The Elderly End of Life

Transcription

1 The Elderly End of Life

2 Heart failure is a disease of the elderly Many patients with heart failure now survive to die of other diseases. There is a pyramid of decisions before resuscitation. Tough discussions today make difficult situations easier ahead.

3 Annual Rates of Heart Failure Discharge By Age Per 1,000 Population * Average Age in Trials * * * > 75 Men Women National Hospital Discharge Survey, CDC/NCHS

4 HF at 5 yrs post MI Mortality p MI From Acute MI to Chronic Heart Failure

5 The elderly will not be undergoing the disease- exchanging interventions of heart transplantation or mechanical circulatory support devices.

6 Mechanical Circulatory Support Pulsatile Axial Centrifugal HeartMate XVE HeartMate II CentriMag Thoratec PVAD Heartware HVAD TandemHeart PVAD

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8 Heart Failure Hospitalizations by LVEF LVEF < 40% 40-55% >55% Sweitzer et al ACC 2005 For the ADHERE Registry Yancy et al JACC ; % patients with dyspnea at rest or minimal exertion 30% with GI symptoms

9 Symptomatic Heart Failure Therapy by LVEF More The Same Than Different Treat congestion Fluid balance HF management Exercise Planning desired activities Better monitoring Cardio-renal limits Palliative care

10 Cumulative Mortality Mortality Increases with Repeated HF Hospitalization Total number of death= 7,401 4 th admission 3 rd admission 2 nd admission 41 th st admission Setoguchi et al American Heart Journal Time Since HF Admission (years)

11 Medial Survival (years) Median Survival After Repeated Hospitalizations Similar With and Without Sudden Death Prevention in Community Population 3.0 Estimated GFR < st hospitalization (n=14,374) 2nd hospitalization (n=3,358) 3rd hospitalization (n=1,123) 4th hospitalization (n=417) Setoguchi et al. AHJ 2007

12 Death and Heart Failure Sudden Death Non-sudden Death Sudden death proportion decreases with HF severity. Non-cardiac non-sudden Increases with older age

13 Deaths After First Heart Failure Hospitalization in Community 14,374 pts in British Columbia 7401 deaths at mean 1.7 mean years after 1 st hosp 62% Mean Age = 77 years In Hosp Card Non-cardiac 22% 16% Cardiac in Long-term Care 9% 7% Sudden during Independent Living Only 7% of deaths occur suddenly out of hospita during independent living Setoguchi et al, AHA 2006

14 What Does the Patient with Heart Failure Want?

15 Heart Failure Population Average age years, 35% female COPD 20-25% Dementia 6 10% Solid Cancer 10-15% Chronic kidney disease 25% Hemodialysis 3-4 % Among Medicare HF population, 40% have > 5 non-cardiac comorbidities Setoguchi et al Am H J 2007 Lee DS et al JAMA 2003 Braunstein et al JACC 2003

16 Not All Expectations Are Great Miss Haversham in Great Expectations, By Charles Dickens

17 Heart failure is a disease of the elderly Many patients with heart failure now survive to die of other diseases. There is a pyramid of decisions before resuscitation. Tough discussions today make difficult situations easier ahead.

18 Uncommon decisions Major Cardiac Surgery Decisions for almost everyone Regarding resuscitation

19 Potential Interventions Examples Examples of anticipated What If decisions for unanticipated outcomes High-risk cardiac surgery in hope of improving HF Less invasive interventions that may improve course of HF Adjunctive HF therapies with potential dependence CABG Unable to come off bypass Ventilator dependence Valve surgery Stroke Pericardial stripping PCI or percutaneous valve Need for urgent surgery? Temporary support devices (IABP, peructaneous VAD, ECMO) NON-CARDIAC Interventions for co-morbidities Unable to wean temporary support device? IV inotropes Unable to wean; move to MCS or discontinue? Temporary dialysis Irreversible renal failure? For symptomatic or functional benefit Delayed benefit only Joint replacement Hernia repair Resection of pulmonary nodule Asymptomatic aneurysm repair Screening colonoscopy Worsening heart failure, Ventilator dependence Stroke Worsening heart failure, Ventilator dependence Stroke

20 Not Likely to Die on the Table With Major Surgery Risk of stroke Risk of prolonged intubation Risk of renal failure Likelihood of prolonged convalescence, perhaps loss of independent living

21 Standardize Informed Consent for Advanced HF Procedures Background/indications Procedure Potential Benefits Potential Risks Alternative strategies Translation to patients should include examples : Of 100 patients like you, lived two years longer with Of 100 patients like you, had strokes that limited their ability to speak/walk/care for themselves Experience of your health care team $ Costs initial $ Costs per year Adapted from Krumholz, Informed Consent to Promote Patient-Centered Care. JAMA 2010:303:1190 Of 100 patients like you, rated their daily activity as near normal Because of your special conditions of , we may expect your outcomes to be better / worse than previous experiences. Expected duration of hospitalization Likelihood of discharge home vs to rehabilitation Months to full functional recovery Family experience

22 Limits to Logic Sometimes No is the right answer for the patient and his family. Godel s Incompleteness Theorem It is not possible to prove every statement that is true. Every logical system contains its own inconsistency. Prove or disprove the statement: This statement cannot be proven. Liar s Paradox: I am lying. True or false? Getting to No

23 Potential Interventions Examples Examples of anticipated What If decisions for unanticipated outcomes High-risk cardiac surgery in hope of improving HF Less invasive interventions that may improve course of HF Adjunctive HF therapies with potential dependence CABG Unable to come off bypass Ventilator dependence Valve surgery Stroke Pericardial stripping PCI or percutaneous valve Need for urgent surgery? Temporary support devices (IABP, peructaneous VAD, ECMO) NON-CARDIAC Interventions for co-morbidities Unable to wean temporary support device? IV inotropes Unable to wean; move to MCS or discontinue? Temporary dialysis Irreversible renal failure? For symptomatic or functional benefit Delayed benefit only Joint replacement Hernia repair Resection of pulmonary nodule Asymptomatic aneurysm repair Screening colonoscopy Worsening heart failure, Ventilator dependence Stroke Worsening heart failure, Ventilator dependence Stroke

24 Mortality Survival with Heart Failure On Inotropic Therapy - 13 Trials Months on Inotropic Therapy Placebo Randomized IV ino Uncontrolled IV ino Oral milrinone Class IV Univ Oregon COSI: Hershberger et al Circulation 2003, 108: 492-7

25 Only in the U.S. is death considered optional. George Wyse M.D. Director of Electrophysiology University of Calgary, Canada

26 Mortality (%) Time Horizon of Lives Saved by ICDs No benefit for first year Window of benefit Control Mortality Mortality with ICD ICD Lives Saved Benefit flat after 2-3 years Year Interim 1.7 Years MADIT II 3 Years DEFINITE 5 Years SCD-HeFT MADIT-II Moss AJ, Zerba W, Hall WJ, et al. N Engl J Med 2002;346: DEFINITE Ellenbogan KA, Levine JH, Berger RD, et al. Circulation 2006;113: SCD-HeFT Bardy GH, Lee KL, Mark DB, et al. N Engl J Med 2005;352:

27 Renal Disease and Repeated Hospitalization Interact to Predict Decreased Survival 4 Setoguchi et al. AHJ 2007 Median Survival (years) st admission 2nd admission 3rd admission 4th admission 0 CKD (n=3,264) No CKD (n=11,110) *CKD defined as estimated glumerular filtration rate < 60mL/min/1.73m2

28 Mortality Even With ICD Trial Data > data: 32% primary ICD are > 75 17% are > 80 years Non CV Other CV Sudden ACT Registry 4566 pts, 264 community centers Epstein et al, Heart Rhythm 2009,

29 2 nd Report of National ICD Registry 10,000 per month in U.S. Average age 68 years 31% over 75 years, 15% over 80 79% for primary prevention 77% symptomatic heart failure %I = 14 / II = 35/ III = 46/ IV = 5 66% have had prior HF hospitalization 12% had ICD during HF hospitalization Hammill et al 2008

30 ICDs During HF Hospitalization What Are We Doing?

31 Quality of Life vs Quality of Death? ICDs # per capita Is 3-10 X higher in U.S. than European countries US

32 You Don t Have to Have a Device Before You Die

33 Potential Interventions Examples Examples of anticipated What If decisions for unanticipated outcomes High-risk cardiac surgery in hope of improving HF Less invasive interventions that may improve course of HF Adjunctive HF therapies with potential dependence CABG Unable to come off bypass Ventilator dependence Valve surgery Stroke Pericardial stripping PCI or percutaneous valve Need for urgent surgery? Temporary support devices (IABP, peructaneous VAD, ECMO) Unable to wean temporary support device? IV inotropes Unable to wean; move to MCS or discontinue? Temporary dialysis Irreversible renal failure? NON-CARDIAC Interventions for co-morbidities For symptomatic or functional benefit Delayed benefit only Joint replacement Hernia repair Resection of pulmonary nodule Asymptomatic aneurysm repair Screening colonoscopy Worsening heart failure, Ventilator dependence Stroke Worsening heart failure, Ventilator dependence Stroke

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35 Uncommon decisions Major Cardiac Surgery Decisions for almost everyone Regarding preferences for end of life

36 Old Conception Life Prolonging/Restorative Care Disease Progression End of Life Care D E A T H

37 A New Vision of Palliative Care Disease Modifying - Life Prolonging Rx Palliation of Symptoms Hospice Disease Progression Bereavement Diagnosis Death

38 The Hospital Admission Is Not The Time To Introduce End of Life Issues

39 Proposed Yearly Review for Patients With Advanced HF Perhaps at the time of influenza vaccination Re-evaluate current therapies and options Discuss prognosis in general terms Elicit goals and preferences Discuss what if with patient and family It is not the patients role to define the everything that they want. It is the physician s responsibility to frame the reasonable options.

40 Update of Discussion After Major Milestones Examples of Milestones ICD Shock Heart failure re-hospitalization Escalating maintenance diuretic doses Need to decrease or discontinue neurohormonal antagonists

41 Words Are Important Only? CMO = Comfort Measures Only

42 AND = Allow Natural Death Instituted by CEO Reverend Chuck Myers, Austin Texas, Now In Over 100 Hospitals

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44 % Referred to Hospice 70 Trend in the Use of Hospice for Heart Failure Compared to Cancer HF EOL cohort (N=7,930) Cancer EOL cohort (N=7,565) Setoguchi et al AHA Calendar Year

45 % ER Visits within 30 Days of Death Trends in ER Visits Prior to Death Heart Failure Compared to Cancer HF EOL cohort (N=7,930) Cancer EOL cohort (N=7,565) Year

46 % Deaths in Acute Care Hospitals Trends in Hospital Deaths Heart Failure Compared to Cancer HF EOL cohort (N=7,930) Cancer EOL cohort (N=7,565) Calendar Year

47 Heart failure is a disease of the elderly Many patients with heart failure now survive to die of other diseases. There is a pyramid of decisions before resuscitation. Tough discussions today make difficult situations easier ahead.

48 Quality Life for the Elderly

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