PALLIATIVE CARE NEEDS OF PEOPLE WITH

END-STAGE HEART FAILURE

PALLIATIVE CARE PALLIATIVE CARE NEEDS OF PEOPLE WITH NEEDS OF PEOPLE WITH

ENDEND--STAGE STAGE HEART FAILUREHEART FAILURE

Nancy M. Albert PhD, CCNS, CCRN, CNAThe Cleveland Clinic Foundation

Cleveland, Ohio

OBJECTIVESOBJECTIVESOBJECTIVES• Provide overview of advanced HF

pathophysiology, modes of death, and treatment• Describe prognostic factors and issues of

determining prognosis• State current guidelines related to end-of-life• Discuss palliative care needs

Symptom managementDepression and anxietySkin breakdownPainSleepGI complaintsConversations

Hypertrophy, remodeling, apoptosis, ischemia, ↑ HR, ↓ HR variability, arrhythmias, fibrosis

Mortality

Hypertrophy, remodeling, apoptosis, ischemia, ↑ HR, ↓ HR variability, arrhythmias, fibrosis

Mortality

Norepinephrine-reduced baroreceptorsensitivity

Angiotensin II-aldosterone-vasopressin

NEUROENDOCRINE ACTIVATIONNEUROENDOCRINE ACTIVATIONNEUROENDOCRINE ACTIVATION

Cytokines

LV REMODELINGLV REMODELINGLV REMODELING

Normal HeartDilated

Cardiomyopathic Heart

↓ β-AR signal transduction, cytokines, RAAS↓ Bioenergetics

Altered Ca2+ handling architectureFetal gene induction

ApoptosisMortality

Mann & Bristow, Circulation 2005;111:2837.

Sudden Death59%

Other15%

HF26%

MERIT-HF: Mode of Deathby HF Severity

MERITMERIT--HF: Mode of DeathHF: Mode of Deathby HF Severityby HF Severity

HF12%

Other24%

Sudden Death64%

NYHA Class II NYHA Class IIISudden Death33%

Other11%

HF56%

NYHA Class IV

n=103 n=232 n=27

Number of Deaths

Patients with NYHA class II-IV HF (n=3991) were randomized to a target 200-mg once-daily dose of metoprolol succinate (n=1990) or placebo (n=2001) and followed for a mean of 1 year.

MERIT-HF Study Group. Lancet. 1999;353:2001-2007.

18%

21%

18%10%

19%

14% MetabolicProgressiveSCDUnwitnesed-SuddenOtherUnknown

Chronic HF: Mode of Death Single center, Disease Mgmt program studyChronic HF: Mode of Death Chronic HF: Mode of Death

Single center, Disease Mgmt program studySingle center, Disease Mgmt program study

Metabolic = Creatinine > 4.0 mg/dL in 1 month of death;Creatinine > 3.0 mg/dL before referral to hospice;Progressive hepatic failure

Progressive = NYHA FC IV symptoms without renal or hepatic failure

Other = Trauma, sepsis or other non-cardiac causesDerfler et al. AJGC 2004;13:299-306

N = 74 deaths

SYSTOLIC HF DeathBrigham & Women’s CM Clinic; EF ≤ 35%

SYSTOLIC HF DeathBrigham & Women’s CM Clinic; EF ≤ 35%

January 2000 - October 20, 2003• 160 deaths; 50% outpatients; 21% SCD

In 6 months before death:• 50% NYHA FC III-IV symptoms• Renal insufficiency and hyponatremia

were worse in months preceding death than at the time of death

• Creatinine: 3.2 vs. 2.3 mg/dL• Sodium: 128 vs. 135 mmol/L

P <.001

Teuteberg et al. J Cardiac Failure 2006;12:47

Reduce Mortality

β-BlockerACEIor ARB

AldosteroneAntagonist

CRT ±an ICD*

Hyd/ISDN*

*For select indicated patients.

ICD*

Treat ComorbiditiesAspirin*

Warfarin*Statin*

Enhance AdherenceEducation

Disease ManagementPerformance Improvement Systems

Evidence-Based Treatment Across the Continuum of LVD and HF

EvidenceEvidence--Based Treatment Across Based Treatment Across the Continuum of LVD and HFthe Continuum of LVD and HF

Hunt SA et al. Circulation 2005;112:1825-1852

Cohn J, et al. J Cardiac Failure. 2003;9:5(suppl):S87.

-4.9%(60%)

-11.2%(85%)

Major Opportunity

Dea

ths

at 2

yea

rs, %

24 month data from placebo arm of ValHeft

Heart Failure-Related Deaths: Impact of Contemporary Therapy

Heart FailureHeart Failure--Related Deaths: Related Deaths: Impact of Contemporary TherapyImpact of Contemporary Therapy

0

2

4

6

8

10

12

14

No ACEI or BB ACEI and BB

Pump FailureSudden Death

HF EtiologyIschemic: 100% Ischemic: 59%

Nonischemic: 41% Nonischemic: 100%Ischemic: 52%

Nonischemic: 48%

NYHA Class I/II/III(35%/35%/30%)

III/IV(87%/13%)

I/II/III(20%/60%/20%)

II/III(71%/29%)

LVEF ≤30% ≤35% ≤35% ≤35%No. Pts 1232 1520 458 2521Follow-Up 20 months 12 months 24 months 45 monthsHazard Ratio 0.69 0.64 0.66 0.77

19.8%

14.2%19.0%

12.0%14.1%

7.9%

28.8%

22.0%

0

5

10

15

20

25

30M

orta

lity,

%

MADIT II1 COMPANION2 DEFINITE3 SCD-HeFT4

Control TherapyP=.007

P=.065P=.004

P=.016

ICD Device Trials in HF & LVDICD Device Trials in HF & LVDICD Device Trials in HF & LVD

1Moss AJ, et al. N Engl J Med. 2002;346:877-883. 2Bristow MR, et al. N Engl J Med. 2004;350:2140-2150.3Kadish A, et al. N Engl J Med. 2004;350:2151-2158. 4Bardy GH, et al. N Engl J Med. 2005;352:225-237.

Control VolumeReduce Symptoms and Improve QOLSalt Restriction*

Diuretics*

Digoxin*

β-BlockerACEIor ARB

AldosteroneAntagonist

Treat Residual SymptomsCRT ±

an ICD* Hyd/ISDN*

*For select indicated patients.

ICD*

Improve Adherence and QOLEducation

Disease ManagementPerformance Improvement Systems

Evidence-Based Treatment in Advanced HF

EvidenceEvidence--Based Treatment Based Treatment in Advanced HFin Advanced HF

Hunt SA et al. Circulation 2005;112:1825-1852

4545

4040

3535

3030

2525

2020

1515

1010BaselineBaseline 1wk1wk 1mo1mo 3mo3mo offoff--

immedimmedoffoff--1wk1wk

offoff--4wk4wk

N=25N=25

Mitral RegurgitationMitral Regurgitation

Ejection fractionEjection fraction

%%

Yu, et al. Circulation 2002;105:438Yu, et al. Circulation 2002;105:438

††, significant diff. compared to 3 mo, significant diff. compared to 3 mo, significant diff. compared to baseline, significant diff. compared to baseline**

**** **

** **††

††††††

†† ††

** ****

**

**

**

Cardiac Resynchronization:Cardiac Resynchronization:Must be Must be ““ONON”” Continuously to Achieve EffectsContinuously to Achieve Effects

Cardiac Device in and active matters.

Renal function matters.

Home and Hospital care matters.

Prognosis Near Death: SupportPrognosis Near Death: Support1.0

0.8

0.6

0.4

0.2

0.0

6-M

onth

Sur

viva

l Est

imat

e

14 13 12 11 10 9 8 7 6 5 4 3 2 1

CHFCOPDCirrhosis

Days to DeathBock et al. New Horizons, 1997; 5:51

VARIABILITY in FC from I-IVVARIABILITY in FC from IVARIABILITY in FC from I--IVIV

VARIABLES ASSOCIATED with POOR PROGNOSTIC

VARIABLES ASSOCIATED with VARIABLES ASSOCIATED with POOR PROGNOSTICPOOR PROGNOSTIC

Serum Na < 136 mg/dL

Serum creatinine ≥2.0 mg/dL

Presence of CVA, COPD, Ca, dementia

Low BP w Acute Decomp. HF

Dyspnea Orthopnea Older age EF < 45 %

↓ In 6 min. walk test

Dependency with ADL’s

Frequent firing of ICD

NYHA FC IV ↑ Resp rate ↓ HRV

PND ↑ HR > 100 bpm

Syncope Atrial Fib

3 or more hospitalizations/yr ↑ serum BNP ↓ Peak VO2

Symptoms when on optimal medical Tx

Problem: We do not know which factors remain the

most important in mortality risk

after multivariate regression…need RESEARCH

Albert NM. Cardiovascular. In Keubler, Davis and Dea (Eds). Palliative Practices. An Interdisciplinary Approach . 2005

PROGNOSTIC MODELSPROGNOSTIC MODELSPROGNOSTIC MODELS• 280 patients w advanced HF from 16 US sites• Applied 4 prognostic models from literature• 148 deaths or transplantations occurred

Average follow-up was 31.2 months• Each model identified patients with different

prognosesLimited overall predictive powerMany component patient characteristics did not have independent prognostic significance

Frankel et al. J Cardiac Failure. 2006;12:430

PROGNOSTIC MODELSPROGNOSTIC MODELSPROGNOSTIC MODELS

• Most powerful prognostic factors within the 4 models:

Increasing ageIschemic cardiomyopathyHx of cardiomyopathyAnkle edemaDecreased peak oxygen consumptionAbsence of beta-blocker use

Frankel et al. J Cardiac Failure. 2006;12:430

Problem: Physician researchers focused on variables

associated with demographics, medical Hx,

drug tx’s but not social or psychological factors

known to affect outcomes …need RESEARCH

GUIDELINES on End-of-LifeGUIDELINES on EndGUIDELINES on End--ofof--LifeLifeACC/AHA (2005)1 HFSA (2006)2

Ongoing discussions w pt/family about prognosis

Ongoing discussions w pt/family about QOL and prognosis

Education about advance directives

Discuss and individualize advanced directives and resuscitation wishes

Ensure continuity of medical care from inpatient to ambulatory

Optimize pt status- medically and psychologically BEFORE discussing end-of-life Consider end-of-life if symptoms warrant:• Frequent hospitalizations• Chronic poor QOL• Need intermittent or chronic IV support• Considered for assist device

1. Hunt SA et al. Circulation 2005;112:1825-1852; 2. HFSA. J Cardiac Fail 2006;12:10-38.

Level C evidence

GUIDELINES on End-of-LifeGUIDELINES on EndGUIDELINES on End--ofof--LifeLifeACC/AHA (2005)1 HFSA (2006)2

Discuss inactivating ICD Give directions about clinical response if does not want resuscitation; Discuss inactivating ICD

Hospice components for symptom palliation include opiates, inotropes and IV diuretics

Individualize strategies for symptom management, limiting testing and interventions

Professionals working with HF pts should examine end-of-life processes and make improvements

Have pts reassess their wishes concerning Tx options as decisions may change over time

Aggressive procedures in the final days of life are not appropriate

Discuss the possibility of unexpected cardiac death. Consider hospice care in the home, hospital or special hospice unit

1. Hunt SA et al. Circulation 2005;112:1825-1852; 2. HFSA. J Cardiac Fail 2006;12:10-38.

Palliative Care Needs

at End of Life

Palliative Palliative Care Needs Care Needs

at End of Lifeat End of Life

Characteristics of patients with HFCharacteristics of patients with HFWomen Men P value

Age, mean 79 73 <0.001HTN % 72 61 0.02DM % 19 29 0.03Smoking % 35 68 <0.001Hyperlipidemia 16 20 NS≥ 3 comorbidities 22 31 0.04History MI 19 26 NSObesity (BMI ≥ 25) 49 62 0.04

Roger et al. JAMA 2004;292:344

43%

37%

12%8%

HospitalHomeSNFOther

Chronic HF: Place of DeathSingle center, Disease Mgmt program studyChronic HF: Place of DeathChronic HF: Place of DeathSingle center, Disease Mgmt program study

Derfler et al. AJGC 2004;13:299-306

N = 74; mean age 57.7 years

MAINSTAY: General Disease Management Rules

MAINSTAY: General Disease MAINSTAY: General Disease Management RulesManagement Rules

ADHERE Registry; All Enrolled Discharges from April 1, 2004 to March 31, 2005 with History of HF and LVEF Documented and < 0.40 (n = 29,759) SciosScios, Inc., Inc.

*Excludes patients with documented contraindications.

16

71

84

53

29

0102030405060708090

100

Patie

nts

Trea

ted

(%)

Chronic Outpatient HF Medication Prior to Hospitalization

ACE Inhibitor* ARB Beta-Blocker* Diuretic Digoxin

The Copernicus Study: The Copernicus Study: Mean Change in SBP by Beta Blocker or Placebo Mean Change in SBP by Beta Blocker or Placebo

Assignment in Severe Chronic HFAssignment in Severe Chronic HF

Rouleau et al. J Am Coll Cardiol. 2004; 43:1423-1429.

Cha

nge

in S

ysto

lic B

lood

Pre

ssur

e (m

mH

g)

*P < 0.05

Carvedilol SBP 85-95 mmHgPlacebo SBP 85-95 mmHgCarvedilol All patientsPlacebo All patients

Months

*

* * *4 6 8 10 12 140 2

-6

-4

-2

0

2

4

6

8

10

12

14

COPERNICUS: Morbidity and Mortality by Systolic Blood

Pressure Quintiles

COPERNICUS: Morbidity and COPERNICUS: Morbidity and Mortality by Systolic Blood Mortality by Systolic Blood

Pressure QuintilesPressure QuintilesBlood

Pressure(mm Hg)

Placebon (%)

Carvediloln (%)

Risk ReductionDeath or

Hospitalization

>125 478 (42) 475 (41) 40% 32%

Risk Reduction(Mortality)

85-95 62 (5) 70 (6) 23% 26%

96-105

106-115

116-125

39% 25%136 (12)128 (11)

244 (22) 224 (19)

221 (20) 251 (22)

35% 22%

39% 46%

Rouleau et al. J Am Coll Cardiol. 2004; 43:1423-1429.

GOAL: Lower impedance & slow progression of structural and functional disease

SBP in Advanced HFSBP in Advanced HFSBP in Advanced HFHealthy heart: SBP is a product of SV and the impedance to ejection (afterload)• Impedance does NOT affect SV, just pressureFailing heart: Impedance controls SV• Neurohormonal & vascular consequences of HF raise

impedanceSV becomes the measure of severity of LV dysfunction

HYPOTENSION is d/t reduced contractile function of the heart

Cohn JN. JACC. 2004;43:1430

MEDICATION Dosage/TimingMEDICATION Dosage/TimingMEDICATION Dosage/Timing• Drugs that peak at same time:

1 - 2 hoursLoop diureticsEplerenoneCaptoprilHydralazine/nitrate combo

Trandolapril

2 - 4 hoursMetolazoneCarvedilolBisoprololCandesartanFosinoprilQuinaprilValsartan

4 - 6 hoursHCTZRamiprilEnalaprilLisinopril (7 hrs)Metoprolol

succinate(6-12 hrs)

PERSISTENT SYMPTOMSPERSISTENT SYMPTOMSPERSISTENT SYMPTOMS• Symptomatic hypotension (orthostasis)• Increasing dyspnea• Worsening renal dysfunction• Hypoperfusion

Decreased urine outputCold, clammy skinMental obtundation, confusion, sleepyDizzy, lightheaded, weak, fatiguedTachycardiaNausea, anorexia, no appetite, bloating

MEDICATIONS for PERSISTENT SYMPTOMS

MEDICATIONS for PERSISTENT MEDICATIONS for PERSISTENT SYMPTOMSSYMPTOMS

• Are HF medication therapies optimized?Right drugs, right doses, right schedule?

• Continuous ambulatory IV inotropic supportMilrinone or dobutamine• May decrease survival • May improve QOL

Regularly obtain hemodynamic data to assess for need

• Nesiritide infusion is NOT supported

BAD PHARMACOLOGICAL BAD PHARMACOLOGICAL THERAPIESTHERAPIES

• Antidepressants that inhibit CNS neuron uptake of dopamine or norepinephrine

SSRI class OK • Drugs used in psychosis; bipolar mania• COX-2 inhibitor-NSAID’s (ALL!!) • Thiazolidinedione (TZD) Type II DM agents• Most antidysrhythmics

Exception: amiodarone

BAD BAD ““OTCOTC”” DRUGS/ THERAPIESDRUGS/ THERAPIES

•• Na+ based antacids Na+ based antacids (Rolaids)(Rolaids)

•• ASA (high dose)ASA (high dose)•• NSAIDNSAID’’ss•• Ginseng Ginseng

(germanium)(germanium)•• GinkgoGinkgo•• EchinaceaEchinacea•• Black licoriceBlack licorice•• DecongestantsDecongestants

Medication SummaryMedication SummaryMedication Summary• Follow “optimal HF drug” guidelines

Unless patient is unable to swallow or is obtunded

• Resist inclination to remove HF drugs if no contraindications

May worsen symptoms / increase suffering• Remove excess non-HF drugs and alternative

therapies• Assess potassium and creatinine if:

Aggressive diuresisAdding aldosterone inhibitor

Survival (%)

0 6Months After Re-Assessment at 4-6 wks

100

40

0

80

18

60

24

20

12

No Cong., n = 801-2 Cong., n = 403-5 Cong., n = 26

Clinical Evidence of Congestion 4 to 6 Clinical Evidence of Congestion 4 to 6 Weeks after Hospitalization & SurvivalWeeks after Hospitalization & Survival

Lucas et al., AHJ. 2000; 140:840

p < 0.0001p < 0.0001

Congestion CriteriaCongestion CriteriaOrthopneaOrthopneaJVDJVDWeight gain Weight gain >> 2 2 lbs in one weeklbs in one week↑↑diuretic dose on diuretic dose on visitvisitEdemaEdema

More than 50% of Patients Have Little or no Weight Loss During Hospitalization

Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21

7% 6%

13%

24%

33%

15%

3% 2%

0

5

10

15

20

25

30

35

Patie

nts

(%)

(<-20) (-20 to -15)(-15 to -10)(-10 to -5) (-5 to 0) (0 to 5) (5 to 10) (>10)

Change in Weight (lbs)

• Among pts. with severe heart failure 1PCWP 33 ± 6 mmHg, CI 1.8 ± 0.5, LVEF 0.18 ± 0.06CXR: 27% no congestion, 41% minimal congestion

• Among pts. with moderate to severe heart failure 2PCWP 30 ± 9 mmHg, CI 2.1 ± 0.8, LVEF 0.18 ± 0.06No rales: 84%, No edema: 80%, No JVP 50%, No orthopnea: 22%

• Hemodynamic congestion may not be recognized clinically (doesn’t translate into symptoms/signs until late) 1 Mahdyoon H et al. Am J Card. 2003; 63: 625

2 Stevenson LW et al. JAMA. 1989; 261: 884

Congestion Often Does not Translate in Signs/SymptomsCongestion Often Does not Congestion Often Does not

Translate in Signs/SymptomsTranslate in Signs/Symptoms

MANAGEMENTMANAGEMENTMANAGEMENTBreathlessness due to CongestionBreathlessness due to Congestion

Exertion At rest Terminal

•• Pharmaceutical and nonPharmaceutical and non--pharmaceutical measurespharmaceutical measures

Correct correctable causeCorrect correctable cause

NonNon-- drug drug TxTxSymptomatic drug Symptomatic drug TxTx

MedicationsDevices

↑ Distal Ca++Reabsorption

↓ Plasma Volume

↓ Uric AcidClearance

Complications of Diuretic Therapy in HFComplications of Diuretic Therapy in HFKaplan, N.M., Treatment of Hypertension: Drug Therapy in Clinical Hypertension (p. 203) in Clinical Hypertension, 6th. Ed. Baltimore: Williams & Wilkins 1994.

HypomagnesemiaHypomagnesemiaDiuretic TherapyDiuretic Therapy

↓ Cardiac Output

↓ Renal Reabsorption of Na (& Mg)

↓ Renal Blood Flow

HyponatremiaHyponatremia

↑ PRA

↓ GFR

↑ ProximalReabsorption

↑ Aldosterone

Kaliuresis

HypokalemiaHypokalemia

Glucose IntoleranceGlucose IntoleranceHypocalcemiaHypocalcemiaHyperuricemiaHyperuricemia

↓ CalciumClearance

Pre-renalAzotemiaPre-renalAzotemia

Neurohumoral Activation

Neurohumoral Activation

VT/VF

SCD

VT/VF

SCD

DEVICE Trends Provide Clinical DEVICE Trends Provide Clinical Information to Monitor Changes in StatusInformation to Monitor Changes in Status

AT/AF (hrs/day)

Ventricular Rate During AT/AF (bpm)

Avg Ventricular Rate (Day/Night)

Pt Activity (hrs/day)

Heart Rate Variability (ms)

% Pacing/day

Impedance

“Wetter” Lungs

DEVICE Monitoring: IntraDEVICE Monitoring: Intra--Thoracic ImpedanceThoracic Impedance

“Dryer” Lungs

IntraIntra--Thoracic ImpedanceThoracic Impedance

MD Programmed Threshold

Reference impedance slowly adapts to daily impedance

Daily impedance is average of one day’s measurements

Accumulation of difference between daily and reference impedance

DIET and FLUIDSDIET and FLUIDSDIET and FLUIDS• Low sodium diet

Educate• Restaurants• Relatives homes

Monitor• Fluids

EducateTricks to decrease thirst• Suck on hard

candy, frozen grapes, cold washcloth…

IF CONGESTION INCREASESIF CONGESTION INCREASESIF CONGESTION INCREASES• Carefully assess adherence to current diuretic regime

Especially related to when taken during day• Increase loop diuretic dose or frequency; give IV• Change loop diuretic agent to one with different

absorption (i.e., furosemide to torsemide)• Add a thiazide diuretic• Topical or oral nitrate at night (if not on during daytime)

May improve sleep / decrease awakenings• Carefully assess adherence to diet and fluid regime and

tighten modifications• Initiate or tighten fluid restriction

Congestion SummaryCongestion SummaryCongestion Summary• Use loop diuretics to control symptoms

Add metolazone p.r.n. but beware of erratic absorption

• Overdiuresis causes increased fatigue and symptoms that mimic worsening HF

• Use low sodium diet 1600 mg sodium/day

• Use fluid restrictionLess than 8 cups/day

DEPRESSIONand

ANXIETY

DEPRESSIONDEPRESSION

05

1015202530

Fatigue Breathlessness Chest Pain0

1020304050607080

KCCQ Physical KCCQ Total SF36 PhysicalroleHAM-D

r 0.33** 0.33 0.32* 0.41** 0.57*** 0.37* * P < 0.05; ** P < 0.01; ***P < 0.001

Effects on health status at 6 months• 139 ambulatory patients with HF in primary care• Mean age 75 ± 9.7 yrs Major depression

Minor depressionNo depression

Sullivan et al. AJGC 2004;13:252-260

Multidimensional Assessment of Fatigue

DEPRESSION and ANXIETYDEPRESSION and ANXIETYDEPRESSION and ANXIETY• Predictors of anxiety and depression in a

consecutive series of 227 hospitalized HF patients; mean age, 77.1 ± 7.9 yrs

Yu et al. J Psychosomatic Research 2004;57:573-581.

Hierarchal regression model with all 4 factorsR2, 0.49

Variables BetaPoor perceived emotional-informational support

0.34

Higher levels of fatigue 0.40Poorer health perception 0.21Not living with family 0.10

• Assess mood, morale and coping skills• Counseling

Support groups (church, community, neighbor, or healthcare initiated)Caretaker classes

• Help patient to retain a sense of control of their disease processes

• Treat depression with serotonin reuptake inhibitors, as needed

• Treat anxiety with short acting and longer acting anxiolytics, as needed

DEPRESSION and ANXIETYDEPRESSION and ANXIETYDEPRESSION and ANXIETY

SKIN BREAKDOWNSKIN BREAKDOWNSKIN BREAKDOWN• Can occur from edema or venous stasis• Can be painful• Treatment:

Assess cause and correct when possibleElastic stockings or elastic wrapsExercise and active ROM exercisesConsult with skin care/wound experts as needed

PAINPAINPAIN• Systematic review of pain in HF

9 descriptive studies; 5 specifically on HF23-75% of patients with HF reported painFactors related to pain:• Anxiety• Depression• Self rating of poor QOL• Dyspnea• More dependencies in ADL’s

Symptom of pain is NOT well understood• PAIN-HF study underway

Godfrey et al. J Cardiac Fail 2006;12:307-313.

PAIN RELIEFPAIN RELIEFPAIN RELIEF• Clinical practice guidelines by ACC/AHA:

No recommendations on pain assessmentNo recommendations on ongoing monitoring1 recommendation on management: “opiates”• No details on opiate therapy

• Palliative care medicine providers are the experts; we defer to you!!

SLEEPSLEEPSLEEP

• Sleep related breathing disorders are prevalent at end-of-life:

OrthopneaParoxysmal nocturnal dyspneaObstructive sleep apneaCentral sleep apneaCheyne stokes respirationsDaytime sleepiness

SLEEPSLEEPSLEEP• Management:

Elevate HOBOral or topical nitrate at nightCPAP for obstructive sleep apneaDiuresis/fluid removal for central sleep apneaOxygen at night? • Does not improve daytime sleepiness• Does not improve health related QOL

CPAP in Central Sleep ApneaCPAP in Central Sleep ApneaCPAP in Central Sleep Apnea

Bradley et al. NEJM 2005;353:2025-33.

0

1.00

80

60

40

20

Tran

spla

ntat

ion-

free

Su

rviv

al (%

)

Time from Enrollment (mo)0 12 24 36 48 60

CPAP group (32 events)Control group (32 events) P = 0.54

CPAP in Central Sleep ApneaCPAP in Central Sleep ApneaCPAP in Central Sleep Apnea

00

10

20

50Ep

isod

es o

f Apn

ea a

nd

Hyp

opne

a(n

o. p

er h

r of s

leep

)

30

40

3 24

P < 0.001 CPAP groupControl group

Bradley et al. NEJM 2005;353:2025-33.

Time from Randomization (mo)

CPAP in Central Sleep ApneaCPAP in Central Sleep ApneaCPAP in Central Sleep Apnea

Bradley et al. NEJM 2005;353:2025-33.

00

LVEF

(%)

24Time from Randomization (mo)

P < 0.007 CPAP groupControl group

15

20

25

30

35

63

Also improved in CPAP group:Mean and minimal oxygen saturation

GI COMPLAINTSGI COMPLAINTSGI COMPLAINTS• Nausea and loss of appetite

Caused by congestion in liver and stomach• Avoid fluid overload

Caused by low cardiac output• Assess for hypoperfusion; treat

• Digoxin toxicityUse low dose (0.125 mg/day)

• Screen for toxicity, as needed• Constipation

Fluid status and morphine• Avoid OTC pre-packaged enemas (Na+ based)• Stool softeners and laxatives OK

END-OF-LIFE CONVERSATIONSENDEND--OFOF--LIFE CONVERSATIONSLIFE CONVERSATIONS

TOPICS• Unfavorable prognosis & treatment failure• Treatment choices and family responses• Advance care planning• Concerns about one’s ability to cope• Life goals and other life-closure issues• Anticipatory mourning• The meaning of illness and the suffering it

creates

ENHANCING CONVERSATIONS• Interpersonal communication skills• Patient centered care

Mutual participation relationships• Informed choice• Patient autonomy

• Need to understand the meaning of illness for the patient

ENDEND--OFOF--LIFE CONVERSATIONSLIFE CONVERSATIONS

Preferences for Death vs. Conditions:Preferences for Death vs. Conditions:Patient Would Rather Die ThanPatient Would Rather Die Than

Spend All of the Time In:Spend All of the Time In:9090

8080

7070

6060

5050

4040

3030

2020

1010

00 6 mos. 6 mos. -- 3 mos.3 mos. 3 mos. 3 mos. -- 1 mo.1 mo. 1 mo. 1 mo. -- 3 days3 daysn=97n=97 n=109n=109 n=107n=107

VentilatorVentilator Feeding tubeFeeding tube Nursing homeNursing home

Levenson et al. JAGS, 2000; 48:5101.

Perc

ent

Levenson et al. JAGS, 2000; 48:5101.

Preferences for Death vs. Symptoms:Preferences for Death vs. Symptoms:Patient Would Rather Die ThanPatient Would Rather Die Than

Spend All of the Time In:Spend All of the Time In:9090

8080

7070

6060

5050

4040

3030

2020

1010

00 6 mos. 6 mos. -- 3 mos.3 mos. 3 mos. 3 mos. -- 1 mo.1 mo. 1 mo. 1 mo. -- 3 days3 daysn=97n=97 n=109n=109 n=107n=107

Perc

ent

PainPain ConfusionConfusion ComaComa

Levenson et al. JAGS, 2000; 48:5101.

Preferences for Care OverPreferences for Care OverThe Last 6 Months of LifeThe Last 6 Months of Life

8080

6060

4040

2020

00 6 mos. 6 mos. -- 3 mos.3 mos. 3 mos. 3 mos. -- 1 mo.1 mo. 1 mo. 1 mo. -- 3 days3 days

Perc

ent

n=217n=217n=222n=222

Comfort CareComfort CareDNRDNR

n=200n=200n=207n=207

n=155n=155n=159n=159

Prefers comfort care, P=.069Prefers comfort care, P=.069Prefers DNR, P=.017Prefers DNR, P=.017

• Balancing therapies:

AggressivePalliative

•Promoting:QOLA gooddeath