End Stage Heart Failure - · PDF file1 End Stage Heart Failure: Management, Disease...

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End Stage Heart

Failure:Management, Disease Trajectory,

and Hospice Eligibility

Terri L. Maxwell PhD, APRN

VP, Strategic Initiatives

Weatherbee Resources Inc

Hospice Education Network Inc

Course Handouts & Post Test

• To download presentation handouts,

click on the attachment icon

• Presenter discloses no financial relationships with a

commercial entity producing healthcare-related products

and/or services. Conflict of interest disclosure and

resolution statement is on file with HEN.

• This presentation is for educational and informational

purposes only. It is not intended to provide legal,

technical or other professional services or advice.

Objectives

• Describe the epidemiology and pathophysiology of end stage heart failure (HF)

• Describe the classification and staging of HF

• State symptoms experienced by patients with HF

• Name the clinical data points necessary to substantiate hospice eligibility for patients with heart failure

Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure

Hospice Education Network (c) 2012

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Heart Failure: Background

• Progressive disorder

resulting from an

underlying disease

causing structural or

functional damage

to the heart

• Weakening the

heart’s pumping

function

Prevalence/Risk Factors

• Close to 6 million

Americans estimated

to have HF

• Number rising d/t

growing population of

elderly

• African Americans have

highest risk of

developing HF

Risk Factors:

•HTN

•Previous MI

•Diabetes

Mellitus

Roger, V. et al. Circulation 2011, 123:e18-e209

HF Pathophysiology

• Clinical syndrome resulting from cardiac damage

from various underlying causes.

• Injury to the myocardium causes remodeling

where the heart tries to compensate by

increasing wall thickness.

• Remodeling results in ventricular dilatation,

hypertrophy and changes in heart shape.

• Remodeling occurs before and continues after

symptoms develop.



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HF: Effects of Remodeling

Classifications

•Right-sided

(systolic) Heart

Failure -

• Causes a back-

up of fluid in the

body, resulting in

swelling and

edema.

Classifications (cont’d)

• Left-sided (diastolic) Heart Failure -

Back-up behind the left ventricle

causes fluid accumulation in the

lungs.

• 20-40% of patients

• CAD is the underlying cause of left-sided

HF in 2/3 of cases



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New York Heart Association

(NYHA) Classification

NYHA Classification

Class I Patients have no limitation in

physical activity

Class II Patients have slight limitation of

physical activity

Class III Patients have marked limitation of

physical activity

Class IV Patients have symptoms even at

rest and are unable to carry on any

physical activity without discomfort

Staging: ACC/AHA System

ACC/AHA Classification System

Stage A High risk for HF, no structural disorder

or symptoms

Stage B Structural heart disorder present, no

symptoms

Stage C HF symptoms associated with

structural heart disease

Stage D Refractory HF with symptoms

occurring at rest despite maximal

medical therapy

Hunt SA, et al . J Am Coll Cardiol 2001;38:2101-13

Signs and symptoms of HF

• Tachycardia

• Dyspnea

• Orthopnea

• Acute pulmonary edema

• Edema- especially of lower extremities

• Fatigue/lethargy

• Anorexia/cardiac cachexia

• Pain- angina/chest pressure/palpitations



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Signs and symptoms of HF (con’t)

• Anxiety

• Depression

• Insomnia

•Memory impairment/confusion

• Nocturia/oliguria

• Decreased mobility

Concomitant Disorders

• HTN

• Hyperlipidemia

• Diabetes Mellitus

• Renal insufficiency

• Pulmonary disease

• Anemia

• Depression

• Arthritis

Cardiac Disease Trajectory

Time

Function

Death

High

Low

Begin to use hospital

often, self-care

becomes difficult

~ 2-5 years, but death

usually seems ““““sudden””””



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Assessing Prognosis: Predictors of Mortality

• Declining LVEF

• Worsening NYHA

functional status

• Worsening renal

status

• Chronic

hypotension

• Hyponatremia

Circulation 2009

ACC/AHA 2005 JACC

HF Prognostic Tools

• Seattle Heart Failure Model

• www.SeattleHeartFailureModel.org

• EFFECT Heart Failure Mortality Prediction

• http://www.ccort.ca/CHFriskmodel.aspx

HF Management

• Symptomatic left

ventricular

dysfunction-

manage with

4 drugs:

• Diuretic,

• ACE inhibitor/ARB,

• Beta blocker &

• (usually) digitalis

ACC/AHA Practice Guidelines 2005



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Symptom Management in HF

• HF- Optimal treatment with ACE inhibitors or ARBs and beta

blockers

• Edema- loop diuretics

• Pain- avoid NSAIDs. Treat angina with nitrates and opioids.

• Dyspnea- manage fluid status with cardiac medications,

supplemental O2 for those with ischemic conditions, opioids.

• Anxiety or insomnia- benzopdiazepines

• Depression- carefully titrated SSRIs if renal status is okay or

methylphenidate (Ritalin)

• Early satiety/nausea- due to pressure from enlarged, congested

liver or gastric stasis. Treat with loop diuretic or spironolactone or

inotropic support. Metoclopramide for gastric stasis, +/- antiemetic

such as haloperiodol.

Specialized interventions

• Inotropic and vasoactive agents (neosynephrine,

dobutamine or milrinone)- force contractility of the

myocardium. No approved oral agents available.

• Cardioverter- defibrillators (ICDs)- implanted to

prevent sudden cardiac death, but do not slow

progression of HF.

• Cardiac transplantation- <5% of pts with HF are

eligible.

• Left Ventricular Device (VAD)- surgically implanted

mechanical pump to improve ventricular pumping.

Demonstrated to increase survival but morbidity and

mortality is high.

HF: End of Life Issues• Prognosis is difficult to predict• Palliative care should be based upon symptoms,

functional status and goals of care

• 2nd leading non-cancer hospice diagnosis

• HF patients have frequent exacerbations requiring trips to the ED and/or hospitalizations

• Patients and family members frequently do not comprehend the terminal nature of the illness• Lack of communication and advanced care planning

NHPCO Facts and Figures, 2010



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LCD Guidelines for Hospice

Eligibility and Recertification

for Heart Failure (HF)

NGS LCD Number L25678

CGS LCD Number L32015

NHIC LCD Number L29881

Part II Non-disease Specific

Guidelines

Note: These guidelines are to be used in conjunction with the

“Non-disease specific baseline guidelines” described in Part II of

the LCD

Both A & B must be met:

A. Impaired functional status- KPS <70 or PPS <70

B. Dependence on assistance for 2 or > ADLs

C. Presence of co-morbidities that contribute to disease burden

• Diabetes

• Dementia

• COPD

1. Optimally treated for heart disease and

2. Patients with CHF or Angina should meet the Class IV criteria of the NYHA classification. Significant CHF may be documented by an ejection fraction of less than or equal to 20%, but is not required if not already available

Part III Disease-Specific

Guideline: HF



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3. Documentation of the following factors will

support but are not required to establish

hospice eligibility:

a. Treatment-resistant symptomatic

supraventricular or ventricular arrhythmias

b. History of cardiac arrest or resuscitation

c. History of unexplained syncope

d. Brain embolism of cardiac origin

e. Concomitant HIV disease

Part III Disease-Specific

Guideline: HF

Documentation

Establishing, evaluating, and explaining

eligibility based upon burden of illness in HF

Assessing and Documenting

Disease Burden in HF

•Dyspnea- with activity and at rest

•Vital Signs

•O2 saturation

• Edema

•Orthopnea

• Severe impairment of ADLs



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Supporting/Ongoing Documentation

• Psychosocial/spiritual needs

• Increased service utilization

• Need for more frequent visits

• Greater involvement by members of IDT

•Medication changes- addition or titration

of opioids, anxiolytics, diuretics, etc.

• Altered mental status- lethargy, confusion

• Increased caregiver stress/burden

Documentation example

“Patient is increasingly dyspneic with

minimal activity. Using MSO4 q 3-4 hr

ATC with moderate relief. Caregiver now

providing assist with all ADLs. Sleeps

sitting up in chair, states he is too SOB

to lie in bed. Lost 2 lbs in past 2 weeks,

despite 3+ LE edema.”

Conclusion

• HF is the #1 cause of death in the US and the 2nd leading non-cancer diagnosis in hospice

• Although irreversible and progressive, HF prognosis is difficult to predict and death may occur suddenly

• Hospice eligibility is based on maximally treated patients with Class IV criteria of the NYHA classification.

• Initial and ongoing comprehensive patient assessment with documentation is necessary for enrollment and recertification.



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Resources

• Cardio Smart by the American College of Cardiology

http://www.cardiosmart.org/

• Heart Failure Online http://www.heartfailure.org/

• Heart Failure Society of America

http://www.abouthf.org/default.htm

• National Heart, Lung and Blood Institute: Heart

Failure

http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/

HF_WhatIs.html

References

• Hunt SA, Baker DW Chin MH, et al. ACC/AHA

guidelines for the evaluation and management of

chronic heart failure in the adult: executive

summary: a report of the American College of

Cardiology/American Heart Association Task Force

on Practice Guidelines. J Am Coll Cardiol

2001;38:2101-13.

• Lang, CC & Mancini, DM. Non-cardiac co-morbidities

in chronic heart failure. Heart 2007;93:665-671

• Roger, V. et al. Heat disease & stroke statistics- 2011

update. Circulation 2011, 123:e18-e209

Course Handouts & Post Test

Thank you for viewing this course on the

Hospice Education Network

The Course evaluation and post test are

available from your course catalog page



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THANK YOU!

Terri Maxwell PhD, APRN

VP, Strategic Initiatives

Weatherbee Resources Inc. &

Hospice Education Network

[email protected]



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