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Heart Failure and Palliative Care:
An audit of a hospital palliative care teams’
involvement with end stage heart failure patients
Dr Dylan Harris
Dr Mel Jefferson
Hospital Palliative Care Team
Department of Palliative Medicine
University Hospital of Wales
Heart Failure: facts and figures
◆ Definition
-“Inability of the heart to keep up with the demands on it”
Heart Failure: facts and figures
◆ Definition
-“Inability of the heart to keep up with the demands on it”
♦ Incidence/Prevalence
- Population prevalence 1 to 3%, 10% in very elderly.
- Incidence & prevalence increase dramatically over the age 75 years
- Number of patients with CHF will increase rapidly because:
(a) increase in survival after acute myocardial infarction
(b) ageing of the population
(c) advances in medical device treatments
Heart Failure: facts and figures
◆ Definition
-“Inability of the heart to keep up with the demands on it”
♦ Incidence/Prevalence
- Population prevalence 1 to 3%, 10% in very elderly.
- Incidence & prevalence increase dramatically over the age 75 years
- Number of patients with CHF will increase rapidly because:
(a) increase in survival after acute myocardial infarction
(b) ageing of the population
(c) advances in medical device treatments
◆ Prognosis
- After first admission for heart failure 5-yr mortality= 75%
- 40% die within 1 year of diagnosis
- 50% die suddenly
NYHA Classification of Heart Failure
Class I: asymptomatic
No limitation in physical activity despite presence of heart
disease.
Class II: mild
Slight limitation in physical activity. More strenuous activity
causes shortness of breath - for example, walking on steep
inclines and several flights of steps. Patients in this group can
continue to have an almost normal lifestyle and employment
Class III: moderate
More marked limitation of activity which interferes with work.
Walking on the flat produces symptoms
Class IV: severe
Unable to carry out any physical activity without symptoms.
Patients are breathless at rest and mostly housebound
NYHA Classification of Heart Failure
Class I: asymptomatic
MORTALITY
No limitation in physical activity despite presence of heart
disease.
20% at 5 years
Class II: mild
Slight limitation in physical activity. More strenuous activity
causes shortness of breath - for example, walking on steep
inclines and several flights of steps. Patients in this group can
continue to have an almost normal lifestyle and employment
3-25% / year
Class III: moderate
More marked limitation of activity which interferes with work.
Walking on the flat produces symptoms
10-45% / year
Class IV: severe
Unable to carry out any physical activity without symptoms.
Patients are breathless at rest and mostly housebound
40-50% / year
One-year survival rates, heart failure and major cancers compared,
mid-1990's, England and Wales
Melanoma of skin
Breast cancer
Cancer of the uterus
Bladder cancer
Prostate cancer
Cancer of the lip, mouth and pharynx
Non-Hodgkins lymphoma
Colon cancer
Heart failure
Ovarian cancer
Cancer of the kidney
Leukaemia
Stomach cancer
Cancer of the oesophagus
Lung cancer
Cancer of the pancreas
0
10
20
30
40
50
60
70
80
90
100
One year survival rate (%)
ONS (2001); Cowie MR et al (2000) Heart 83: 505-510
www.heartstats.org
Heart Failure:
disease trajectory
Heart Failure: Palliative Care Needs
Murray SA, Boyd K, Kendall M et al. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in
the community. BMJ 2002;325:929-
Heart Failure: Palliative Care Needs
Audit Standard
Audit Standard
“practices and hospitals should audit ….
(1) The number and percentage of people with
heart failure for whom specialist palliative care
advice has been sought …..
(2) The access to palliative care support …..
(3) When the aim of treatment is to control
symptoms a palliative approach … good
symptom control, psychological support and
open communication about disease outcome
should be offered to all patients…..”
Audit
• Type
– Retrospective Case Note Audit (Medical notes
and palliative care notes)
• Audit Period
– April 2005-April 2007
• Patient Identification
– Patients from ISCO Database with diagnosis
“heart failure”
Audit Criteria
(1) The number and percentage
of people with heart failure for
whom specialist palliative care
advice has been sought …..
The number and percentage of people with
heart failure for whom specialist palliative care
advice has been sought …..
• Patients identified from ISCO
= 21
(April 2005-April 2007)
• Patients audited
= 18
(2 not heart failure, 1 no notes)
• % of patients ??
– ? % admissions
– ? % heart failure deaths
– ? % admissions with stage III/IV heart failure
Audit: Patient characteristics
• Age:
• 53-95 years
• mean 76.1 years
• Sex:
• 10 (56%) male
• 8 (44%) female
• NYHA:
• Class III: 4 (22%)
• Class IV: 14 (78%)
Audit Criteria
(2) “The access to palliative care
support ….”
-Are heart failure referrals accepted (and what are they
referred for) ?
-How long does to take for patients to be seen by the
palliative care team ?
“The access to palliative care
support ….”
Heart failure referrals accepted: yes
Time to generate referral
unclear:
7 patients (39%)
same day:
7 patients (39%)
1 day:
3 patients (16%)
3 days:
1 patient (6%)
Time from referral to assessment
0 (same day):
1 day:
2 day:
15 patients (83%)
2 patient (11%)
1 patient (6%)
“The access to palliative care
support ….”
Reason for referral
•
•
•
•
Symptom management
Support
Discharge
Unclear
13 patients
4
3
3
(72%)
(24%)
(17%)
(17%)
Audit Criteria
(3) “good symptom control,
psychological support and open
communication about disease outcome
should be offered to all patients…..”
- What symptoms do patients have and how many ?
- What interventions do we suggest ?
- Is there any evidence they help ?
“good symptom control, psychological support and open
communication about disease outcome should be offered to all
patients…..”
SYMPTOM
% PATIENTS
Breathlessness
89%
Pain
44%
Anxiety
72%
Nausea/vomiting
28%
Chest secretions
17%
Constipation
11%
Oedema
11%
Fatigue
6%
Anorexia
6%
Mouth
6%
Family anxiety/support
56%
“good symptom control, psychological support and open
communication about disease outcome should be offered to all
patients…..”
Heart Failure Patients:
Symptom type and prevalence (%)
Breathlessness
100
80
Anxiety
89
Pain
72
Nausea/vomiting
56
60
Constipation
44
40
20
Chest secretions
Oedema
28
17
11 11
0
1
Fatigue
6 6
6
Anorexia
Mouth
Family support
“good symptom control, psychological support and open
communication about disease outcome should be offered to all
patients…..”
•
•
•
•
1 symptom
2 symptoms
3 symptoms
4 or more
0 patients
7 patients (39%)
6 patients (33%)
5 patients (28%)
“good symptom control, psychological support and open
communication about disease outcome should be offered to all
patients…..”
• Interventions
• Support for patient and their family/carer
• Breathlessness
– Opiate po or sc (75% patients)
– Benzodiazpeines if anxiety factor (100%)
• Nausea/vomiting:
• Constipation:
• Anxiety:
• Chest secretions:
anti-emetic depending on mechanism
laxative
benzodiazepines,
haloperidol, levomepromazine
hyosine
• Benefit for our suggested interventions
• How to measure ?
•
•
•
•
“still breathless but not troubled by it so much”
“does not feel as anxious as he did yesterday”
“no pain”
“appears comfortable, no longer grimacing”
• Little variation in other variables/intervention
“good symptom control, psychological support and open
communication about disease outcome should be offered to all
patients…..”
SYMPTOM
% PATIENTS BENEFIT FROM
INTERVENTION*
Breathlessness
56%
Pain
75%
Anxiety
54%
Nausea/vomiting
80%
Chest secretions
33%
Constipation
0%
Oedema
0%
Fatigue
0%
Anorexia
0%
Mouth
0%
*absence of evidence rather than evidence of absence
• Outcomes
• RIP:
• Home:
• Other:
13 patients (72%)
3 patients (17%)
2 patients (11%)
• Length of interaction: 1-30 days (mean 5.7 days)
• Patients referred for discharge and got home= 2/3 (1 RIP)
Conclusions
• 83% referrals seen the same day
• Given the prevalence of symptomatic heart
failure inpatients referral rate seems low
• Polysymptomatic patients:
– >60% have 3 or more symptoms
• Large need for family support
• Palliative care interventions seem to help
– Difficult to measure objectively.
– More accurate documentation of symptom response
would be useful e.g. ESTAS
Conclusions
• Which patients should be seen?
Palliative Medicine 2006;20:211-214
Palliative Medicine 2007;21:385-390
Future directions
- Collaborative working between palliative care and heart failure
services
- Various approaches, dependent on
(1) local expertise of the HF team
(2) and their interest/enthusiasm to engage with palliative care
Locally:
-open referral policy
-easy access for advice
-collaborative working with interested and palliative care
“friendly” cardiologist and geriatrician
-heart failure MDT attended by a member of the palliative care
team