKING
• Emotional roadblocks
• Depression and anxiety
• Limitations of cognition, literacy, and numeracy
• Family dynamics
• Culture and religion
• Language differences
• Time
• Resolving conflict
Circulation 2012
DIFFICULT DISCUSSIONS NOW WILL SIMPLIFY DISCUSSIONS IN THE FUTURE………..
Similar to cancer
Dyspnea
Fatigue
Anorexia
Cachexia
Pain
Postural hypotension
Anxiety
Depression
Different from cancer
More edema
More renal dysfunction
More signs of poor perfusion
COMMON SYMPTOMS EXPERIENCEDBY HF AND CANCER PATIENTS
TIME TO INTERACT
Click icon to add picture
What percentage of patients on your service have cancer?
Have heart failure or cardiac disease?
Heart Failure
Less Predictable
-Loss of functional abilities at onset of diagnosis
-Slower decline with repeated hospitalization
-Pump failure versus sudden death
PROGNOSIS AND THE ADVANCED HEART FAILURE TRAJECTORY
Compared to Cancer
Predictable Course
-Longer functional abilities before downward slide
-Average lifespan of 6 months after begin to decline
PROGNOSIS AND THE ADVANCED HEART FAILURE TRAJECTORY
PROGNOSIS AND THE ADVANCEDHEART FAILURE TRAJECTORY
Clinical signs of reduced tissue perfusion:
-low MAP
-renal insufficiency
-poor response to diuretics
-lack of improvement with therapy
These patients have worse prognosis…..
RISK ESTIMATESIN ADVANCED HEART FAILURE
• MDs and RNs always overestimate survival
-In prospective cohort of terminally ill patients:
20% accurate
63% optimistic
17% pessimistic
**inaccuracy increased the longer the relationship
BMJ 2000
PROGNOSIS FOR QUANTITY AND QUALITY OF LIFE ADAPTED FROM SPILKER
Outcomes Relevant to Individual Patient
Direct/Indirect Medical Costs
Caregiver Burden
Lost Opportunities
Survival
QOL
WHEN SHOULD HOSPICE BE CONSIDERED IN AHF?
• Frequent hospitalizations
• Poor QOL with inability to perform ADLs
• Need for intermittent or continuous intravenous support
• Consideration of assist devices as destination therapy
• Preference for comfort care over life sustaining treatment
PATIENT ASSESSMENT IN HEART FAILURE
BREATHINGASSESSMENT
• Have you felt SOB? Do you wake up SOB at night?
• Can you speak as much as you want?
• What makes breathing easier?
• Do you cough? Is it worse than usual?
• Do you cough up secretions?
• Have you increased your oxygen?
SLEEPASSESSMENT
• Have HF symptoms kept you from sleeping?
• Do you sleep in bed or a chair?
• Are you able to lay flat in bed?
• How many pillows do you use?
• Have you recently slept more or less than usual?
DIET ASSESSMENT
• Have you recently eaten more salty foods or drank more water than usual?
• How often do you eat out?
• Have you gained or lost weight recently?
• Have you experienced swelling?
• How far up your legs do you have edema?
• Are your clothes, rings, belt and shoes tighter than one week or one month ago?
MEDICATIONASSESSMENT
• Have you taken all prescribed meds?
• Did you run out of any medications?
• Have you had diarrhea/vomiting?
• Have you taken extra diuretic meds?
• Have you changed the dose of any meds?
• Do you take any OTC meds or herbal supplements?
ACTIVITY ASSESSMENT
• How far can you walk?
• Can you dress, bathe, prepare food, climb stairs without stopping to rest?
• What activities could you do recently but not now because of worsened symptoms?
• Have you decreased your activity level?
CONFUSION ASSESSMENT
• Do you have difficulty remembering information or feelings of confusion?
• Have you had other health problems that may make your heart failure worse?
POSSIBLE EXAM FINDINGSIN HEART FAILURE PATIENTS
• Resting tachycardia
• Increased respiratory rate
• Decreased strength of peripheral pulses
• Orthostatic changes in pulse and BP
• JVD
• Rales
• Wheezes
• Decreased breath sounds (effusions)
• Irregular rhythm
• S3 or S4
• Murmurs
• Ascites
• RUQ pain/tenderness
• Cyanosis
• Peripheral edema
• Muscle wasting
EVIDENCE-BASED TREATMENT ACROSS THE CONTINUUM OF SYSTOLIC LVD AND HF
Control Volume Improve Clinical Outcomes
DiureticsRenal ReplacementTherapy*
DigoxinHFSA 2010
-BlockerACEIor ARB
AldosteroneAntagonist
or ARB
Treat Residual Symptoms
CRT an ICD*
HDZN/ISDN**In selected patients
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACE-I):
• Alleviates symptoms, improves clinical status
• Enhances overall sense of well-being
• Improves duration of exercise
• Reduces hospitalization and risk of death
• If target doses cannot be reached, intermediate doses should be used
Benazepril, Captopril, Lisinopril, Monopril
ANGIOTENSIN RECEPTOR BLOCKERS (ARB):
• ARBs if ACE-I intolerant d/t cough or angioedema (valsartan and candesartan)
• Reduces hospitalizations and mortality
Candesartan, Losartan, Valsartan
ALDOSTERONE ANTAGONISTS:
• Reduced risk of death, reduction in HF hospitalization
• Improvement in functional class
• May help manage volume overload
• D/C K supplements and avoid high K foods
Spironolactone, Eplerenone
BETA-BLOCKERS:
• Inhibits the adverse effects of the SNS
• Lessens symptoms, improve clinical status, reduce risk of death
• Begin as soon as LV dysfunction is diagnosed
• Initiate at low dose w/gradual increases
Atenolol, Metoprolol, Carvedilol
I
DIGOXIN:
• Benefit likely due to neurohormonal mechanism rather than inotropic effect, does not improve survival
• No loading dose necessary in SR
• Can be used for rate control of AF
• New info supports using lower doses and targeting a dig level of 0.5-1ng/ml
DIURETICS:
• Loop diuretics (furosemide, bumetanide, torsemide) increase sodium excretion by 20-25% of proximally filtered load
• Improves exertion and breathlessness
• Thiazides (HCTZ, metolazone) increase sodium excretion 5-10% (preferred in HTN HF secondary more persistent antihypertensive effects)
• For optimal synergy, give thiazide 30 min (IV) or 60 min (po) before loop
• Monitor K and magnesium closely
ASA & WARFARIN:
• ASA if patient has CAD
• Warfarin only if other indication such as AF or history/risk of embolic event
NITRATES
• Relieve dyspnea
Nitroglycerin, Isosorbide
INOTROPESDOBUTAMINE & MILRINONE:
• Dobutamine stimulates beta receptors
• Increases CO and SV
• Milrinone vasodilator via phosphodiesterase inhibition
• Decreases afterload and preload, increases CO
*As a bridge to transplant or in outpatient setting in pts who could not otherwise be discharged as palliative measure
SYMPTOM MANAGEMENT:FATIGUE
• Treat sleep disordered breathing
• Central sleep apnea
• Obstructive sleep apnea
• Treat anemia
• Iron
• EPO
• Aranesp
Diuretics:
Loop diuretics such as Furosemide and Torsemide
Thiazide diuretics such as Metolazone
Vasodilators such as IV Nesiritide
Inotropes:
Dobutamine, Milrinone, Dopamine
Opiods:
Morphine
Fentanyl
SYMPTOM MANAGEMENTDYSPNEA
SYMPTOM MANAGEMENT DYSPNEA
• Non pharmacologic:
• Dietary sodium restriction
• Fluid restriction
• Upright positioning in bed, recliner or chair
• Utilize fan on face
• Oxygen
SYMPTOM MANAGEMENTPAIN
• Anti-anginals
• Opiods
• NSAIDS should be avoided
• Pharmacologic
• Loop diuretics
• Thiazide diuretics
NSAIDS should be avoided
• Non pharmacologic
• Dietary sodium restriction
• Leg elevation
• Calf pumping
• Rest periods in recumbent position
• Compression stockings
SYMPTOM MANAGEMENTDEPENDENT EDEMA
Pharmacologic:
Megesterol acetate
Mirtazipine
Non Pharmacologic:
Small frequent meals
Soft, easy to chew foods
Rest before and after meals
Nutritional supplements
Entice with favorite foods
SYMPTOM MANAGEMENTANOREXIA
Pharmacologic:
Benzodiazepines
Titrate to effective dose
Neuroleptics
Haldol
Olanzapine
Non Pharmacologic:
HF Education
Advanced care planning
Relaxation exercises
Distraction
SYMPTOM MANAGEMENTANXIETY/AGITATION/CONFUSION
TIME TO INTERACT
Click icon to add picture
Does Hospice of Union County have a
deactivation policy?
Did you know that 50% of Hospices had an ICD
delivery in the last year?
END OF LIFECARE PLANNING
• Should be consistent with patient values, preferences and goals
• CLINICIANS SHOULD INITIATE THE CONVERSATION
• Deactivation of ICD is desirable avoiding pain/distress
• Active discontinuation VAD is often appropriate
DISCONTINUATION OF MEDICATIONS
• Medications
• Statins
• Anti-hypertensives
• Coumadin
ICD/CRT-D DEACTIVATIONINDICATIONS
• Patient/family request
• Irreversible cognitive failure
• Imminent death
• DNR order
• Withdrawal anti-arrhythmic drugs
VENTRICULAR ASSIST DEVICEDEACTIVATION
• For use as destination therapy
• 2 year mortality is 40-50%
• Develop acceptable device withdrawal plan
www.thoratec..com
DOCUMENTATION FOR DEVICE DISCONTINUATION
• Confirm patient has requested the deactivation
• Capacity of the patient or surrogate to make decision
• Confirm alternative therapies have been discussed
• Confirm consequences of deactivation have been discussed
• Specific device to be deactivated
• Notify family if appropriate
BIBLIOGRAPHY
Allen, L, Stevenson, L, Grady, K et al. Decision Making in Advanced Heart Failure: A Scientific Statement From the American Heart Association. Circulation. 2012; 125:1928-1952.
Sandesh, D, Abernethy, A, Rogers, J, O’Connor, C. Preferences of People with advanced heart failure-a structured narrative literature review to inform decision making in the palliative care setting. Am Heart J 2012; 164:313-19.e5.
Morrison, L, Calvin, A, Nora, H, Storey, C. Managing Cardiac Devices Near the End of Life: A Survey of Hospice and Palliative Care Providers. American Journal of Hospice & Palliative Medicine. 2010; 27 (8):545-551.
Paul, S, and Glotzer, J. Clinical Evaluation of the Heart Failure Patient. American Association of Heart Failure Nurses. November 2004 on www.aahfn.org.
BIBLIOGRAPHY
Kutner, J. An 86-Year-Old Woman With Cardiac Cachexia Contemplating the End of Her Life: Review of Hospice Care. JAMA. 303(4), 27 January 2010: 349-356.
www.aha.org
www.heartfailureguideline.org