1. Dr Dylan Harris Dr Mel Jefferson
Heart Failure and Palliative Care: An audit of a hospital palliative care teams’ involvement with end stage heart failure patients
Dr Dylan Harris
Dr Mel Jefferson
Hospital Palliative Care Team
Department of Palliative Medicine
University Hospital of Wales

2. Heart Failure: facts and figures
◆ Definition
-“Inability of the heart to keep up with the demands on it”

3. Heart Failure: facts and figures
◆ Definition
-“Inability of the heart to keep up with the demands on it”
♦ Incidence/Prevalence
- Population prevalence 1 to 3%, 10% in very elderly.
- Incidence & prevalence increase dramatically over the age 75 years
- Number of patients with CHF will increase rapidly because:
(a) increase in survival after acute myocardial infarction
(b) ageing of the population
(c) advances in medical device treatments

4. Heart Failure: facts and figures
◆ Definition
-“Inability of the heart to keep up with the demands on it”
♦ Incidence/Prevalence
- Population prevalence 1 to 3%, 10% in very elderly.
- Incidence & prevalence increase dramatically over the age 75 years
- Number of patients with CHF will increase rapidly because:
(a) increase in survival after acute myocardial infarction
(b) ageing of the population
(c) advances in medical device treatments
◆ Prognosis
- After first admission for heart failure 5-yr mortality= 75%
- 40% die within 1 year of diagnosis
- 50% die suddenly

5. NYHA Classification of Heart Failure
Class I: asymptomatic No limitation in physical activity despite presence of heart disease.
Class II: mild Slight limitation in physical activity. More strenuous activity causes shortness of breath - for example, walking on steep inclines and several flights of steps. Patients in this group can continue to have an almost normal lifestyle and employment
Class III: moderate More marked limitation of activity which interferes with work. Walking on the flat produces symptoms
Class IV: severe Unable to carry out any physical activity without symptoms. Patients are breathless at rest and mostly housebound

6. NYHA Classification of Heart Failure
Class I: asymptomatic No limitation in physical activity despite presence of heart disease.
MORTALITY
20% at 5 years
Class II: mild Slight limitation in physical activity. More strenuous activity causes shortness of breath - for example, walking on steep inclines and several flights of steps. Patients in this group can continue to have an almost normal lifestyle and employment
3-25% / year
Class III: moderate More marked limitation of activity which interferes with work. Walking on the flat produces symptoms
10-45% / year
Class IV: severe Unable to carry out any physical activity without symptoms. Patients are breathless at rest and mostly housebound
40-50% / year

7. mid-1990's, England and Wales
One-year survival rates, heart failure and major cancers compared,
mid-1990's, England and Wales
ONS (2001); Cowie MR et al (2000) Heart 83:

8. Heart Failure: disease trajectory

9. Heart Failure: Palliative Care Needs
Murray SA, Boyd K, Kendall M et al. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ 2002;325:929-

10. Heart Failure: Palliative Care Needs

11. Audit Standard

12. Audit Standard “practices and hospitals should audit ….
(1) The number and percentage of people with heart failure for whom specialist palliative care advice has been sought …..
(2) The access to palliative care support …..
(3) When the aim of treatment is to control symptoms a palliative approach … good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”

13. Audit Type Audit Period Patient Identification
Retrospective Case Note Audit (Medical notes and palliative care notes)
Audit Period
April 2005-April 2007
Patient Identification
Patients from ISCO Database with diagnosis “heart failure”

14. Audit Criteria
(1) The number and percentage of people with heart failure for whom specialist palliative care advice has been sought …..

15. Patients identified from ISCO = 21
The number and percentage of people with heart failure for whom specialist palliative care advice has been sought …..
Patients identified from ISCO = 21
(April 2005-April 2007)
Patients audited = 18
(2 not heart failure, 1 no notes)
% of patients ??
? % admissions
? % heart failure deaths
? % admissions with stage III/IV heart failure

16. Audit: Patient characteristics
Age:
53-95 years
mean 76.1 years
Sex:
10 (56%) male
8 (44%) female
NYHA:
Class III: 4 (22%)
Class IV: 14 (78%)

17. Audit Criteria (2) “The access to palliative care support ….”
-Are heart failure referrals accepted (and what are they referred for) ?
-How long does to take for patients to be seen by the palliative care team ?

18. “The access to palliative care support ….”
Heart failure referrals accepted: yes
Time to generate referral
unclear: 7 patients (39%)
same day: 7 patients (39%)
1 day: 3 patients (16%)
3 days: 1 patient (6%)
Time from referral to assessment
0 (same day): 15 patients (83%)
1 day: 2 patient (11%)
2 day: 1 patient (6%)

19. “The access to palliative care support ….”
Reason for referral
Symptom management 13 patients (72%)
Support (24%)
Discharge (17%)
Unclear (17%)

20. Audit Criteria
(3) “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”
- What symptoms do patients have and how many ?
- What interventions do we suggest ?
- Is there any evidence they help ?

21. “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”
SYMPTOM
% PATIENTS
Breathlessness
89%
Pain
44%
Anxiety
72%
Nausea/vomiting
28%
Chest secretions
17%
Constipation
11%
Oedema
Fatigue 6%
Anorexia
Mouth
Family anxiety/support
56%

22. “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”

23. 1 symptom 0 patients 2 symptoms 7 patients (39%)
“good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”
1 symptom 0 patients
2 symptoms 7 patients (39%)
3 symptoms 6 patients (33%)
4 or more 5 patients (28%)

24. Support for patient and their family/carer Breathlessness
“good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”
Interventions
Support for patient and their family/carer
Breathlessness
Opiate po or sc (75% patients)
Benzodiazpeines if anxiety factor (100%)
Nausea/vomiting: anti-emetic depending on mechanism
Constipation: laxative
Anxiety: benzodiazepines, haloperidol, levomepromazine
Chest secretions: hyosine

25. Benefit for our suggested interventions
How to measure ?
“still breathless but not troubled by it so much”
“does not feel as anxious as he did yesterday”
“no pain”
“appears comfortable, no longer grimacing”
Little variation in other variables/intervention

26. % PATIENTS BENEFIT FROM INTERVENTION*
“good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”
SYMPTOM
% PATIENTS BENEFIT FROM INTERVENTION*
Breathlessness
56%
Pain
75%
Anxiety
54%
Nausea/vomiting
80%
Chest secretions
33%
Constipation 0%
Oedema
Fatigue
Anorexia
Mouth
*absence of evidence rather than evidence of absence

27. Length of interaction: 1-30 days (mean 5.7 days)
Outcomes
RIP: 13 patients (72%)
Home: 3 patients (17%)
Other: 2 patients (11%)
Length of interaction: 1-30 days (mean 5.7 days)
Patients referred for discharge and got home= 2/3 (1 RIP)

28. Conclusions 83% referrals seen the same day
Given the prevalence of symptomatic heart failure inpatients referral rate seems low
Polysymptomatic patients:
>60% have 3 or more symptoms
Large need for family support
Palliative care interventions seem to help
Difficult to measure objectively.
More accurate documentation of symptom response would be useful e.g. ESTAS

29. Conclusions Which patients should be seen?
Palliative Medicine 2006;20:
Palliative Medicine 2007;21:

30. Future directions
- Collaborative working between palliative care and heart failure services
- Various approaches, dependent on
(1) local expertise of the HF team
(2) and their interest/enthusiasm to engage with palliative care
Locally:
-open referral policy
-easy access for advice
-collaborative working with interested and palliative care “friendly” cardiologist and geriatrician
-heart failure MDT attended by a member of the palliative care team