the palliation of end-stage heart disease dr. jana pilkey md, frcp(c) internal medicine, palliative...
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The Palliation of End-Stage The Palliation of End-Stage Heart DiseaseHeart Disease
Dr. Jana Pilkey MD, FRCP(C)
Internal Medicine, Palliative Medicine
April 30, 2009
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“It is easier to die of Cancer than Heart or Renal failure” John Hinton (Medical Attending Physician) 1963
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ObjectivesObjectives
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 CHFTo discuss prognostication in CHF
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Heart FailureHeart Failure
The inability of heart to meet the metabolic demands of the body
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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
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Clinical FeaturesClinical Features
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Clinical FeaturesClinical Features
– 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
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Clinical FeaturesClinical Features
Differences From Cancer– More edema– Predicting death more
difficult– Mistaken belief condition
more benign than cancer– No local pressure effects– Less anemia
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Comparison Between Comparison Between Terminal IllnessesTerminal Illnesses
Symptom Cancer AIDS HD COPD RD
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% 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)
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Terminal CHFTerminal 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%
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(Janssen, Pall Med, 2008)
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Experience of PatientsExperience 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)
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Experience of PatientsExperience 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”
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Classic Pharmacologic Classic Pharmacologic ManagementManagement
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
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Pharmacologic ManagementPharmacologic Management
Drug NYHA 1 NYHA 2 NYHA 3 NYHA 4 Survival Hospital
Admits
Functional Status
Diuretic X
ACE-I
Spirono-lactone
X X
B-blocker
X
Digoxin X
Oxford 2002
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Symptom Oriented PalliationSymptom 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
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Symptom Oriented PalliationSymptom Oriented Palliation
How to Manage Dyspnea?– Oxygen– CHF medications– Opioids – Other
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Symptom Oriented PalliationSymptom Oriented Palliation
Depression and Anxiety– Regular assessment– Exercise program– Relaxation exercises– Antidepressants – Consider nocturnal opioid +/-
benzodiazipine
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Issues in Palliative CareIssues in Palliative CareLack support networks & communicationPrognostication difficultDNR difficult issue
– Written on 5% (47% in Ca, 52% in AIDS)– Wanted by pt in 23% – 40% rescind (Gibbs 2002)
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Issues in Palliative CareIssues 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)
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Implantable Cardioverter Implantable Cardioverter Defibrillators and PacemakersDefibrillators 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
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PrognosticationPrognostication
NYHA Class 1 Year Mortality
I 5-10%
II-III 15-30%
IV 50-60%
Median survival 16 months from first hospitalization
Median survival all patients: 2 Years !!(Hanratty 2002)
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Case StudyCase Study90 y.o. female admitted for CHF and COPD
with chest pain and dyspneaHr 98, rr 28, bp 96/64Na 134, K 4.7, Creat 130, Urea 24Hgb 110EF 18%
Prognosis??
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CHF Risk Model (Canadian Cardiovascualr Outcomes Research Team, JAMA
2003)www.ccort.ca/CHFriskmodel.aspAge (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
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30-Day Score 30-Day Mortality Rate
(%)
60 0.4
61-90 3.4
91-120 12.2
121-150 32.7
>150 59.0
One-Year Score
One-Year Mortality Rate
(%)
60 7.8
61-90 12.9
91-120 32.5
121-150 59.3
>150 78.8
CHF Risk Model
Our patient has a score of 127
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When Should I Refer?When Should I Refer?
Prognosis < 6 monthsDifficulty controlling symptomsActively dyingCall anytime with questionsVirtual Hospice
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http://virtualhospice.ca
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SummarySummary
CHF has a very poor prognosisCHF greatly affects quality of lifeUse CHF & other meds for symptom controlDiscuss prognosis earlyConsider prognostic models
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ReferencesReferences 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.
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ReferencesReferencesZambroski, 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.