a palliative care approach for people with advanced heart ... · 7 national and international...
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A palliative care approach for people with advanced
heart failure
Dr Amy Gadoud
NIHR Clinical Lecturer Hull York Medical School
@agadoud
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Palliative Care Team Winner
The Last Year of Life Project - BAWC
Palliative Care Managed Clinical Network
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Background
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“More
malignant
than
cancer”
Stewart et al. EJHF. 2001:3(3):315-22
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National and international consensus
guidelines recommend a palliative care
approach in heart failure
Current UK policy recommends
identification of those requiring palliative
care based on prognosis (last year of life)
Whellan et al. Journal of cardiac failure. 2014;20(2):121-34.
Jaarsma et al. European Journal of Heart Failure. 2009;11(5):433-43.
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Heart failure has an unpredictable course
and clinicians may not discuss a palliative
care approach for fear of causing alarm and
destroying hope “prognostic paralysis”
Murray, S. A., Boyd, K., & Sheikh, A. (2005). Palliative care in chronic
illness: We need to move from prognostic paralysis to active total
care. BMJ : British Medical Journal, 330(7492), 611–612.
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A palliative care approach for people with advanced heart failure
Prognostic variables associated with last year of life
Study methodsStudy methods
Perceptions of patients, carers and
clinicians
Findings Findings
Synthesis
Clinical recommendations
Recognition compared with cancer patients
Study methods
Findings
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Explore aspects of a palliative care
approach for people with advanced heart
failure: recognition of need, transitions in
care and impact on patients, family carers
and clinicians
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A palliative care approach for people with advanced heart failure
Prognostic variables associated with last year of life
Study methodsStudy methods
Perceptions of patients, carers and
clinicians
Findings Findings
Synthesis
Clinical recommendations
Recognition compared with cancer patients
Study methods
Findings
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Systematic literature review
32 articles included
Predictors were explored in a single or only a
few studies, often in restricted populations
Gold Standards Framework Prognostic
Indicator Guide
Clinical usefulness?
Prognostic markers of the last
year of life
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A palliative care approach for people with advanced heart failure
Prognostic variables associated with last year of life
Study methodsStudy methods
Perceptions of patients, carers and
clinicians
Findings Findings
Synthesis
Clinical recommendations
Recognition compared with cancer patients
Study methods
Findings
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Secondary analysis of contemporaneously
collected UK primary care records using
Clinical Practice Research Datalink
Used Quality and Outcomes Framework codes
for palliative care registration as a proxy of
recognition of the need for a palliative care
approach
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Heart failure decedents in 2009 were poorly
represented on the palliative care register; 7%
(234/3122), compared to 48% (3669/7608) of
cancer patients
Palliative-registered heart failure patients were
more likely to be entered close to death
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Time from first time coded as on a palliative care
register to date of death for each disease group
05
10
15
20
25
30
35
<=
1 w
ee
k
-6 w
ee
ks
-6 m
on
ths
-1 y
ea
r
-2 y
ea
rs
-5 y
ea
rs
>5
ye
ars
<=
1 w
ee
k
-6 w
ee
ks
-6 m
on
ths
-1 y
ea
r
-2 y
ea
rs
-5 y
ea
rs
>5
ye
ars
A Palliative care register & cancer only (n=3 692) B Palliative care register & heart failure only (n=233)
Pe
rce
nt
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First use of CPRD, worlds largest primary care
database to explore palliative care
Able to link to other databases e.g. Hospital
Episode Statistics (HES)
Potential to look at other conditions
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A palliative care approach for people with advanced heart failure
Prognostic variables associated with last year of life
Study methodsStudy methods
Perceptions of patients, carers and
clinicians
Findings Findings
Synthesis
Clinical recommendations
Recognition compared with cancer patients
Study methods
Findings
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Explore perceptions of patients, carers and
health care professionals regarding the
transition to a palliative care approach in heart
failure
Qualitative semi-structured interviews with 19
patients receiving a palliative approach to care,
with their carers, and with clinicians
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Coping e.g. humour, stoicism, counting blessing,
family support, life experiences, belief systems
Symptoms variety and distress
Social isolation and reducing social world
Not so evident in clinician interviews, symptom
(need based recognition), literature on hope
humour maintain person hood, services such as
day hospice for social isolation
Coping and symptoms
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Patient and carers quickly and readily talked
about their deteriorating health dying and death
and in detail
Clinicians very concerned to bring up
conversation
Key finding: looked at deviant cases (“duty of
doctor”)
Communication and
understanding
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Variable disease trajectory discussed by both
groups
Patient often “palliative” for long periods
(sampling strategy)
Clinicians concerned about getting timing right
(when irreversibly physically deteriorating)
Patients more accepting of uncertainty and
positive at times “got to see my grandson”
Recognition of palliative
phase
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Explored each dyad/ triad recognition could be
patient initiated
Just needs decision to be made, no dissent in
team
Leads to consequences such as access to
services
Decision making and
consequences
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The noise started in the hospital at half past six on a
morning, early morning shift of nurses coming in and
doing those who had messed the beds, you know. But
it was the noise that they made doing it and the lights
are all on, and that was still happening at half past
eleven at night. I said “When do I get any sleep?” So
eventually I grabbed the doctor and said “I must go
out. If I’m going to die I’ll die in bed at home, not here.
It’s too noisy, wouldn’t be able to die for people
making a noise.”(Patient 7)
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Patient: I’m planning ahead for the future because I
know what’s going to happen and I want to be
prepared for it. I don’t want to leave [wife] with a, a
lot of odds and ends to tie up. They’ll all be ready and
in place.
Wife: He still hasn’t got, shown me how to do the
television yet [laughs] so he can’t go yet.
Patient: Well SON will show you how to do that.
(Patient 13)
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More from clinicians than patients
Fluidity of teams, different roles in each patient
May never meet, communication often on need/task
basis
Seem to respect each others input
No clear responsibility, who initiates conversations
Different approach proactive v reactive; regular
visits v patient initiated
Also comorbidity, specialism and complex balance
of treatments
Team roles
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Clinicians’ fears about initiation of difficult
conversations were unfounded in this group
The approach to care was felt to be beneficial
even in those who stabilised or improved
Uncertainty should not prevent exploration of
patients’ wishes about the focus of their care
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Synthesis
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A palliative care approach before the very end
of life is beneficial in this group
A problem based flexible approach to
recognising the need for palliative care rather
than prognosis is recommended
Focus less on predicting when patients will die
but more on palliative care assessment of needs
and future aims of care
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Future research
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Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.
Developing and evaluating complex interventions: the new Medical
Research Council guidance. BMJ : British Medical Journal. 2008;337:
a1655. doi:10.1136/bmj.a1655.
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Higginson et al. BMC Medicine 2013 11:111 doi:10.1186/1741-7015-11-111
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Antoine de Saint-Expury: ‘if you want to build a ship,
don’t drum up people together to collect wood and
don’t assign them tasks and work, but rather teach
them to long for the endless immensity of the sea’
Fenning SJ. Why identify 'end-of-life'
in palliative care? BMJ Supportive &
Palliative Care 2013;4(1):6-6.
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Patient, carer and health care professional participants
Supervisors: Prof Miriam Johnson, Prof Una Macleod and
Dr Pat Ansell
Dr Eleanor Kane Department of Epidemiology
University of York
PhD Funding: Clinical Fellowship: Hull York Medical
School and data obtained under Medical Research
Council initiative with GPRD, Association of Palliative
Medicine for transcription costs
Current funding: NIHR and Academy of Medical
Sciences
Acknowledgements and
grateful thanks..
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Gadoud A, Kane E, Macleod U, Ansell P, Oliver S, Johnson M. Palliative Care among
Heart Failure Patients in Primary Care: A Comparison to Cancer Patients Using
English Family Practice Data. PLoS One. 2014;9(11):e113188
Gadoud AC, Johnson MJ. Response: what tools are available to identify patients with
palliative care needs in primary care: a systematic literature review and survey of
European practice? BMJ Supportive & Palliative Care. 2014;4(2):130.
Gadoud A, Johnson M. What palliative care clinicians need to know about heart
failure? Progress in Palliative Care. 2014; 22(1):26-31.
Gadoud A, Macleod U, Kane E, Ansell P, Johnson M. A palliative care approach for
people with advanced heart failure: recognition of need, transitions in care, and
effect on patients, family carers, and clinicians. The Lancet. 2014; 383:S50.
Gadoud A, Jenkins SM, Hogg KJ. Palliative care for people with heart failure:
Summary of current evidence and future direction. Palliative Medicine. 2013;
27(9):822-8.
Johnson MJ, Gadoud A. Palliative care for people with chronic heart failure: when is it
time? Journal of Palliative Care. 2011; 27(1):37-42.
References
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Thank you Any questions or comments?
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