Advanced Heart Failure: Palliative Care and Hospice. Objectives. Models of Care. Susan Glod, MD

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1 Advanced Heart Failure: Palliative Care and Hospice Susan Glod, MD Objectives Redefining Palliative Medicine How can we help? Identifying barriers What next? Models of Care Goal: Prolong life Goal: Prolong life Goal: Comfort Palliative Care Hospice 1

2 The Trouble With Heart Failure What the patient wants. What we can do. Palliative Care Understand goals. Clarify values. Set expectations. Keep stakeholders informed. Complex symptom management. Maximize functionality and independence. Caregiver support. Address all domains of suffering. Palliative Care 2

But Americans with heart failure: 6 million ABMS certified HPM physicians: 4000 Pain in HF Outpatients with Advanced HF Pain interferes with normal work (%) Pain interferes with walking (%) Pain

3 But Americans with heart failure: 6 million ABMS certified HPM physicians: 4000 Pain in HF Outpatients with Advanced HF Pain interferes with normal work (%) Pain interferes with walking (%) Pain Interferes with general activity (%) All-cause mortality in heart failure (HF) patients by severity of depression. Moraska A R et al. Circ Heart Fail 2013;6: Copyright American Heart Association 3

Acute HF Symptoms Mean +/ SD Pain 3.6 +/ 3.6 Tired 6.3 +/ 2.

5 Depressed 2.1 +/ 2.9 Anxious 3.3 +/ 3.3 Drowsy 3.4 +/ 3.4 Appetite 4.7 +/ 3.4 Well being 5.

Hospitalizations Symptom management Who? Why? What do patients want? To die at home.

4 Acute HF Symptoms Mean +/ SD Pain 3.6 +/ 3.6 Tired 6.3 +/ = symptom is not present 10 = symptom is at its worst possible Nauseated 2.4 +/ 3.5 Depressed 2.1 +/ 2.9 Anxious 3.3 +/ 3.3 Drowsy 3.4 +/ 3.4 Appetite 4.7 +/ 3.4 Well being 5.7 +/ 2.6 Shortness of breath 6.1 +/ 3.1 Functional Impairment When? Hospitalizations Symptom management Who? Why? What do patients want? To die at home... but to be hospitalized for exacerbations. To die an unaware death... but to leave the ICD on. To die with family But not to burden them. Not to disappoint their providers. 4

5 Functional Impairment Who? When? Hospitalizations Device therapy is considered Symptom management Goals of care Why? Caregivers Need Help Too They have unmet needs: Information about disease progression Physical care, symptom control Emotional, spiritual, bereavement support They have less positive caring experiences when patients are symptomatic. Caregiving impacts health. Functional Impairment Caregiver fatigue Who? When? Hospitalizations Device therapy is considered Other escalations in therapy Symptom management Goals of care Caregiver support Why? 5

6 But Does Palliative Care Help? May improve attitudes towards completion of advance directives. May improve pain and decrease opioid use. But more data is needed What about hospice? Skilled Nursing Social Work Volunteers Patient and Family Physician Spiritual Counseling Bereavement Counseling Published in Journal of Palliative Medicine. May 2013, 16(5): DOI: /jpm Mary Ann Liebert, Inc. FIG. 1. Trajectory of congestive heart failure. 6

of anticoagulants + CAD What about hospice? 2000 2010 Medicare Hospice Beneficiaries 513,000 1.

7 Predictors of Trajectory Rule out Unexpected Death Dehydration Dysphagia + Speech therapy Malignant neoplasm prostate + secondary neoplasm bone and bone marrow Rule in Unexpected Death Long term use of anticoagulants + CVD CVD + Afib Long term use of anticoagulants + CAD What about hospice? Medicare Hospice Beneficiaries 513, M Mean LOS in days Median LOS in days % Noncancer diagnoses (11.4% HF) Medicare spending 2.9B 13B % For profit agencies The hospice conundrum Hell 7

8 References Davidson PM, Abernethy A, Newton PJ, Clark K, Currow DC. The caregiving perspective in heart failure: a population based study. BMC Health Serv Res Sep 3;13(1):342. Dev S, Abernethy AP, Rogers JG, O'Connor CM. Preferences of people with advanced heart failure a structured narrative literature review to inform decision making in the palliative care setting. Am Heart J Sep;164(3): e5. Evangelista LS, Motie M, Lombardo D, Ballard Hernandez J, Malik S, Liao S. Does preparedness planning improve attitudes and completion of advance directives in patients with symptomatic heart failure? J Palliat Med Dec;15(12): doi: /jpm Epub 2012 Sep 18. Goodlin SJ, Wingate S, Albert NM, Pressler SJ, Houser J, Kwon J, Chiong J, Storey CP, Quill T, Teerlink JR; PAIN HF Investigators. Investigating pain in heart failure patients: the pain assessment, incidence, and nature in heart failure (PAIN HF) study. J Card Fail Oct;18(10): Hupcey JE, Penrod J, Fogg J. Heart failure and palliative care: implications in practice. J Palliat Med Jun;12(6): Malik FA, Gysels M, Higginson IJ. Living with breathlessness: a survey of caregivers of breathless patients with lung cancer or heart failure. Palliat Med Jul;27(7): Moraska AR, Chamberlain AM, Shah ND, Vickers KS, Rummans TA, Dunlay SM, Spertus JA, Weston SA, McNallan SM, Redfield MM, Roger VL. Depression, healthcare utilization, and death in heart failure: a community study. Circ Heart Fail May;6(3): Schwarz ER, Baraghoush A, Morrissey RP, Shah AB, Shinde AM, Phan A, Bharadwaj P. Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation. J Palliat Med Jan;15(1):12 5. Shah AB, Udeoji DU, Baraghoush A, Bharadwaj P, Yennurajalingam S, Schwarz ER. An evaluation of the prevalence and severity of pain and other symptoms in acute decompensated heart failure. J Palliat Med Jan;16(1): Stevenson DG. Growing pains for the Medicare hospice benefit. N Engl J Med Nov;367(18):

Patients with heart failure (HF) experience a myriad of

Patients with heart failure (HF) experience a myriad of JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 1, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0231 Brief Reports Does the Type and Frequency of Palliative Care Services Received by Patients with