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TRANSCRIPT
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Disease Management, Advance
Directives, and End-of-Life Care
in Heart Failure
HFSA 2010 Recommendations
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
1 of 2
HFSA 2010 Practice GuidelinePatient Education
Recommendation 8.1 (1 of 2)
It is recommendedthat patients with HF and their familymembers or caregivers receive individualized education
and counseling that emphasizes self-care.
This education and counseling should be delivered byproviders using a team approach in which nurses withexpertise in HF management provide the majority ofeducation and counseling, supplemented by physician
input and, when available and needed, input from dietitians,pharmacists and other health care providers.
Streng th o f Evidence = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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HFSA 2010 Practice GuidelinePatient Education
Recommendation 8.1 (2 of 2)
Teaching is not sufficient without skill
building and specification of critical target
behaviors. Essential elements of patient
education to promote self-care with
associated skills are shown in Table 8.1
Streng th o f Evidence = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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HFSA 2010 Practice GuidelineTable 8.1 Elements of Patient Education
Element Skills and Target Behaviors
Definition of HF and cause
of patients HF
Discuss basic HF information,
cause of patients HF, and how
symptoms relate to HF status
Recognition of escalating
symptoms and concrete
plan for response to
particular symptoms
Identify specific signs and
symptoms (e.g. increasing
fatigue or shortness of breath,
edema, increasing fatigue)
Perform daily weights and know
how to respond to evidence ofvolume overload
Develop action plan for
notifying provider, changing diet,
fluid and diuretics
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
2 of 3
HFSA 2010 Practice GuidelineTable 8.1 Elements of Patient Education
Element Skills and Target Behaviors
Indications and use of each
medication
Reiterate dosing schedule, basic
reason for specific medications,
what to do if a dose is missed
Modify risks for HF
progression
Initiate smoking cessation
Maintain BP in target range
Maintain normal HgA1c if diabetic
Maintain specific body weight
Specific activity/exercise
recommendations
Comply with prescribed exercise
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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HFSA 2010 Practice GuidelineTable 8.1 Elements of Patient Education
Element Skills and Target Behaviors
Specific diet, sodium,
and alcohol
recommendations
Understand and comply with
sodium restriction
Demonstrate ability to read foodlabel for sodium per serving and
sort into high- and low-sodium
Reiterate limits for alcohol
consumption or abstinence if
history of abuse
Treatment adherence Plan and use a medication systemthat promotes adherence
Plan for refills
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7/26Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelinePatient Education
Recommendat ion 8.2
It is recommendedthat patients literacy, cognitive status,psychological state, culture, and access to social andfinancial resources be taken into account for optimal
education and counseling.
Because cognitive impairment and depression are commonin HF and can seriously interfere with learning, patientsshould be screened for these.
Patients found to be cognitively impaired need additionalsupport to manage their HF.
Strength of Evidence = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelinePatient Education
Recommendat ion 8.3
It is recommendedthat educational sessions begin with anassessment of:
Current HF knowledge
Issues about which the patient wants to learn
The patients perceived barriers to change.
Address specific issues and their causes
eg, medication non-adherance and whether it is due to a lack ofknowledge, cost, forgetting, or some other cause
Employ strategies that promote behavior change, includingmotivational approaches. Strength of Evidence = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelinePatient Education
Recomm endat ion 8.4
It is recommendedthat the frequency and intensity of patient educationand counseling vary according to the stage of illness. Patients inadvanced HF or with persistent difficulty adhering to the recommendedregimen require the most education and counseling.
Patients should be offered a variety of options for learning about HFaccording to their individual preferences:
videotape
one-on-one or group discussion
reading materials, translators, telephone calls, mailed information
Internet
visits
Repeated exposure to material is essential because a single session isnever sufficient.
Streng th of Evidenc e = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelinePatient Education
Recommendat ion 8.5
It is recommendedthat during the care process patients be asked to:
Demonstrate knowledge of the name, dose, and purpose of eachmedication
Sort foods into high and low sodium categories
Demonstrate their preferred method for tracking medicationdosing
Show provider daily weight log
Reiterate symptoms of worsening HF
Reiterate when to call the provider because of specific symptomsor weight changes
Streng th of Evidenc e = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelinePatient Education
Recommendat ion 8.6
During acute care hospitalization, only essential educationis recommended, with the goal of assisting patients tounderstand:
Heart failure
The goals of its treatment
Post-hospitalization medication and follow up regimen.
Education begun during hospitalization should be:
Supplemented and reinforced within 1-2 weeks after discharge Continued for 3-6 months
Reassessed periodically
Streng th of Evidenc e = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineDisease Management
Modifiable Factors Leading to HospitalReadmissions for HF (1 of 2)
Inadequate patient and family or caregiver education andcounseling
Poor communication and coordination of care amonghealth care providers
Inadequate discharge planning
Failure to organize adequate follow-up care
Clinician failure to emphasize non-pharmacologic aspectsof HF care, such as dietary, activity and symptommonitoring recommendations
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineDisease Management
Modifiable Factors Leading to HospitalReadmissions for HF (2 of 2)
Failure to address the multiple and complex medical, behavioral,psychosocial, environmental and financial issues that complicatecare, such as:
older age presence of multiple co-morbidities
lack of social support or social isolation
failure of existing social support systems
functional or cognitive impairments
poverty
presence of anxiety or depression
Failure of clinicians to use evidence-based practice and followpublished guidelines in the prescription of pharmacologic andnon-pharmacologic therapy
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineDisease Management
Recommendat ion 8.7
Patients recently hospitalized for HF and other patients athigh risk should be consideredfor referral to acomprehensive HF disease management program that
delivers individualized care.
High risk patients include those with renal insufficiency,low output state, diabetes, COPD, persistent NYHA class IIIor IV symptoms, frequent hospitalization for any cause,multiple active co-morbidities, or a history of depression,cognitive impairment, inadequate social support, poorhealth literacy, or persistent nonadherence to therapeuticregimens.
Streng th of Evidence = A
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
1 of 2
HFSA 2010 Practice GuidelineDisease Management
Recommendation 8.8 (1 of 2)
It is recommendedthat HF diseasemanagement programs include the following
components based on patient characteristicsand needs.
Comprehensive education and counseling individualizedto patient needs
Promotion of self care, including self-adjustment ofdiuretic therapy in appropriate patients (or with familymember/caregiver assistance)
Emphasis on behavioral strategies to increase adherence
Streng th of Evidenc e = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
2 of 2
HFSA 2010 Practice GuidelineDisease Management
Recommendation 8.8 (2of 2)
It is recommendedthat HF disease management programsinclude the following components based on patientcharacteristics and needs.
Vigilant follow-up after hospital discharge or after periodsof instability
Optimization of medical therapy
Increased access to providers
Early attention to signs and symptoms of fluid overload
Assistance with social and financial concerns
Streng th of Evidenc e = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineDisease Management
Recommendation 8.9
It is recommendedthat HF disease
management include integration andcoordination of care between the primary
care physician and HF care specialists
and with other agencies, such as home
health and cardiac rehabilitation.Streng th of Evidence = C
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineDisease Management
Recommendat ion 8.10
It is recommendedthat patients in a HF disease managementprogram be followed until they or their family/caregiverdemonstrate:
Independence in following the prescribed treatment plan
Adequate or improved adherence to treatment guidelines
Improved functional capacity and symptom stability.
Higher risk patients with more advanced HF may need to befollowed permanently.
Patients who experience increasing episodes of exacerbations orwho demonstrate instability after discharge from a programshould be referred again to the service.
Streng th o f Evidence = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineQuality of Life Discussions
Recommendation 8.11
It is recommendedthat patient and familyor caregiver discussions about quality of
life and prognosis be included in the
disease management of HF.
Streng th of Evidence = C
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineEnd-of-Life Care
Recommendation 8.12
It is recommendedthat:
Seriously ill patients with HF and their families be educated to understandthat patients with HF are at high risk of death, even while aggressive effortsare made to prolong life.
Patients with HF be made aware that HF is potentially life-limiting, but thatpharmacologic and device therapies and self-management can prolong life. Inmost cases, chronic HF pharmacologic and device therapies should beoptimized as indicated before identifying that patients are near end-of-life.
Identification of end-of-life in a patientshould be made in collaboration withclinicians experienced in the care of patients with HF when possible.
End-of-life management should be coordinated with the patient's primarycare physician.
As often as possible, discussions regarding end-of-life care should beinitiated while the patient is still capable of participating in decision-making.
Strength of Evidence = C
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineEnd-of-Life Care
Recommendation 8.13
End-of-life care should be consideredin patients who haveadvanced, persistent HF with symptoms at rest despiterepeated attempts to optimize pharmacologic, cardiac device,
and other therapies, as evidenced by one or more of thefollowing:
HF hospitalization Streng th o f Evidence = B
Chronic poor quality of life with minimal or no ability to
accomplish activities of daily livingStreng th o f Evidence = C
Need for continuous intravenous inotropic therapysupport Streng th o f Evidence = B
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineEnd-of-Life Care
Recommendation 8.14
It is recommendedthat end-of-life carestrategies:
Be individualized
Include core HF pharmacologic therapies, effectivesymptom management, and comfort measures
Avoid unnecessary testing
New life-prolonging interventions should be discussed withpatients and caregivers with careful discussion of whether
they are likely to improve symptoms
Streng th o f Evidence = C
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineEnd of Life CareResuscitation and SCD
Recommendat ion 8.15
It is recommendedthat a specific discussion about resuscitationbe held in the context of planning for overall care and foremergencies with all patients with HF.
The possibility of SCD for patients with HF should beacknowledged. Specific plans to reduce SCD (for example withan ICD) or to allow natural death should be based on theindividual patients risks and preferences for an attempt atresuscitation with specific discussion of risks and benefits ofinactivation the ICD.
Preferences for attempts at resuscitation and plans for approachto care should be readdressed at turning points in the patientscourse or if potentially life-prolonging interventions areconsidered.
Streng th o f Evidence = C
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineEnd-of-Life Care
Recommendation 8.16(NEW in 2010)
It is recommendedthat, as part of end-of-life care,patients and their families/caregivers have a plan to
manage a sudden decompensation, death, orprogressive decline.
Inactivation of an implantable defibrillation deviceshould be discussed in the context of allowing
natural death at end of life. A process fordeactivating defibrillators should be clarified in allsettings in which patients with HF receive care.
Streng th of Evidence = C
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Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice GuidelineTable 8.4 Legal Advance Directives (NEW in 2010)
Living WillDurable Power of Attorney
for Health Care (DPOA/HC)
Uses standard language in the
patients state of residence,
identifying whether specific orgeneral life-prolonging
interventions should be initiated
or continued in the face of
imminent death.
Some states require 2 MDs to
certify that that patient has a
terminal illness.
Designates one or more individuals
to make health care decisions on
behalf of the person at a future timeif the person is unable to speak
independently.
Does not typically identify specific
interventions, patients should be
encouraged to make their proxy
aware of generally preferred
approaches to care.
Patients with HF should be
encouraged to appoint a DPOA/HC.
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Lindenfeld J, et al. HFSA 2010 Comprehensive
HFSA 2010 Practice GuidelineEnd-of-Life Care
Recommendation 8.17
Patients with HF undergoing end-of-life
care should be consideredfor hospice
services that can be delivered in the
home, a hospital setting or a special
hospice unit.Streng th o f Evidence = C