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Devon Neale Geriatrics and Palliative Medicine UNM SOM

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Objectives To review the differences between hospice and palliative care services To discuss the management of symptoms commonly experienced by heart failure patients at end of life To address important issues in advance care planning for patients with heart failure

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Hospice care vs. Palliative care Hospice: A health care benefit Medicare benefit (Part A) since 1983; many private insurances have a hospice benefit Two MDs certify prognosis < 6 months if disease runs its usual course Focus is on comfort and relief of suffering, not life prolongation Interdisciplinary team provides care It is not a place; primarily home-based

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The Old Model of Palliative Care Medicare Hospice Benefit Life Prolonging Care

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What is Palliative Care? Palliative care as defined by WHO: An approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through prevention of and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual www.capc.org

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Hospice care vs. Palliative care Palliative care Can be provided in conjunction with life prolonging treatment (no need to choose between treatment plans) Does not take the place of curative care! No prognostic requirement; no age requirement; not limited to any specific diagnosis; not just actively dying Primarily hospital-based The goal is not to hasten nor prolong death

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New Model of Palliative Care Palliative Care Bereavement Hospice Care Life Prolonging Care

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Why is PC important in the management of HF? HF is very common: #1 cause hospitalizations in Medicare population A leading cause of death in US High symptom burden: Pain, dyspnea, fatigue, edema, depression Physical function scores 2SD below average Symptoms are treatable

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Palliative Care in HF Management In general, PC has been demonstrated to improve patient outcomes: Symptom management Quality of life Satisfaction with care palliative care can be integrated with conventional HF care that emphasizes life-prolonging treatment. This duality of care should be considered a normal approach to patients with HF* *Hauptman and Havranek, Arch Intern Med 2005

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Key elements of PC for HF Discussing prognosis and treatment options Eliciting patients goals of care Supporting advance care planning Team-based approach to symptom management Physical Psychological Emotional Spiritual Existential Caregiver support

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Cardiac Medications As indicated: Ace-inhibitor Beta-blocker Diuretic Spironolactone ALLEVIATE SYMPTOMS AND IMPROVE QoL

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Prognostication in HF Very difficult: we are unable to predict timing of exacerbations or sudden cardiac death (up to 50% of patients) In general, clinicians tend to overestimate life expectancy (by a factor of 5.3)* Increased duration of patient-physician relationship, less accurate prognostication *Christakis and Lamont, BMJ 2000

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Why is prognostication important?

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Allows patients to: Identify priorities based on life expectancy Make informed decisions about their care Complete advance directives and designate a PoA Attend to legal and financial matters Focus on life closure and legacy issues Emphasize participation in pleasurable activities

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General Statistics New diagnosis of HF in the community:* 1yr mortality: 24% 2yr mortality: 37% 6yr mortality: 75% 50% of HF patients die within 5yrs of diagnosis One-year mortality after first HF admission in elderly patient with comorbidities: 60% *Senni et al, Arch Intern Med 1999, Ho et al, Circulation 1993

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Functional Capacity The most important predictor of mortality in HF Decline in functional capacity is associated with high 3 month mortality* *Lunney JR, JAMA 2003

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Date of download: 11/13/2012 Copyright 2012 American Medical Association. All rights reserved. From: Patterns of Functional Decline at the End of Life JAMA. 2003;289(18):2387-2392. doi:10.1001/jama.289.18.2387 Error bars indicate 95% confidence intervals. Figure Legend :

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NYHA class Symptoms1 year mortality with optimal treatment INo symptoms5-10% IISymptoms with ordinary activity 5-10% IIIMarked limitation of physical activity 10-15% IVSymptoms at rest30-40%

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Prognostication in HF Poor prognostic factors: Ischemic etiology Recent cardiac hospitalization High BUN, cr > 1.4, Na

Resources: Fast facts: http://www.eperc.mcw.eduhttp://www.eperc.mcw.edu Brief answers to >200 palliative questions / topics Heart Failure Society of America: www.hfsa.orgwww.hfsa.org Information for clinicians and patients/families Palliative Care for Patients with Heart Failure Pantilat and Steimle, JAMA 2004 UNM Inpatient Palliative Care Consult: x24868

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Questions or Comments? Dneale@salud.unm.edu