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Disease Management, Advance

Directives, and End-of-Life Care

in Heart Failure

HFSA 2010 Recommendations


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Lindenfeld J, et al. HFSA 2010 Comprehensive

Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

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HFSA 2010 Practice GuidelinePatient Education

Recommendation 8.1 (1 of 2)

It is recommendedthat patients with HF and their familymembers or caregivers receive individualized education

and counseling that emphasizes self-care.

This education and counseling should be delivered byproviders using a team approach in which nurses withexpertise in HF management provide the majority ofeducation and counseling, supplemented by physician

input and, when available and needed, input from dietitians,pharmacists and other health care providers.

Streng th o f Evidence = B


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Teaching is not sufficient without skill

building and specification of critical target

behaviors. Essential elements of patient

education to promote self-care with

associated skills are shown in Table 8.1



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HFSA 2010 Practice GuidelineTable 8.1 Elements of Patient Education

Element Skills and Target Behaviors

Definition of HF and cause

of patients HF

Discuss basic HF information,

cause of patients HF, and how

symptoms relate to HF status

Recognition of escalating

symptoms and concrete

plan for response to

particular symptoms

Identify specific signs and

symptoms (e.g. increasing

fatigue or shortness of breath,

edema, increasing fatigue)

Perform daily weights and know

how to respond to evidence ofvolume overload

Develop action plan for

notifying provider, changing diet,

fluid and diuretics


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Indications and use of each

medication

Reiterate dosing schedule, basic

reason for specific medications,

what to do if a dose is missed

Modify risks for HF

progression

Initiate smoking cessation

Maintain BP in target range

Maintain normal HgA1c if diabetic

Maintain specific body weight

Specific activity/exercise

recommendations

Comply with prescribed exercise


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Specific diet, sodium,

and alcohol

recommendations

Understand and comply with

sodium restriction

Demonstrate ability to read foodlabel for sodium per serving and

sort into high- and low-sodium

Reiterate limits for alcohol

consumption or abstinence if

history of abuse

Treatment adherence Plan and use a medication systemthat promotes adherence

Plan for refills


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Recommendat ion 8.2

It is recommendedthat patients literacy, cognitive status,psychological state, culture, and access to social andfinancial resources be taken into account for optimal

education and counseling.

Because cognitive impairment and depression are commonin HF and can seriously interfere with learning, patientsshould be screened for these.

Patients found to be cognitively impaired need additionalsupport to manage their HF.

Strength of Evidence = B


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Recommendat ion 8.3

It is recommendedthat educational sessions begin with anassessment of:

Current HF knowledge

Issues about which the patient wants to learn

The patients perceived barriers to change.

Address specific issues and their causes

eg, medication non-adherance and whether it is due to a lack ofknowledge, cost, forgetting, or some other cause

Employ strategies that promote behavior change, includingmotivational approaches. Strength of Evidence = B


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Recomm endat ion 8.4

It is recommendedthat the frequency and intensity of patient educationand counseling vary according to the stage of illness. Patients inadvanced HF or with persistent difficulty adhering to the recommendedregimen require the most education and counseling.

Patients should be offered a variety of options for learning about HFaccording to their individual preferences:

videotape

one-on-one or group discussion

reading materials, translators, telephone calls, mailed information

Internet

visits

Repeated exposure to material is essential because a single session isnever sufficient.

Streng th of Evidenc e = B


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Recommendat ion 8.5

It is recommendedthat during the care process patients be asked to:

Demonstrate knowledge of the name, dose, and purpose of eachmedication

Sort foods into high and low sodium categories

Demonstrate their preferred method for tracking medicationdosing

Show provider daily weight log

Reiterate symptoms of worsening HF

Reiterate when to call the provider because of specific symptomsor weight changes



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Recommendat ion 8.6

During acute care hospitalization, only essential educationis recommended, with the goal of assisting patients tounderstand:

Heart failure

The goals of its treatment

Post-hospitalization medication and follow up regimen.

Education begun during hospitalization should be:

Supplemented and reinforced within 1-2 weeks after discharge Continued for 3-6 months

Reassessed periodically



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HFSA 2010 Practice GuidelineDisease Management

Modifiable Factors Leading to HospitalReadmissions for HF (1 of 2)

Inadequate patient and family or caregiver education andcounseling

Poor communication and coordination of care amonghealth care providers

Inadequate discharge planning

Failure to organize adequate follow-up care

Clinician failure to emphasize non-pharmacologic aspectsof HF care, such as dietary, activity and symptommonitoring recommendations


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Modifiable Factors Leading to HospitalReadmissions for HF (2 of 2)

Failure to address the multiple and complex medical, behavioral,psychosocial, environmental and financial issues that complicatecare, such as:

older age presence of multiple co-morbidities

lack of social support or social isolation

failure of existing social support systems

functional or cognitive impairments

poverty

presence of anxiety or depression

Failure of clinicians to use evidence-based practice and followpublished guidelines in the prescription of pharmacologic andnon-pharmacologic therapy


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Recommendat ion 8.7

Patients recently hospitalized for HF and other patients athigh risk should be consideredfor referral to acomprehensive HF disease management program that

delivers individualized care.

High risk patients include those with renal insufficiency,low output state, diabetes, COPD, persistent NYHA class IIIor IV symptoms, frequent hospitalization for any cause,multiple active co-morbidities, or a history of depression,cognitive impairment, inadequate social support, poorhealth literacy, or persistent nonadherence to therapeuticregimens.

Streng th of Evidence = A


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It is recommendedthat HF diseasemanagement programs include the following

components based on patient characteristicsand needs.

Comprehensive education and counseling individualizedto patient needs

Promotion of self care, including self-adjustment ofdiuretic therapy in appropriate patients (or with familymember/caregiver assistance)

Emphasis on behavioral strategies to increase adherence



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Recommendation 8.8 (2of 2)

It is recommendedthat HF disease management programsinclude the following components based on patientcharacteristics and needs.

Vigilant follow-up after hospital discharge or after periodsof instability

Optimization of medical therapy

Increased access to providers

Early attention to signs and symptoms of fluid overload

Assistance with social and financial concerns



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Recommendation 8.9

It is recommendedthat HF disease

management include integration andcoordination of care between the primary

care physician and HF care specialists

and with other agencies, such as home

health and cardiac rehabilitation.Streng th of Evidence = C


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Recommendat ion 8.10

It is recommendedthat patients in a HF disease managementprogram be followed until they or their family/caregiverdemonstrate:

Independence in following the prescribed treatment plan

Adequate or improved adherence to treatment guidelines

Improved functional capacity and symptom stability.

Higher risk patients with more advanced HF may need to befollowed permanently.

Patients who experience increasing episodes of exacerbations orwho demonstrate instability after discharge from a programshould be referred again to the service.



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HFSA 2010 Practice GuidelineQuality of Life Discussions

Recommendation 8.11

It is recommendedthat patient and familyor caregiver discussions about quality of

life and prognosis be included in the

disease management of HF.

Streng th of Evidence = C


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HFSA 2010 Practice GuidelineEnd-of-Life Care

Recommendation 8.12

It is recommendedthat:

Seriously ill patients with HF and their families be educated to understandthat patients with HF are at high risk of death, even while aggressive effortsare made to prolong life.

Patients with HF be made aware that HF is potentially life-limiting, but thatpharmacologic and device therapies and self-management can prolong life. Inmost cases, chronic HF pharmacologic and device therapies should beoptimized as indicated before identifying that patients are near end-of-life.

Identification of end-of-life in a patientshould be made in collaboration withclinicians experienced in the care of patients with HF when possible.

End-of-life management should be coordinated with the patient's primarycare physician.

As often as possible, discussions regarding end-of-life care should beinitiated while the patient is still capable of participating in decision-making.

Strength of Evidence = C


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Recommendation 8.13

End-of-life care should be consideredin patients who haveadvanced, persistent HF with symptoms at rest despiterepeated attempts to optimize pharmacologic, cardiac device,

and other therapies, as evidenced by one or more of thefollowing:

HF hospitalization Streng th o f Evidence = B

Chronic poor quality of life with minimal or no ability to

accomplish activities of daily livingStreng th o f Evidence = C

Need for continuous intravenous inotropic therapysupport Streng th o f Evidence = B


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Recommendation 8.14

It is recommendedthat end-of-life carestrategies:

Be individualized

Include core HF pharmacologic therapies, effectivesymptom management, and comfort measures

Avoid unnecessary testing

New life-prolonging interventions should be discussed withpatients and caregivers with careful discussion of whether

they are likely to improve symptoms

Streng th o f Evidence = C


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HFSA 2010 Practice GuidelineEnd of Life CareResuscitation and SCD

Recommendat ion 8.15

It is recommendedthat a specific discussion about resuscitationbe held in the context of planning for overall care and foremergencies with all patients with HF.

The possibility of SCD for patients with HF should beacknowledged. Specific plans to reduce SCD (for example withan ICD) or to allow natural death should be based on theindividual patients risks and preferences for an attempt atresuscitation with specific discussion of risks and benefits ofinactivation the ICD.

Preferences for attempts at resuscitation and plans for approachto care should be readdressed at turning points in the patientscourse or if potentially life-prolonging interventions areconsidered.

Streng th o f Evidence = C


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Recommendation 8.16(NEW in 2010)

It is recommendedthat, as part of end-of-life care,patients and their families/caregivers have a plan to

manage a sudden decompensation, death, orprogressive decline.

Inactivation of an implantable defibrillation deviceshould be discussed in the context of allowing

natural death at end of life. A process fordeactivating defibrillators should be clarified in allsettings in which patients with HF receive care.

Streng th of Evidence = C


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HFSA 2010 Practice GuidelineTable 8.4 Legal Advance Directives (NEW in 2010)

Living WillDurable Power of Attorney

for Health Care (DPOA/HC)

Uses standard language in the

patients state of residence,

identifying whether specific orgeneral life-prolonging

interventions should be initiated

or continued in the face of

imminent death.

Some states require 2 MDs to

certify that that patient has a

terminal illness.

Designates one or more individuals

to make health care decisions on

behalf of the person at a future timeif the person is unable to speak

independently.

Does not typically identify specific

interventions, patients should be

encouraged to make their proxy

aware of generally preferred

approaches to care.

Patients with HF should be

encouraged to appoint a DPOA/HC.


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Recommendation 8.17

Patients with HF undergoing end-of-life

care should be consideredfor hospice

services that can be delivered in the

home, a hospital setting or a special

hospice unit.Streng th o f Evidence = C

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