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?