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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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
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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
HF: Effects of Remodeling
Classifications
• Right-sided
(systolic) Heart
Failure • Causes a backup 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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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
New York Heart Association
(NYHA) Classification
NYHA Classification
Class I
Class II
Class III
Class IV
Patients have no limitation in
physical activity
Patients have slight limitation of
physical activity
Patients have marked limitation of
physical activity
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
Stage B
Stage C
Stage D
High risk for HF, no structural disorder
or symptoms
Structural heart disorder present, no
symptoms
HF symptoms associated with
structural heart disease
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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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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
Function
High
Low
Begin to use hospital
often, self-care
becomes difficult
Death
Time
~ 2-5 years, but death
usually seems “ sudden”
”
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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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
dysfunctionmanage with
4 drugs:
•
•
•
•
Diuretic,
ACE inhibitor/ARB,
Beta blocker &
(usually) digitalis
ACC/AHA Practice Guidelines 2005
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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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
Part III Disease-Specific
Guideline: HF
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
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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
Part III Disease-Specific
Guideline: HF
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
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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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
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
Hospice Education Network (c) 2012
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Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: Heart Failure
THANK YOU!
Terri Maxwell PhD, APRN
VP, Strategic Initiatives
Weatherbee Resources Inc. &
Hospice Education Network
[email protected]
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