Palliative Pearls for the Cardiac Patient

Transcription

1 Palliative Pearls for the Cardiac Patient 1 Lisa Simonian, DNP, CRNP, SANE-A Geoffrey P. Dunn, MD, FACS Liz Stroup, MSW Objectives Revisit the definition and purpose of Palliative Care Discuss palliative and end of life care in the setting of acute/severe cardiac disease Describe how cardiac care teams can maximize the experience with Palliative Care collaboration 1

2 palliative Latin Pallium to mask or to cloak Focuses on the last years or months of life when death is now foreseeable rather than merely a possibility Palliative Care - Current Definition Interdisciplinary care that aims to relieve suffering and improve the quality of life for patients and families with serious illness. It is offered simultaneously with all other appropriate medical treatment. Pallia ve care hospice 2

3 Surgeons and the origins of Palliative Care The term, Palliative Care was coined by Canadian surgeon, Balfour Mount, in Wanted surgeons to consider their impact on quality of life Goal was to anticipate, prevent, and treat the suffering patients experienced in the late phases of life threatening illness 3

4 The Domains of Palliative Care Pain management Non-pain symptom management Communication skills - adverse news disclosure - goals of care - advance directives Ethics & conflict resolution Self-awareness American College of Cardiology Symptoms NYHA Class III/IV symptoms Frequent HF admissions Recurrent ICD shocks Refractory Angina Anxiety or Depression adversely affecting patient s quality of life or ability to manage illness 4

5 American College of Cardiology American College of Cardiology Milestones VAD Transplant TAVR Home Inotropic therapy 5

6 No specific therapy is excluded from consideration. The test of palliative treatment lies in the agreement that the expected outcome is relief from distressing symptoms, easing of pain, and improvement in quality of life. Dialysis, transplantation, and chemotherapy ARE compatible with palliative care. The decision to intervene is based on the treatment s ability to meet the stated goals, rather than its effect on the underlying disease. Meet Rita 6

7 Rita 85 year old widowed female Retired LPN Lives alone in her own home, independent in all ADLs, still drives Two daughters, one living OOT PMH significant for HTN, HLD, CKDII, OA Enjoys driving to Ohio to get the cheapest gas, garage sales, going to the casino with friends, senior groups, card club, feeding the birds.and her cat. The Skinny at the Senior Center 1. Loss of independence 2. Declining health 3. Running out of money 4. Not being able to live at home 5. Death of a spouse or other family member 6. Inability to manage their own activities of daily living 7. Not being able to drive 8. Isolation or loneliness 9. Strangers caring for them 10. Fear of falling or hurting themselves 7

8 Hope for the best, plan for the worst Goals of Care Conversations Grounded in shared decision making Based on prognosis Explores the benefits and burdens of treatment choices Patient s values and preferences These are not one time discussions, nor can decisions be expected at initial meetings unless emergent decisions are required Many of the best goals of care discussions are unscheduled and take place with nursing, physical therapy, Fr. Murphy. 8

9 Prognostication and the big picture Frame prognostic information in terms of ongoing function, return to baseline and what the new normal will likely be. Offer pathways and scenarios for families to process Understand patient/families worst fears How well as opposed to how long 9

10 The surprise question Would you be surprised if this patient were alive in one year? It s a family affair What are the family dynamics? Who is(are) the decision maker(s)? What is the level of health literacy? What spiritual beliefs and needs are present? What previous myths and legends are you competing with? 10

11 What Do You Want Us to Do if Your Heart Stops? I want to die in an ICU with a tube in every hole Said No One.Ever Studies have shown that approximately 80% of Americans would prefer to die at home, if possible. Currently, 60% of Americans die in acute care hospitals, 20% in nursing homes and only 20% at home 11

12 End of life care/hospice evaluation Can I die here? Can I die at home? I don t know if I could still live there if she died in the house I don t want to suffer I don t want to drown I just want to be left alone Why don t you have a hospice house? Why does it cost so much? Will the insurance pay for that? What happens next? 12