“It is easier to die of Cancer than Heart or Renal failure” John Hinton (Medical Attending Physician) 1963
Objectives To define Congestive Heart Failure (CHF) To gain an understanding of what a CHF patient experiences at end of life To employ a symptom-oriented approach to CHF To discuss prognostication in CHF
Heart Failure The inability of heart to meet the metabolic demands of the body
New York Heart Association (NYHA) Classification – Class 1 – No dyspnea (but low EF on echo) – Class 2 – Dyspnea on strenuous activity – Class 3 – Dyspnea on activities of daily living – Class 4 – Dyspnea at rest
Terminal CHF Severe symptoms in last 48-72 hrs prior to death (SUPPORT study) – Breathlessness 66% – Pain 41% – Severe confusion 15% Regional Study of Care of the Dying (RSCD) study – Dyspnea 50% – Pain 50% – Low mood 59% – Anxiety 45%
Experience of Patients Lung Cancer – Cancer/tx takes over – Feel worse on treatment – Financial benefits – Services available – Care prioritized as “cancer” or “terminal” Cardiac Failure – Shrinking social world – Feel better on treatment – Less benefits – Services less available – Less priority as “chronic illness”
Issues in Palliative Care Lack support networks & communication Prognostication difficult DNR difficult issue – Written on 5% (47% in Ca, 52% in AIDS) – Wanted by pt in 23% – 40% rescind (Gibbs 2002)
Issues in Palliative Care Hospitalization improves symptoms in 35-40% (Ward, 2002) Palliative care - 4% of dying CHF – (40% in cancer pts) (Gibbs, 2002) CHF pts - poor function by hospice admission – (Zambroski, 2005)
Implantable Cardioverter Defibrillators and Pacemakers Leave Pacemakers intact Turn off/disable ICD’s – 73% - no discussion about turning off prior to last hours (Goldstein, 2004) – 8% - receive shocks minutes before death (Goldstein, 2004) – Plan ahead ! Inform Funeral Home
Prognostication Very difficult to prognosticate Markers of poor prognosis (< 6 months) – Liver failure, renal failure, delirium – Unable to tolerate ACE-I due to bp – NYHA Class 4 – EF < 20% – Frequent hospitalizations – Cachexia CCORT prognostic protocol (Hauptman 2005, Taylor 2003, Ward 2002)
Prognostication NYHA Class1 Year Mortality I5-10% II-III15-30% IV50-60% Median survival 16 months from first hospitalization Median survival all patients: 2 Years !! (Hanratty 2002)
Clinical Assessment Document ventricular function, administer medical therapy Address symptoms, discuss prognosis, involve MDT Progression Reassessment Reassess and treat exacerbating factors Readdress symptoms, reassess goals of care Increase involvement of MDT Consider advanced therapeutic options Ineligible or Declines Palliative Approach Generally includes medical and symptom treatment
Summary CHF has a very poor prognosis CHF greatly affects quality of life Use CHF & other meds for symptom control Discuss prognosis early Consider prognostic models
References Ward, Christopher. The Need For Palliative Care in the Management of Heart Failure. Heart 2002; 87:294-8. Murray, Scott. Dying of Lung Cancer or Cardiac Failure: Prospective Qualitative Interview Study of Patients and Their Carers in the Community. BMJ. 2002; 325:929-34 Gibbs, JSR. Living With and Dying From Heart Failure: The role of Palliative Care. Heart 2002; 88; 36-39. Hauptman, Paul. Integrating Palliative Care Into Heart Failure Care. Arch Intern Med. 2005; 165; 374-8. Seamark, David. Deaths From Heart Failure in General Practice: Implications for Palliative Care. Pall Med; 2002; 16: 495-8. Talyor, George. A Clinician’s Guide to Palliative Care. Blckwell Science. 2003: 47-75.
References Zambroski, Cheryl. Patients With Heart Failure Who Die in Hospice. AM Heart J 2005; 149:558-64. Pantilat, Steven. Palliative Care for Patients with Heart Failure. JAMA, 2004; 291: 2476-82. Hanratty, Barbara. Doctors’ Perceptions of Palliative Care for Heart Failure: Focus Group Study. BMJ 2002:325: 581-585. Nanas John. Long-term Intermittent Dobutamine Infusion, Combined with Oral Amiodarone for End-Stage Heart Failure. Chest 2004; 125: 1198-1204. Lopez-Candales, Angel. Need for Hospice and Palliative Care Services in Patients with End-Stage Hearat Failure Treated with Intermittent Infusion of Inotropes. Clin. Cardio. 2004, 27, 23-28. Goldstein, NF.Management of implantable cardioverter defibrillators in end-of- life care.Ann Intern Med. 2004 Dec 7;141(11):835-8.