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

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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

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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

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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