The Role of Palliative Care in Readmission Reduction Steven Z. Pantilat, MD

Transcription

1 The Role of Palliative Care in Readmission Reduction Steven Z. Pantilat, MD Professor of Clinical Medicine Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care Director, Palliative Care Program and Palliative Care Leadership Center Department of Medicine University of California, San Francisco

2 Congestive Heart Failure 5 million US adults have CHF 1 in 5 adults will develop heart failure Affects 10% of adults 75 years and older Most frequent cause of hospitalization in elders Treatments increase quality and length of life AHA Heart and Stroke Statistical Update Redfield et al. JAMA 2003;289:

3 Death from Heart Failure 250,000 deaths per year US - 10% of deaths Median survival after diagnosis is 5 yearsdiastolic and systolic dysfunction As malignant as cancer Survival after first hospitalization worse for HF than for breast cancer, colon cancer 1/3 to 1/2 of deaths from heart failure are sudden at every stage of disease Stewart et al. Eur J Heart Fail 2001; 3: Stevenson and Stevenson J Cardio Electrophys 2001;12:112-4 Tribouilloy et al. Eur Heart J 2008;29: Roger et al. JAMA 2004;292:344-50

4 End-of-Life Care in Heart Failure In last 6 months of life 80% of patients hospitalized Average days in hospital: 20 Average days in ICU: 4.6 Costs rising: $36,216 Readmissions common 36% die within one year of HF-related hospitalization Unroe et al. Arch Int Med 2011;171: Curtis et al. Arch Intern Med 2008;168:

5 Trajectory of Death from Heart Failure (and other chronic diseases) Cancer Health Status Crises Decline Death Time

6 Site of Death in the US Site All* Heart Failure^ Hospital 50% 35% Nursing home 23% 34% Home 23% 31% Hospice 41% 12% *Teno et al. Brown Site of Death Atlas of the U.S., 2004 ^Teno et al. JAMA 2004;291:88-93

7 Symptoms in Patients with Serious Illness Symptom Cancer COPD HF Pain 35-96% 34-77% 41-78% Fatigue 32-90% 68-80% 69-82% Dyspnea 10-70% 90-95% 60-88% Depression 3-77% 37-71% 9-56% Insomnia 9-69% 55-65% 36-48% Solano et al. J Pain Sympt Man 2006;31:58-69

8 Symptoms in Patients with Chronic Disease Symptom Inpt CA Outpt CA HF Pain 43-81% 50% 41-78% Fatigue 81% 18% 69-82% Dyspnea 19-61% 71% 60-88% Depression 37% 59% 9-56% Mean # 14 +/ /- 6 Pantilat et al. J Card Failure 2010;16:S88 Weiss et al. Lancet 2001;357: Ng and von Gunten J Pain Sympt Man 1998;16: Levenson et al. JAGS 2000;48:S101-9 Solano et al. J Pain Sympt Man 2006;31:58-69

9 Pain in People with Heart Failure Common and persistent: up to 78% of patients Etiology includes Heart disease Treatments Co-morbidities Associated with depression, poor quality of life No trials of interventions Pantilat et al. J Card Failure 2010;16:S88 Godfrey et al. J Card Failure 2006;12: Lorenz et al. Ann Int Med 2008;148:147-59

10 Palliative Care comprehensive, interdisciplinary care, focusing primarily on promoting quality of life for patients living with a terminal [or serious, chronic] illness and for their families assuring physical comfort [and] psychosocial support. It is offered simultaneously with all other appropriate medical treatments. Billings JA. J Pall Med 1999;1:73-81

11 Palliative Care for Patients with Heart Failure High morbidity and mortality create need for palliative care Risk of sudden death means that palliative care must be integrated into care at every stage of illness Frequent exacerbations leading to re-admissions where palliative can intervene Palliative care proven to improve symptoms, quality of life, satisfaction, and patient and family outcomes Pantilat and Steimle JAMA 2004;291: Wright et al. JAMA 2008;300: Morrison J Palliat Med 2005;8:S79-87

12 Challenges in Providing PC for People with Heart Failure Heart disease: difficult prognosis, exacerbations difficult to gauge Cardiology: misperception of PC, denial of death, reluctance to hand over patient PC: Lack of HF knowledge (stopping meds), cancer focus Patient: reluctance to accept PC System: lack of coordination of services, confusion over role of HF nurse specialists Selman et al. Pall Med 2007;21:385-90

13 Palliative Care Consults and HF: UCSF Experience 10% of HF patients receive PC consults 8% of PC consults are for patients with heart disease After PC consult 40% go home with hospice and only 3 patients readmitted after discharge to hospice 30% die inpatient

14 Which Patients Need Palliative Care? Every patient initially Would I be surprised if this patient died in the next year? Worsening HF, multiple hospitalizations History of sudden death Considering intervention- ICD, transplant HFSA 2006 Comprehensive Heart Failure Practice Guideline Adams et al. J Card Failure 2006;12:10-37 Hunt et al. Circ :

15 Palliative Care for Patients with Heart Failure Combine optimal medical therapy with PC Concurrent care model inpt and outpt Symptom management, prognosis, advance care planning, psychosocial support, hospice referral Use existing interdisciplinary PC and HF teams and self care interventions Educate and train patients, providers Pantilat and Steimle JAMA 2004;291: Selman et al. Pall Med 2007;21: McAlister et al. JACC 2004;44:810-19

16 Psychosocial/Spiritual Care For Heart Failure Patients Eric Cassellʼs definition of suffering is still very useful: Suffering is defined as the state of severe distress associated with any events that threaten the intactness of a person. Suffering can occur in relation to any aspect of the person: physical, emotional, relational/ social, spiritual Eric Cassell, NEJM, 1982;306:639-45

17 Psychosocial/Spiritual Care For Heart Failure Patients Main areas of psychosocial and spiritual suffering in patients with HF: Quality of life: impact of symptoms (dyspnea, fatigue, anxiety, depression), treatments, and repeated hospitalizations on quality of life Social functioning: loss of identity/family roles, sexuality, sense of agency, and participation in relational life both within and outside the family

18 Psychosocial/Spiritual Care For Heart Failure Patients Main areas of psychosocial and spiritual suffering in patients with HF: Individual and family coping skills: communication patterns, family conflict about goals of care, repeated adjustments, role of hope, life meaning, and dignity

19 Psychosocial/Spiritual Care For Heart Failure Patients Assessing spiritual and existential concerns within a palliative care consult: What do you still want to accomplish during your life? What thoughts have you had about why you got this illness at this time? What might be left undone if you were to die today?

20 Psychosocial/Spiritual Care For Heart Failure Patients Assessing spiritual and existential concerns within a palliative care consult: Given that your time is limited, what legacy do you want to leave your family? What do you want your children and grandchildren to remember about you? Caregiver burden: given that the unit of care is the patient and family, PC can also help the family to cope during the patientʼs illness and their own bereavement

21 Conclusion Heart failure is a leading cause of death in the developed world, yet few patients with heart failure receive palliative care Palliative care should be provided concurrent with all appropriate disease specific treatment Patients with heart failure have many distressing symptoms that need treatment Discussing key issues early can promote better care and lead to reduced readmissions We have much to offer of ourselves to our patients