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Christine Westphal NP MSN ACNS-BC ACHPN CCRN Director/Nurse Practitioner Palliative and Restorative Integrated Services Model (PRISM) Oakwood Healthcare.

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Presentation on theme: "Christine Westphal NP MSN ACNS-BC ACHPN CCRN Director/Nurse Practitioner Palliative and Restorative Integrated Services Model (PRISM) Oakwood Healthcare."— Presentation transcript:

1 Christine Westphal NP MSN ACNS-BC ACHPN CCRN Director/Nurse Practitioner Palliative and Restorative Integrated Services Model (PRISM) Oakwood Healthcare System Dearborn, Michigan A Bridge Over Troubled Waters: Palliative Care in Heart Failure



4 Objectives 1. Describe the trajectory of heart failure. 2. List three palliative care outcomes in end stage heart failure with related interventions 3. List palliative care resources available to the patient, family and healthcare provider

5 Definitions Structural or functional disorder which impacts ability of the heart to eject or fill with blood –Systolic (decreased ejection) EF < 40% Occurs most frequently –Diastolic (impaired filling) Impaired relaxation Ventricular stiffness

6 Etiology Ischemic cardiomyopathy/CAD 59-70% Non-ischemic cardiomyopathy –CVNon-CV Valve disease Obesity HTN Illicit drugs Atrial fibrillation Cardiotoxic medications Infection Sleep apnea Congenital abnormalities Anemia Idiopathic dilated cardiomyopathy

7 Ventricular Dysfunction: Output Neuroendocrine activation Renin-Angiotensin-Aldosterone Sympathetic Nervous System Vasopressin Pressure/volume HR, BP, Myocardial O 2 consumption Sodium/water retention/edema Ischemia, dsyrhythmias Decreased end organ perfusion Ventricular hypertrophy Ventricular remodeling Fibrosis Cell death (apotosis) Natiuretic Peptides ANP (atrial) BNP (brain) Attempts to compensate Diuresis Decrease neuroendocrine response Immune up-regulation Cytokines Tumor necrosis factor Interleukins

8 Copyright ©2009 American Heart Association 2009 WRITING GROUP ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE, et al. Circulation 2009;119:1977-2016 Recommended Therapy by Stage

9 Heart Failure Facts Increasing prevalence, particularly in the elderly 550,000 new cases annually Affects 6-10% of US patients > 65 –Leading cause of Medicare hospitalization > 1 million hospitalizations annually –20% of hospitalizations age > 65 >3 billion ED/office visits annually $33 billion spent in 2007 Lloyd-Jones et al (2009) Heart Disease and Stroke Update. Circulation;119;480-486 Heart Failure Society of America (2006) J Card Fail;12;e86-e103. Koelling T et al (2005) Circulation; 111: 179–185 Burt C & Schappert S (2004) Vital Health Stat 13; No. 157: 1–70.

10 Contributing Factors Poor adherence to diet, self-care and medication recommendations –Lack of understanding –Depression/anxiety/cognitive impairment –Complexity of the plan—multiple co- morbidities and specialists –Inadequate follow-up/discharge support –Lack of access Social and/or financial reasons

11 Progressive, chronic Last 6 months end-stage patients spend 1 out of 4 days in hospital Russo et al (2008) J Card Fail; 14:651-658 End-stage marked by worsening symptoms, functional decline and repeated hospitalizations Teuteberg et al (2006). J Card Fail; 12: 47-53. Goldberg & Jessup (2007) Circulation;116:360-362. Bradley et al (2003). JAMA 289: 730-740.

12 And Deadly Cardiac disease is leading cause of death in Michigan 2008 Michigan Resident Death File MDCH 2.5 M Medicare recipients 2001-2005 1 year mortality 37% Curtis et al (2008) Arch Intern Med; 168:2481-88. About half of patients die within 5 years –Approximately 25% of survive beyond 5 years MacIntyre et al (2000) Circulation; 102: 1126-1131 Khand et al (2000) J Am Coll Card; 36: 2284-1186

13 Significant Mortality Indicators If stage IV (D) and with optimal tx, but shows: –Dobutamine or milrinone dependence –Decompensation despite resynchronization –Frequent AICD firing –Greater than 1.9 hospitalizations/6 months –Not candidate for transplantation Kuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach. St. Louis: Mosby. Hershberger et al (2003) Cardiac Fail; 9: 180-181 Albert et al (2002) Cleve Clin Med J. ; 69: 321-328 Alla et al ( 2000) Am Heart J ;139: 895-904

14 Additional Factors Increase Risk Resting HR >100 Creatinine >2.2 mg/dl Serum NA < 134 after treatment Repeated hospitalization for HF Age >70 Additional serious co-morbidities Dependent for ADL—poor functional status Kuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach. St. Louis: CV Mosby

15 Living with Heart Failure “It’s not about death, it’s really about living with a disease…” Joanne Lynn MD SUPPORT Primary Investigator


17 Study to Understand Prognoses and Preferences for Treatment (SUPPORT) Approx 950 heart failure patients with EF < 20% –68% readmitted within 2 months –79% experienced a 5 # wt loss in 2 mo –76% required services for ADL assist –23% decided to forego resuscitation Krumholz et al.(1998) Circulation;98:648-655

18 Living with Serious Illness 90 Million with serious illness annually 70% admitted to hospital in last 6mo –1:4 inadequate symptom control –1:3 inadequate emotional support –1:3 inadequate education on self-care –1:3 inadequate post-discharge plan Many died in the hospital Dartmouth atlas www. Teno et al (2004) JAMA; 29(1):88-93 Covinsky et al (1994) JAMA 272(23): 1838-44. Commonweath Fund Report (2007)

19 The Heart Failure Experience Study comparing HF and lung CA patients HF patients had: –Less information about illness, prognosis and treatment –Less involvement in decisions about CPR, ventilation and artificial nutrition –Frustration with losses and social isolation –Less involvement with palliative care –More stress, distress and less quality of life –Fewer supportive services Murray et al (2002) Br Med J;325:929-932

20 “Palliative care should be considered a normal approach to patients with heart failure…” Hauptman et al (2005) Arch Intern Med;165:374-378

21 What is Palliative Care? An evidence-based specialty practice that: –Focuses on relief of suffering particularly for people with serious, life-limiting illnesses –Helps patients and families to have best quality of life regardless of stage of illness or need for other therapies –Optimizes function, decision-making and personal growth


23 Growth of Palliative Care 1998: No PC programs 2008: Over 50% of hospitals with 50 or more beds have a PC program –Center to Advance Palliative Care, 2008

24 Oakwood Hospital & Medical Center Dearborn Detroit Receiving Hospital Providence Hospital St. John Hospital St. Joseph Mercy Ann Arbor St. Joseph Mercy Pontiac Beaumont Hospital Henry Ford Detroit and Wyandotte University of Michigan

25 Palliative Care: A Bridge Over Troubled Waters Communication –Support system –Treatment options/benefits & burdens –Clarify goals, values and preferences –Advance directives & resuscitation status –Match needs and resources Quality of life –Symptom control –Optimize function –Psycho-social-spiritual support Satisfaction Widera & Pantilat (2009) Current Opin Support Pall Care;3:247- 251.

26 Michigan Dignified Death Act Patients with a life limiting illness must be informed about treatment options including: –Benefits and burdens of treatment –Right to refuse treatment –Palliative care –Pain control –Hospice for patients with terminal illnesses Michigan Law No. 239 (333.5652)

27 Palliative Care Impact Less likely to die in the hospital Experience fewer ICU/CCU admissions in the last six months of life Spend less time in an ICU/CCU in the last six months of life –Center to Advance Palliative Care, 2008

28 Satisfaction Patient family satisfaction –Relief of symptoms –Improved communication –Smooth access and seamless care Physician Satisfaction –Collaboration –Saved physician time PRISM Quality Data 2007-2010 Campbell (2004). Making cents: Cost-effectiveness of palliative care. Presentation

29 Improved symptom control 50% 60% 70% 80% 90% 100% Controlled AnxietyDyspnea Non-palliative care Palliative care North Kansas City Hospital

30 Common Symptoms Dyspnea Pain Anxiety Depression Fatigue Edema/anasarca Anorexia/cachexia

31 SUPPORT Study N=957 HF Patients 92 (10%) died during hospitalization –43% had dyspnea –35% had severe pain 865 survivors –32% had dyspnea –19% had severe pain SUPPORT Principal Investigators (l995). JAMA; 274: 1591-1598

32 Dyspnea Prevalence DxPrevalence % # StudiesN COPD90-954372 Heart Dz60-886948 CA10-702010,029 AIDS11-622504 Bausewein C et al (2007). Respir Med; 101(3):399-410 Solano, et al. (2006) J Pain Symp Mgt, 31(1):58-69.

33 Dyspnea Awareness of uncomfortable breathing –Subjective “Respiratory distress” –Observed physical and/or emotional signs

34 Pathophysiology Increased work of breathing –Airway constriction –Obstruction: secretions, infections, effusions –Weakness Chemical –Hypercapnia –Hypoxia Neuromechanical dissociation –Muscle tension/effort do not match expansion Thomas and von Guten, (2002) Lancet Onc;3(4):223-228.

35 Measurements * Numeric Report *Vertical Dyspnea Visual Analog Scale *Borg Scale Dyspnea Exertion Scale –Level I: Walk w/o SOB to –Level 5: Breathless @ rest 10= Severe distress 0= No distress No tool superior to others. All are unidimensional. ACCP (2010)Consensus statement on management of dyspnea in patients with advanced lung or heart disease. Chest; 137(3): 674-691

36 Asphyxia produces innate, non- voluntary, observable behaviors –Tachycardia –Tachypnea –Accessory muscle use –Paradoxical breathing –Nasal flaring –Fear expressions and behaviors Campbell ME et al (2010) J Palliat Med. Mar;13(3):285-90. Campbell ME (2008). J Palliat Med. Jan-Feb;11(1):44-50. Respiratory Distress Observation Scale

37 Facial Expression: Fear Campbell, ELNEC 2006

38 BREATH AIR Bronchospasm –Albuterol and ipratropium –Steroids Rales –Limit fluids, evaluate protein –Consider diuretics, ACE-I, other Effusions –Thoracentesis/catheter Airway obstruction –Aspiration precaution/suction Thick secretions –Strong cough? Neb. Saline/humidity –Thin? Hyoscyamine, atropine ophthl solution, scopolamine, glycopyrrolate Hemoglobin low –Transfusion? Anxiety –Position –Pursed lip breathing –Fan –Music –Massage –Biofeedback –Opioids –Benzodiazepines Interpersonal issues –Counseling, support Religious concerns –Spiritual advisor

39 “ Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.” Thomas Sydenham (17 th century)

40 Opioids in Dyspnea Multiple mechanisms of action –Decrease chemoreceptor response –Decrease anxiety –Increase peripheral vasodilation –Alter perception through afferent pathways

41 Dosing No one opioid is better than the other Recommended starting p.o.doses (q3-4hrs) –Morphine sulfate 2.5-5mg –Hydrocodone 2.5-5mg –Oxycodone 2.5-5mg –Hydromorphone 1-2 mg –Codeine 30mg May start higher in opioid tolerant pts. Titration: 25-50% every 12 hours Convert to sustained release formulas if available IV: PO 1:3 conversion. Infusions if needed

42 Nebulized Opioids Theory: action on airway receptors Ambiguous evidence –Small studies and case reports –2 RCT report nebulized morphine no better than saline If trial is warranted: –Morphine sulfate 2.5-10mg added to 2ml saline (preservative free or non-flavored elixirs) every 4 hours and every 1-2prn –Hydromorphone 0.25-1mg as above Westphal & Campbell AJN (2002) May Supplement 11-15 ACCP (2010) Chest; 137(3): 674-691


44 Respiratory Arrest!?! Sedation precedes respiratory suppression Respirations are NOT impacted by prudent dosing Improved pulmonary parameters –Citron et al. Am J Med, 1984 No difference in duration of survival –Campbell et al. Crit Care Med, 1999; Chan et al. CHEST, 2004) Respiratory failure Always occurs during dying with or without opioids Dead people don’t breathe!

45 Hypotension?!? Hypotension most often with IV dosing in the presence of volume depletion and/or in the elderly. Consider the goals of care.

46 Oxygen No studies support use for dyspnea without hypoxemia at rest or min. activity ACCP (2010). Chest; 137(3): 674-691 Judicious use of bi-pap or c-pap –May benefit cognitively intact pts with COPD or neurodegenerative disorders. Not for dying pt. Use of fans or blowing air may be as effective in advanced disease. –Stimulates facial nerve and non specific nasal receptors Galbraith et al J Pain Symp Mgmt 2010; 39(5): 831-838 Spector etal 2007. AACN Adv. Clin Issues; 18(1):48-57 Gallager & Roberts J Pain Pal Care Pharmacotherapy 2004;18(4): 3-15.

47 Refractory respiratory distress All previously described interventions fail to relieve patient distress Complete sedation may be indicated –Benzodiazepines, barbiturates, propofol –Patient and clinician mutually agree to this approach –May be the only compassionate strategy IF all other approaches fail NHPCO Position statement and Commentary on use of palliative sedation in imminently dying terminally ill patients. J Pain Symp Mgmt 2010 39(5): 914-923

48 Terminal Congestion Explain to family—anticipate as a normal occurrence Position lateral (“recovery position”) Decrease fluids and feedings Consider diuretics if pulmonary edema If oral secretions are excessive--anticholinergics –Scopolamine –Atropine ophthalmic solution 1% –Glycopyrrolate (Robinul) –Hyoscyamine (Levsin)

49 Pain Up to 41% of patients experience pain with heart failure Most pain is general in nature Causes –Angina –Edema –Osteoarthritis –Diabetic neuropathy Levenson et al (2000)Am Geriatr Soc


51 FLACC Scale

52 WHO Analgesic Ladder Start at the level of the pain Avoid NSAIDS-- diuretics may need to be adjusted Start with PRN and then consider longer acting scheduled doses Transdermal difficult to titrate Stay with same drug Use equianalgesic tables if converting drugs

53 Anxiety General Anxiety Disorder (GAD) Affects 2-3% of adults annually Higher in patients with medical disorders Most common psychiatric symptom in patients with CV disease Associated with increased morbidity and mortality Mueller et al. (2005) Curr Psych Rep; 7: 245-251

54 Reasons Symptoms –Dyspnea and pain Medications and lifestyle –Antihypertensives, steroids –Smoking cessation, caffeine intake or withdrawal Losses –Role changes –Mobility/ability Uncertain future –Hospitalizations –Risk of sudden death Concerns –Family –Finances

55 Simple Screening “During the past 4 weeks have you been bothered by feeling anxious or worried most of the time?”

56 Anxiety Screening Tools MR FISC –Motor tension, Restlessness, Fatigue, Irritability, Sleep and Concentration impairments Burke & Wright 2007 Anxiety disorders and medical comorbidities. NY: Jobson Medical Information. State-Trait Anxiety Inventory General Anxiety Disorder- 7 Spritzer Arch Int Med 2006;166:1092-1097 Beck Anxiety Inventory Hospital Anxiety and Depression Scale

57 Factors Affecting Adjustment Symptom control Attitude and coping skills Social support

58 Psychotherapy Cognitive behavior therapy and relaxation showed up to 60% post- treatment recover at 6 months compared with 4% for analytical psychotherapy Fisher et al (1999) Psychol Med;29:1425-1434

59 Pharmacology FDA approved drugs for GAD –Buspirone –Benzodiazepines (situational, short-term) Alprazolam Diazepam Midazolam –Selective Serotonin Uptake Inhibitors (SSRI) Paroxetine Escitalopram –Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) Venlafaxine

60 Depression Decreased concentration Energy loss/fatigue Pleasure loss (ahedonia) Recurrent thoughts of death Expressions of sadness, worthlessness, suicide Sleep disturbances Significant weight loss

61 Heart failure and depression Reported prevalence ranges from 17-58% \ Artininan (2003) AJN; 103(12): 32-42) Depression is correlated with inability to adjust to decreased functional status Turvey et al (2006) J CV Nsg; 21(3):178-185) When severity of depression is controlled for, patients taking antidepressants had a greater incidence of death and hospitalization for cardiovascular events. –Association was independent of the severity of failure –An independent relationship was not established Sherwood A, et al. (2007) Arch Intern Med; 167(4):367–73.

62 “Are you depressed” Best sensitivity Best specificity Best predictive value Can further clarify using 0-10 scale. –Scores >5 should be assessed by a specialist Lloyd-Williams M et al (2003). Pall Med (17(1):40-43

63 Screening Tools Beck Depression Inventory Beck A & Steer R(1987) San Antonio TX: The Psychological Corp Hospital Anxiety and Depression Scale Zabora JR (1998). Psycho-oncology. NE: Oxford University Press Geriatric Depression Scale Koenig H et al (l988). Am Geriatr Soc;36: 699-706.

64 Pharmacologic Management Selective Serotonin Reuptake Inhibitors (SSRI) –Citalopram (Celexa), fluoxetine (Prozac), fuvoxamine (Luvox),paroxetine (Paxil), sertraline (Zoloft) Little/No anticholinergic effects Low risk of conduction abnormalities No orthostatic hypotension Very little/no sedation Low seizure risk

65 Psycho-stimulants May be useful for immediate feelings of enhanced mood, decreased fatigue and increased appetite Dextroamphetamine 2.5-5mg daily or methylphenidate 2.5 mg am and noon Side effects: tremor, tachycardia, psychoses at higher doses Esper in Kuebler et al (2007) Palliative and End of Life Care. Phil, PA: Saunders

66 Fatigue and Activity Intolerance Up to 80% May be associated with: –Activity intolerance –Malaise –Weakness –Loss of strength –Loss of energy Impacts quality of life

67 Fatigue Measurements Fatigue Symptom Inventory Hann 1998 –Severity, frequency, interference, occurrence Multidimentional Fatigue and Symptom Scale Stein l998 –General, physical, emotional, mental and vigor Revised Piper Fatigue Scale Piper l998 –Behavioral, severity, meaning, sensory, cognition and mood Jacobsen P (2004). J Natl Cancer Inst Mono; 32; 94

68 Interventions Activity records/energy conservation Sleep habits –Mid day 30 minute naps –No evening naps –Stimulus reduction Medication review Anxiety and depression management Transfusions/erythropoetin production Exercise Davidson et al (2001) Psycho-oncology 10(5):389-397

69 Think outside the box!

70 Pet Therapy Heart failure patients visited by volunteer-dog team for 12 minutes demonstrated significantly greater decreases in: –Pulmonary artery systolic pressure –Wedge pressure –Serum epinephrine and nor-epinephrine levels –State anxiety scores compared to patients who received no visit or a visit by a volunteer only –Cole et al. (2007)AJCC;16(6):575-588.

71 Tai Chi Heart failure patients who participated in supervised Tai Chi classes in addition to usual care demonstrated significantly increased quality of life and distance walked compared to patients who received usual care. No increases in peak oxygen uptake or adverse outcomes were reported. Yeh et al (2004) Am J Med;117:541-548.

72 Massage Systematic review of 20 studies showed massage decreased: –Anxiety –Depression –Pain –Corisol –Catecholamines –Heart rate, blood pressure and respiratory rate Field T. (1998) Am Psychol;53:1270-1281

73 Biofeedback Randomized controlled trial of 90 HF patients using biofeedback for 6 weeks along with standard care. Patients in the intervention group demonstrated: –45% decrease in anxiety –25% decrease in depression Moser D, et al (1999) Circulation;100:I-99.

74 Relaxation Guided progressive relaxation reduced dyspnea in end stage pulmonary disease Gift AG et al (1992). Nurs Res; 41(4):242-246. Renfroe KL (1988) Heart Lung; 41(4): 408-413. ACCP (2010) Chest; 137(3): 674-691

75 Continuum of Care Office Community In Patient Out Patient Home Care Hospice

76 End of Life Care Refractory dyspnea Terminal pulmonary congestion Terminal delirium Cardiac cachexia and anorexia Inactivation of devices

77 Hospice Care Palliative care in the last 6 months of life –NYHA III or IV –EF < 20% –Intractable or frequent, recurrent symptoms despite medical optimization –Other Symptomatic arrhythmias, History of arrest Cardiogenic brain embolism


79 –Anytime during the illness –May include curative therapies –Most often a consult service –Reimbursed as any other consult –Usually ends with discharge –6 month prognosis –Services covered by Medicare and most 3 rd party payers— excluding room/board –Therapies for comfort and quality of life including medications –Admission to service –13 mo. Bereavement support National Consensus Project for Quality Palliative Care 2005

80 HF and Hospice HF primary diagnosis for approximately 9% of patients Mean LOS 60 days (national overall 51.3 days) Expense of some therapies may preclude use of hospice if hospice was expected to pay for these Goodlin et al (2005)J Pain Symp Manage;;29(5):525-528

81 HF Survival and Hospice Study of 4493 Medicare recipients Hospice vs non hospice Hospice patients with heart failure, lung CA, pancreatic CA and colon CA had statistically significant longer life compared to non- hospice patients No statistically significant difference for breast and prostate CA Connor, S et al (2007)Journal of Pain & Symptom Management. 33(3):238-46.

82 Information Resources Michigan Hospice and Palliative Care Organization – Local hospice and palliative care services Get Palliative Care –www. National Hospice and Palliative Care Organization –

83 Palliative Care can be … “It’s not about death, it’s really about living with a disease…. Joanne Lynn MD SUPPORT Primary Investigator

84 Like a bridge over troubled waters

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