End of Life Care in IJN Our journey Dato Dr. David Chew Soon Ping Consultant Cardiologist National Heart Institute Malaysia
End of Life Dying is final part of everyone journey in life Deaths used to occur in homes, surrounded by loved ones Because of illness at end of life, more patients are dying in hospitals and in ICU
Practice of Medicine First do no harm Cure sometimes, to relieve often, to comfort always IJN: Management of cardiovascular disease (medical/intervention/surgical)
Outcomes of Illness and Therapies Generally good outcomes Some patients have severe illnesses or co-morbidities and succumb Post cardiothoracic operative deaths Pediatric cardiology deaths Cardiology deaths
Cardiology Deaths 2010-2013 AMI 153 155 ACS HF valve 129 93 HF IHD HF DCM 41 140 70 Sepsis Misc NSTEMI Total = 781
Terminal Cardiac Illness Sudden or acute: sudden death, acute coronary syndrome and cardiogenic shock Gradual or chronic: slow deterioration of advanced or end stage heart failure, multi-organ failure
Place of Death 85% in Intensive Care/CCU 5% in HDU 10% in ward Often involves therapies like: inotropes, IABP, ventilation, dialysis, antibiotics, CPR
Acute illness 60 yr old man, DM, HPT Acute anterior MI, primary PCI to LAD, complicated by cardiogenic shock. IABP, ventilated. Inotropes. Acute renal failure dialysis Progressively hypotensive. Cardiac arrest. CPR. Expired after 4 days
End of Life The final phase of the patient s illness when death is imminent or nearly so From a few hours to several weeks Sometimes obvious but often uncertainties exist if the end is truly near, particularly acute illness
End of Life Care Often intensive & expensive care Bleak outcome Survivors often have limited extension of life which is of poor quality Are we doing too much? Do patients want it? Are we really carrying out the best care for patients?
End of Life Care Approach is often to continue with aggressive medical and supportive treatment, even though we see that response to therapy is unsatisfactory and patient is at end of life Often assume that all out care is what the patient and family wants Fear of censure if this is not done
Patient Perspective at End of Life Patients who are dying often spend their final days with a significant burden of pain and other symptoms Some receive care they would not have chosen to receive, and suffer a distressing and prolonged death
Patients in Critical Care Physician family discussions often focus on the patient s critical illness, treatments and prognosis When patients do not respond to therapies, then the family members are informed that patient is dangerously ill Seldom a discussion of what the patient would want in his care
No CPR Sometimes when we know that further efforts are futile, we discuss about Not attempting CPR in the event of cardiorespiratory arrest Seldom withdraw therapies that have been initiated and allow natural death
Chronic illness 77 year old man Heart failure EF 30% SSS on DDD PPM, paroxysmal AF Pulmonary fibrosis on home oxygen therapy Pneumonia and respiratory failure BiPAP, antibiotics Inotropes, Expired after 11 days
Advanced Heart Failure Advanced heart failure is a disease process that carries a high burden of symptoms, suffering, and death. Life expectancy < 1 year for most patients
Advanced Heart Failure 1. Moderate to severe symptoms of dyspnea and/or fatigue at rest or with minimal exertion (NYHA functional class III or IV) 2. Objective evidence of severe cardiac dysfunction demonstrated by at least 1 of the following: Left ventricular ejection fraction <30% Restrictive mitral inflow pattern by Doppler High left and/or right ventricular filling pressures Elevated B-type natriuretic peptide
Advanced Heart Failure - cont 3. Severe impairment of functional capacity i.e inability to exercise, 6-min walk distance <300m, or peak oxygen uptake <12 to 14 ml/kg/min 4. Episodes of fluid retention and/or reduced cardiac output 5. History of at least 1 hospitalization in the past 6 months 6. Characteristics should be present despite optimal medical therapy
Advanced HF Standard oral therapies no longer offer adequate symptom relief Advanced HF requires specialized interventions or a fundamental change in therapeutic approach
Quality of Life and Care in Heart Failure
Important Considerations for patients
Advanced Care planning Physicians should initiate and develop with the patient a comprehensive plan for end-of-life care Consistent with patient values, preferences, and goals Understand their illness and options Discussion with family members Identify a surrogate decision maker
Advance Care Planning in HF Discussions should be timely but preferably not during acute illness Proactive, anticipatory, iterative approach to patient s preferences Routinely and at milestones like ICD shocks, hospitalizations for HF
Problems with Advance Care planning Advance planning not acceptable because patients believed that negative outcomes can result from negative thoughts Physicians may also feel uncomfortable talking about death
Possible Benefits of advanced care planning Increased the likelihood that the patient s preferences would be known and followed (86% versus 30%, P<0.001) Decreased family members stress, anxiety, and depression
End of Life Care Patients should receive the intensity of care they would choose at the end of life To prolong life ( at all costs ) or not to prolong the dying process
End of Life Care Patients who are dying need to be treated with dignity, compassion and respect Commitment to high quality care and excellent services Individual care plan with appropriate and regular review
Aspects of End of Life Care Identification, assessment, and treatment of pain and other types of physical, psychological, emotional, and spiritual distress Control of symptoms and relief of discomfort Psychosocial and family support
Symptom relief Relief of symptoms of dyspnea and pain Oxygen relieves dyspnea in hypoxic patient Intermittent or continuous iv diuretics/inotropes Low-dose opiates
Communication Health care providers need to be compassionate and sensitive Good communication important between patients, families, and health care providers Regular updates to provide objective information, to share opinions, and to reach consensus on goals of care
Heart Failure and CPR Only about 5% of HF patients required resuscitation for an in-hospital cardiac arrest. However, when it did occur, the outcomes were very poor. Only 9% of the individuals who had a cardiac arrest and received CPR in hospital actually made a full neurologic recovery and were able to return home
Discontinuation of therapies Deactivation of ICD Withdrawal or withholding of mechanical ventilation in anticipation of death Discontinuation of mechanical circulatory support
Challenges Improving communication Shared decision making Healthcare personnel commitment to give quality care for the patient at end of life
Summary Assess patients to determine if they may be approaching end of life Communicate on treatment options, prognosis and patient wishes Advance care planning Curative/restorative care and palliative care
Patient & Family choice 63 yr old lady CABG 15 yrs ago, ischemic cardiomyopathy EF 15% DM, HPT, renal failure approaching endstage Monthly admissions for HF, more and more resistant to diuretics and inotropes Declined dialysis, palliative care toward the end
Quality of Care at End of Life Good care for the dying is as important as good care at any other time of life The secret of the care of the patient is caring for the patient