Download Clinical Governance - Hospice in the Weald

Specialist palliative care for
patients with heart failure
Dr Katie Taylor
Consultant in Palliative Medicine
Objectives
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Identify which patients to refer to hospice
Review symptom management
Think about rationalising medications
Be aware of services which the hospice could
provide
Questions to consider
• What are the barriers to providing good end
of life care for patients with heart failure?
• What works well?
• What is more challenging?
• Are there specific patient examples that you
can share?
Some heart failure statistics
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500,000 people in UK
76y - average age at diagnosis
30-40% die within 1 year
Costs NHS £378.6 million/year
2% of all NHS inpatient bed days
5% of all emergency admissions
• Cardiovascular disease statistics 2014 BHF
More statistics
• Prevalence of heart failure rising
– Ageing population
– Improved survival with IHD
– Improved heart failure treatment
• 6 month mortality rate falling:
– 26% 1995 to 14% 2005
• Hospital admissions predicted to rise by 50%
over next 25 years
NYHA classification
Morbidity
• Significant symptom burden
• Patients have poor understanding of illness
progression
• Less likely to plan for death & dying
– 83-95% die in acute or elderly care hospital bed
– 1% die in hospice
When to refer to hospice
The typical disease trajectories identified in patients with different diseases.
Integrated palliative/cardiology
services
• Which deterioration is the terminal one?
• Change of emphasis from active to
palliative management difficult
• Indicators of poor prognosis provide a
trigger for conversations about future plans
• “what would you want to do if things get
worse”
• Heart failure MDT
Indicators of Poor Prognosis
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Previous admissions with worsening heart failure
No identifiable reversible precipitant
Receiving optimum tolerated conventional drugs
Worsening renal function and low sodium
Failure to respond within 2-3 days to appropriate
change in diuretic or vasodilator drugs
Sustained hypotension
Up to 50% patients with heart failure die suddenly
Specific clinical indicators for heart failure:
― CHF NYHA Stage 3 or 4
― Patient thought to be in last year of life
― Repeated hospital admissions with heart failure
symptoms
― Physical or psychological symptoms despite optimal
tolerated therapy
Roles of specialist palliative care
Symptoms
Anderson et al (2001) Pall Med 15(4): 279-86
SOB
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Non-pharmacological
Relaxation/distraction
Breathing retraining
Lifestyle changes
Hand-held fan
Complementary tx
Exercise group
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Drugs
Oramorph 2.5mg 4hrly
Lorazepam 0.5mg prn
GTN spray
Fatigue
• Exclude reversible causes
– Hb, TFTs, U&E, calcium, magnesium
• Review medication
– Beta blockers, ACE
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Screen for anxiety/depression
Pace activity
Graded exercise
Dietary advice
Polypharmacy
• Chronic use of >4 medications
– 36% patients over 75 take >4 drugs
– 50% drugs are not taken as prescribed
• Drug interactions
• Adverse reactions
• Pill burden
ADRs
Rationalising medications
• Which medications are providing immediate
symptom benefit?
• Which medications might produce rebound
symptoms/rapid deterioration if stopped?
Consider 1st
Consider 2nd
Consider 3rd
Discontinue drugs with only long
term benefit (mortality)
Weigh up
advantages/disadvantages of
continuing drugs with medium
term benefit
(morbidity/mortality)
Continue drugs for short term
benefit (morbidity)
Statins
Digoxin (in sinus rhythm)
ACE/ARB
Beta blocker
Spironolactone
Loop & thiazide diuretics
Digoxin/beta-blockers (in AF)
Anti anginals
Drugs for co-morbidities
Hypoglycaemics
Antihypertensives
Thyroxine
Warfarin
Subcutaneous furosemide
• Patient selection
• Advanced CHF
• Wish to avoid
hospital
• Need parenteral
diuretics
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Indications
Symptom management
End of life
Unresponsive to high
dose oral diuretics
• PPC home/hospice
• Poor venous access
Paracentesis
• Patients with right heart failure
– Ascites persists despite aggressive diuretic tx
– Symptomatic
• 4-6 litre slow paracentesis
• Over few days
Input from palliative care
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Hospital
Hospice day service
Hospice in the home
Hospice inpatient unit
Counselling
Carer support