1. The Palliation of End-Stage Heart Disease Dr. Jana Pilkey MD, FRCP(C) Internal Medicine, Palliative Medicine April 30, 2009

3. “It is easier to die of Cancer than Heart or Renal failure” John Hinton (Medical Attending Physician) 1963

4. 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

5. Heart Failure The inability of heart to meet the metabolic demands of the body

6. 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

8. Heart Failure NYHA Grade 4 – Dyspnea at rest – Often have hypotension – Clinical features of CHF – Typically EF < 20% (Grade 4 Ventricle)

10. Mechanisms

11. Natural History Develops slowly or suddenly Often ends in sudden death Main cause: coronary disease 1-2% of general population, 20% of elderly (Hauptman 2005) Affects all ages

14. Clinical Features

15. – Dyspnea – Cachexia – Lethargy – Pain – Anxiety & depression – Insomnia & confusion – Postural Hypotension – Jaundice – More infections – Polypharmacy – Fear the future O’Brien et al. BMJ 1998 Similarities To Cancer

16. Clinical Features Differences From Cancer – More edema – Predicting death more difficult – Mistaken belief condition more benign than cancer – No local pressure effects – Less anemia

18. Comparison Between Terminal Illnesses SymptomCancerAIDSHDCOPDRD Pain 35-96%63-80%41-77%34-77%47-50% Depression 3-77%10-82%9-36%37-71%5-61% Delirium 6-93%30-65% 18-32%18-33% Fatigue 32-90%54-85%69-82%68-80%73-87% Dyspnea 10-70%11-62%60-88%90-95%11-62% Anorexia 30-92%57%21-41%35-67%25-64% (J Pain and Symp Manage, 2006)

19. (Janssen, Pall Med, 2008)

20. 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%

21. (Janssen, Pall Med, 2008)

22. Experience of Patients Lung Cancer – Clear trajectory – Feel well; told ill – Understand diagnosis/ prognosis – Relatives anxious – Swing between hope/ despair Cardiac Failure – Unclear trajectory – Feel ill; told well – Don’t understand diagnosis/ prognosis – Relatives isolated/exhausted – Daily hopelessness (Murray 2002)

23. 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”

25. Classic Pharmacologic Management Ace-I & Angiotensin II antagonists – (HOPE, CHARM, ONTARGET) B- blockers – (US Carvedilol Study, CIBIS II, Merit, BEST, COPERNICUS etc.) Diuretics / Spironolactone – (RALES trial) Digoxin – (DIG Trial) Opioids

26. Pharmacologic Management DrugNYHA 1NYHA 2NYHA 3NYHA 4SurvivalHospital Admits Functional Status Diuretic X    ACE-I     Spirono- lactone X X   B- blocker X    Digoxin X    Oxford 2002

28. Symptom Oriented Palliation Pain Management – Angina – 41-77% (J Pain Sympt Manage 2006) – Pain inadequately dealt with in 90% (Gibbs 2002) How To Manage? – Anti-anginals – Opioids – Revascularization – TENS, Spinal cord stimulators

29. Symptom Oriented Palliation How to Manage Dyspnea? – Oxygen – CHF medications – Opioids – Other

30. Symptom Oriented Palliation Depression and Anxiety – Regular assessment – Exercise program – Relaxation exercises – Antidepressants – Consider nocturnal opioid +/- benzodiazipine

32. 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)

34. 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)

35. 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

37. 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)

38. 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)

40. Case Study 90 y.o. female admitted for CHF and COPD with chest pain and dyspnea Hr 98, rr 28, bp 96/64 Na 134, K 4.7, Creat 130, Urea 24 Hgb 110 EF 18% Prognosis??

41. CHF Risk Model (Canadian Cardiovascualr Outcomes Research Team, JAMA 2003) www.ccort.ca/www.ccort.ca/CHFriskmodel.asp Age (year) Respiratory Rate (breaths/min) (minimal 20;maximal 45) Systolic blood pressure (mmHg) Blood Urea Nitrogen ( mmol/L) Sodium Concentration <136 mEq/L Yes No Cerebrovascular Disease Yes No Dementia Yes No COPD Yes No Hepatic Cirrhosis Yes No Cancer Yes No Hemoglobin <100 g/L (not required for 30-day Score) Yes No

43. 30-Day Score30-Day Mortality Rate (%)  60 0.4 61-903.4 91-12012.2 121-15032.7 >15059.0 One-Year Score One-Year Mortality Rate (%)  60 7.8 61-9012.9 91-12032.5 121-15059.3 >15078.8 CHF Risk Model Our patient has a score of 127

44. When Should I Refer? Prognosis < 6 months Difficulty controlling symptoms Actively dying Call anytime with questions Virtual Hospice

46. 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

48. 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

49. 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.

50. 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.