Heart Failure Care. Course Handouts & Post Test. Objectives: o To download presentation handouts, click on the attachment icon

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1 Heart Failure Care John Morris MD FCCP FAAHPM Medical Director of Palliative Care Course Handouts & Post Test o To download presentation handouts, click on the attachment icon o Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN. o This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Heart Failure Care Objectives: o Identify the burdens of caring for heart failure patients and the keys to successful management of heart failure. o Discuss the challenges of prognostication and tools to help determine hospice eligibility. o Describe a hospice heart failure program and key components of improved end of life care for heart failure. 1

2 Epidemiology o Improving survival with HF Surgery AICD o Increasing incidence of HF o More people living longer with increasing debility o Frail, elderly, debilitated, symptomatic --with co-morbid conditions Heart Failure is a Major Public Health Problem in the United States o Nearly 300,000 patients die of HF as primary or contributory cause each year More than Lung CA, Breast CA, Prostate CA and HIV combined o Number of heart failure deaths has increased despite advances in treatment o End-stage HF has one of the largest effects on quality of life of any advanced disease. o More hospitalizations than any other condition Burden on HF Patients o Symptoms similar to advanced cancer o Compared with cancer, HF patients; Worse QOL More physical discomfort More depression Decreased spiritual well being Bekelman et al. J Gen Int Med 2009; 24: 592 2

3 Heart Failure o More deaths than any other disease o More symptoms than cancer o More time in hospital away from home o Most expensive last year o Less palliative care and hospice utilization 12% nationally Illness Trajectories JACC Role of Palliative Care in HF 3

4 Palliative Care Data o Improved care o Increased life expectancy o Decrease cost o Improved patient and family satisfaction o Decrease ER, Hospital utilization with more time at home Brumley JAGS 55: Heart Failure Definition o Clinical Syndrome with abnormal filling or ejecting blood from the heart o Fluid backs up Right: edema of legs Left: pulmonary edema Classification of Heart Failure Stages of HF: ACC/AHA Stage A: High risk of developing HF Stage B: Asymptomatic LV dysfunction Stage C: Past or current Symptoms of HF Stage D: End-stage HF NYHA Functional Class Class I: No limitation of physical activity Class II: Slight limitation of physical activity and symptoms with ordinary activity Class III: Marked limitation of physical activity and symptoms with less than ordinary exertion Class IV: Symptoms of HF at rest 4

5 HF Medical Care NYHA II o Etiology o Precipitating factors o Diuretics o ACE inhibitors o Beta Blockers o Eval for OSA NYHA III o Spironolactone o Digoxin if EF< 35% o Hydralazine/ NTG o AICD for EF< 35% HF Medical Care NYHA IV o Fluid management o Eval for Transplant o Eval for LVAD o Eval for inotropes NYHA IV EOL o Stop non symptom meds o Continue some meds ACE inhibitors ARB Diuretics Beta blocker if BP ok o Consider inotropes Burden on HF Patients o Symptoms similar to advanced cancer o Compared with Cancer, HF patients; Worse QOL More physical discomfort More depression Decreased spiritual well being Bekelman et al. J Gen Int Med 2009; 24: 592 5

6 HF Symptoms Most common symptoms in ES HF o Dyspnea o Fatigue o Pain o Depression o Anxiety o Nausea o Constipation Dyspnea 3 Step Treatment Dyspnea should be regularly assessed and rated on scale 1. Optimize medications and oxygen Diuretics with spironolactone ACE Inhibitors / vasodilators Inotropes Oxygen (only if hypoxic) 2. Non- pharmacologic Treatments 3. Palliative Treatments Dyspnea: Nonpharmacologic Approaches o Breathing exercises: Pursed lip o Fan: cool air movement o Relaxation techniques Progressive muscle, mental imagery, etc. Counseling o Noninvasive Ventilation (BiPAP) o Music o Control Action plan Energy conservation 6

7 Dyspnea Palliation o Opioids Po/ IV effective (nebulized probably not) No significant respiratory depression at effective dose 2-5mg morphine q4h effective start o Anxiolytics Not effective for dyspnea, but for anxiety Effective for dyspnea-anxiety-dyspnea cycle HF Fatigue o Neurohormonal basis of symptoms Renin-angiotensin- aldosterone o ACE Inhibitors o ARB s and beta blockers show modest help o Spironolactone o Sleep Apnea evaluation o Diet : low Na improves fatigue HF Fatigue o Reduce Caffeine o Exercise Inspiratory muscle training Leg strengthening o Stimulants: Methylphenidate o Depression Depressed patients have more fatigue Treat depression and fatigue improves 7

8 Pain in HF o Common: 25% with Mod to Severe o Undertreated in HF o Site of pain variable o Treatment Opioids safe Start low, go slow NSAID s contraindicated due to kidney Consider PT, injections, heat, cold, topical etc Depression in HF o Common 20-36% of HF patients o Associated with Increased death, cost, rehospitalization o Treatment Be Careful SSRI generally 1st line Rx May cause hyponatremia or fluid retention SNRI probably safe TCA may increase QTc Psychostimulants safe methylphenidate Anxiety in HF o Ticking time bomb o Fear that any moment may be last o Anxiolytics Lorazepam o Engage spouse Empower, sense of control o Mindfulness techniques o Education 8

9 Palliative Care for HF o Nonphysical suffering Fear of prolonged death Fear of sudden death Fear of being burden to family Loss of control Financial stress frequent bankruptcy in ES HF Logistical: where can I live? o Team support Team with MD, NP, RN, SW, chaplain, bereavement to relieve physical, emotional, spiritual, and logistical suffering Palliative Care Data o Improved care o Increased life expectancy o Decreased cost o Improved patient and family satisfaction o Decreased ER, hospital utilization with more time at home Brumley JAGS 55: Hospice Care o Comprehensive multidisciplinary care for terminally ill patients and their families that can be provided in any location. Care is provided to relieve physical, psychological, social, and spiritual suffering. o Prognosis 6 months if runs its normal course o Care provided by team of professionals o Family cared for as a whole o 24/7 support o Government benefit 9

10 Hospice Benefits o Nursing Care: The nurse visits routinely; 24-hour/7-day per week emergency contact is also provided. o Social Work: counseling and planning (living will, DPOA, etc) o Counseling Services including SW and chaplaincy o Case oversight by the physician Hospice Medical Director o All medications and supplies related to the terminal illness.. o Durable medical equipment: hospital bed, commode, wheelchair, etc. o Home Health Aid and Homemaker Services. o Speech therapy, Nutrition, PT, and OT services as needed o Bereavement support to family after the death o Short term General Inpatient Care for problems that cannot be managed at home-most commonly intractable pain, delirium, or caregiver breakdown o Short term Respite Care-up to 5 days to permit family caregivers to take a break Hospice Advantages for HF o RN visits to prevent exacerbations o Symptom management expertise o SW procures equipment, counsels pt and family o Advance care planning o CNA provides personal care o Volunteer provides socialization o Hospice pays for medication and equipment o 24/7 service and support o Support for caregiver/family o Bereavement support Barriers to Hospice o Physicians overestimate prognosis (3-5x) o Fear of talking about End of Life issues o Physicians don t know how to have conversation o Misconceptions about hospice among doctors and public o Inadequate training in EOL care o People overestimate benefit of technology, medicine, CPR o Hospice referrals too late 10

11 HF EOL Conversations o Patients and families benefit from EOL talk Sudden death Chronic illness o Education about HF helps people fight Diet, fluid management, exercise o Prognostic talk should be honest and acknowledge difficulty -- giving ranges o Technology important part of conversation AICD, LVAD, Inotropes HF EOL Conversations o Assessment: Ask the patient what he or she understands about his or her condition. o Prognosis: Be conscious that prognostic uncertainty is no excuse for a failure to communicate about the implications of advanced heart disease. o Preparation: Prepare the patient emotionally for what to expect. Provide approximate time estimates (eg, months or years?). Talk about some likely scenarios. HF EOL Conversations o Preferences: Discuss healthcare proxy, goals if patient is permanently brain injured cardiopulmonary resuscitation, ventilators, and location of care. Discuss deactivation of ICD/cardiac resynchronization therapy/vad, if applicable. o Planning for the worst: Suggest getting financial and emotional affairs in order. Help to mobilize community and family supports (eg, palliative care, home care, hospice referrals). 11

12 AICD Conversations o Physicians generally lack experience o Patients who are shocked describe poor QOL o Many patients prefer natural death o Need plan for deactivating devices o Physicians need to be able to talk about advantages and burdens of these devices HF EOL Conversations Where do you want to spend your time? What procedures do you want done? o Communication Skills SPIKES Ask- Tell Ask Hope for best.. Plan for all o Hospice: What have you heard about hospice? Some think only for cancer, only dying Hospice benefits Heart Failure Prognosis o NYHA Class Class II 1 year survival 90% Class III 1 year survival 85% Class IV 1 year survival 20-50% Eichorn, E. Am J Med 2001; 110:14S-35S o Seattle Heart Failure Model Validated for stable outpatients, not hospital 12

13 Heart Failure o Clinical Poor Prognostic Factors Hospitalization Poor EF Ventricular arrhythmias Cachexia Co-morbidities: DM, COPD, Liver, CVA, CA, HIV o Lab Poor Prognostic Factors Anemia Hyponatremia Cr >1.4 or BUN >30 Heart Failure in Hospital o Poor Prognostic signs BUN >40 BP <115 Cr >2.75 Still only 20% hospital mortality Fonarow et al JAMA 2005 Four Seasons Hospice Care o Prognosis: 6 months if runs natural course Class IV HF Prognostic models helpful Class III HF with comorbidities o Medicare A Benefit 100% coverage HF meds Equipment Medical care o 24/ 7 Medical care o Cardiac Program for special needs of HF o Inpatient, crisis, respite, routine levels of care 13

14 Physician Concerns about Hospice for Heart Failure o Will my patient get appropriate treatment for reversible problems? o Will hospice nurse just give morphine and let my patient die too soon? o What does hospice team know about HF? o I am not ready to give up treatments! ACCF/AHA/ACP HF EOL Skills Comfort measures o Goal 1 Current medication assessed and nonessentials discontinued o Goal 2 As required, subcutaneous drugs written up according to protocol (pain, agitation, respiratory tract secretions, nausea, vomiting) o Goal 3 Discontinue inappropriate interventions (blood tests, antibiotics, intravenous fluids or drugs, turning regimens, vital signs);document not for cardiopulmonary resuscitation Psychological and insight issues o Goal 4 Ability to communicate in English assessed as adequate (translator not needed) o Goal 5 Insight into condition assessed ACCF/AHA/ACP HF EOL Skills Religious and spiritual support o Goal 6 Religious and spiritual needs assessed with patient and family Communication with family or others o Goal 7 Identify how family or other people involved are to be informed of patient s impending death o Goal 8 Family or other people involved given relevant hospital information Communication with primary healthcare team o Goal 9 General practitioner is aware of patient s condition Summary o Goal 10 Plan of care explained and discussed with patient and family o Goal 11 Family or other people involved express understanding of plan of care 14

15 Hospice Complex Cases o Process to take more complex patients into hospice Dobutamine drip IV diuretics Full code AICD CPAP/ BiPAP Complex goals and care plan individualized Cardiac Program Elements of program: o Education RN SW, Chaplain, CNA s, Volunteers, Bereavement o Medications o Patient Education o Clinical protocols Cardiac Education o HF RN Education program Definition Risk factors Pathophysiology Clinical Medications Management of exacerbations o Post education testing 15

16 Cardiac Education o HF Skills Lab for Nurses Physical assessment Relaxation exercises Phone assessment Chest pain Dyspnea IV skills Mentoring by Cardiac RN Cardiac Program Staff HF Education o SW, Chaplain Anxiety, depression Meaning, hope o CNA s ADL s Energy conservation o Volunteers Cardiac Program o Patient education AHA Week 1 How to contact FS, medications Week 2 Manage edema Week 3 Eating well with HF Week 4 Dyspnea and O2 Week 5 Energy conservation, exercise Week 6 Stress reduction, caregiver care Action plan for emergencies 16

17 HF Emergencies o Start action plan o Call hospice first o 24/7 Nurse visits o Dyspnea protocol o Chest pain protocol o Monitoring available o Inpatient unit available o Physician visits o Close coordination with local cardiologist / PCP HF Emergency Kit o NTG o Morphine o Ativan o Lasix o Zaroxolyn o Oxygen o IV set HF Emergency Protocols o Acute Shortness of Breath Sit up, O2, relaxation Lasix po Call on call nurse Call nurse physical assessment No relief: Lasix IV, morphine No relief: Lasix IV, morphine, zaroxolyn Call hospice MD 17

18 HF Spiritual Care o Patients want to discuss spiritual issues o Consider spiritual issues very important o Goal: achieve peace, meaning Compassionate presence, active listening Validating emotions, unconditional acceptance Life review HF Caregiver Issues o HF patients often housebound, anxious, depressed, irritable. o Caregivers report: social isolation, boredom, resentment, relational tension, fatigue, anger, guilt, depression, insomnia, helplessness, loss of freedom, anticipatory grief, identity loss Benefit from Cardiac Program team: RN, SW, chaplain, CNA, MD, volunteer, bereavement counselor Benefits of Hospice in HF o Improved symptom management o Improved stress, psychosocial/ spiritual care o HF Patients live avg 81 days longer o Less financial stress o More time spent in desired location o Caregiver survival Decrease in death rates of caregivers with hospice o Patient and family satisfaction 18

19 References ACCF/ACP/AHA/ISHLT: Consensus Statement Palliative Care in HF J Am Coll Cardiol 2009; 54: Management of Patients with Advanced HF J Am Coll Cardiol 2010; 56: Palliative Care in Treatment of HF Circulation 2009;120: Palliative Care in HF JAMA, May 26, 2004 Vol 291, No. 20 Living and Dying with HF Heart 2002;88(Suppl II):ii36 ii39 Symptoms, Comorbidities Health Care in HF JPM Vol 14, Number 6, 2011 Questions? John Morris MD FCCP FAAHPM jmorris@fourseasonscfl.org Four Seasons Center of Excellence o Consulting Hospice, Palliative Care & Research o Palliative Care Immersion Course o Mentoring physicians, nurse practitioners and physician assistants Course Handouts & Post Test Thank you for viewing this course on the Hospice Education Network The Course evaluation and post test are available from your course catalog page To achieve credit for this course, close the video portion when completed and click on Start Test 19