Download Palliative Care: A Bridge Over Troubled Waters

A Bridge Over Troubled Waters:
Palliative Care in Heart Failure
Christine Westphal NP MSN
ACNS-BC ACHPN CCRN
Director/Nurse Practitioner
Palliative and Restorative Integrated Services Model (PRISM)
Oakwood Healthcare System
Dearborn, Michigan
Objectives
1.
2.
3.
Describe the trajectory of heart failure.
List three palliative care outcomes in
end stage heart failure with related
interventions
List palliative care resources available
to the patient, family and healthcare
provider
Definitions

Structural or functional
disorder which impacts ability
of the heart to eject or fill with
blood
– Systolic (decreased ejection)
• EF < 40%
• Occurs most frequently
– Diastolic (impaired filling)
• Impaired relaxation
• Ventricular stiffness
Etiology
Ischemic cardiomyopathy/CAD 59-70%
 Non-ischemic cardiomyopathy

– CV
Non-CV
• Valve disease
•
• HTN
•
• Atrial fibrillation
•
medications
• Infection
•
• Congenital abnormalities •

Obesity
Illicit drugs
Cardiotoxic
Sleep apnea
Anemia
Idiopathic dilated cardiomyopathy
Ventricular Dysfunction: Output
Neuroendocrine activation
Renin-Angiotensin-Aldosterone
Sympathetic Nervous System
Vasopressin
HR, BP, Myocardial O2 consumption
Sodium/water retention/edema
Ischemia, dsyrhythmias
Decreased end organ perfusion
Ventricular hypertrophy
Ventricular remodeling
Fibrosis
Cell death (apotosis)
Natiuretic Peptides
ANP (atrial)
BNP (brain)
Pressure/volume
Immune up-regulation
Cytokines
Tumor necrosis factor
Interleukins
Attempts to compensate
Diuresis
Decrease neuroendocrine
response
Recommended Therapy by Stage
Copyright ©2009 American Heart Association
2009 WRITING GROUP ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE, et al. Circulation 2009;119:1977-2016
Heart Failure Facts



Increasing prevalence, particularly in
the elderly
550,000 new cases annually
Affects 6-10% of US patients > 65
– Leading cause of Medicare hospitalization

> 1 million hospitalizations annually
– 20% of hospitalizations age > 65


>3 billion ED/office visits annually
$33 billion spent in 2007
Lloyd-Jones et al (2009) Heart Disease and Stroke Update.
Circulation;119;480-486
Heart Failure Society of America (2006) J Card Fail;12;e86-e103.
Koelling T et al (2005) Circulation; 111: 179–185
Burt C & Schappert S (2004) Vital Health Stat 13; No. 157: 1–70.
Contributing Factors

Poor adherence to diet, self-care and
medication recommendations
– Lack of understanding
– Depression/anxiety/cognitive impairment
– Complexity of the plan—multiple comorbidities and specialists
– Inadequate follow-up/discharge support
– Lack of access
• Social and/or financial reasons
Progressive, chronic

Last 6 months end-stage patients spend 1 out
of 4 days in hospital
Russo et al (2008) J Card Fail; 14:651-658

End-stage marked by worsening symptoms,
functional decline and repeated hospitalizations
Teuteberg et al (2006). J Card Fail; 12: 47-53.
Goldberg & Jessup (2007) Circulation;116:360-362.
Bradley et al (2003). JAMA 289: 730-740.
And Deadly

Cardiac disease is leading cause of death in
Michigan
2008 Michigan Resident Death File MDCH

2.5 M Medicare recipients 2001-2005
1 year mortality 37%
Curtis et al (2008) Arch Intern Med; 168:2481-88.

About half of patients die within 5 years
– Approximately 25% of survive beyond 5 years
MacIntyre et al (2000) Circulation; 102: 1126-1131
Khand et al (2000) J Am Coll Card; 36: 2284-1186
Significant Mortality Indicators

If stage IV (D) and with optimal tx, but
shows:
– Dobutamine or milrinone dependence
– Decompensation despite resynchronization
– Frequent AICD firing
– Greater than 1.9 hospitalizations/6 months
– Not candidate for transplantation
Kuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach.
St. Louis: Mosby.
Hershberger et al (2003) Cardiac Fail; 9: 180-181
Albert et al (2002) Cleve Clin Med J. ; 69: 321-328
Alla et al ( 2000) Am Heart J ;139: 895-904
Additional Factors Increase Risk







Resting HR >100
Creatinine >2.2 mg/dl
Serum NA < 134 after treatment
Repeated hospitalization for HF
Age >70
Additional serious co-morbidities
Dependent for ADL—poor functional status
Kuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach.
St. Louis: CV Mosby
Living with Heart Failure
“It’s not about death,
it’s really about living
with a disease…”
Joanne Lynn MD
SUPPORT Primary Investigator
Study to Understand Prognoses and
Preferences for Treatment (SUPPORT)

Approx 950 heart failure patients with
EF < 20%
– 68% readmitted within 2 months
– 79% experienced a 5 # wt loss in 2 mo
– 76% required services for ADL assist
– 23% decided to forego resuscitation
Krumholz et al.(1998) Circulation;98:648-655
Living with Serious Illness

90 Million with serious illness annually

70% admitted to hospital in last 6mo
–
–
–
–

1:4 inadequate symptom control
1:3 inadequate emotional support
1:3 inadequate education on self-care
1:3 inadequate post-discharge plan
Many died in the hospital
•
•
•
•
Dartmouth atlas www. Dartmouthatlas .org
Teno et al (2004) JAMA; 29(1):88-93
Covinsky et al (1994) JAMA 272(23): 1838-44.
Commonweath Fund Report (2007)
The Heart Failure Experience

Study comparing HF and lung CA patients
 HF patients had:
– Less information about illness, prognosis and
treatment
– Less involvement in decisions about CPR,
ventilation and artificial nutrition
– Frustration with losses and social isolation
– Less involvement with palliative care
– More stress, distress and less quality of life
– Fewer supportive services
Murray et al (2002) Br Med J;325:929-932
“Palliative care should be
considered a normal
approach to patients with
heart failure…”
Hauptman et al (2005) Arch Intern Med;165:374-378
What is Palliative Care?

An evidence-based specialty practice that:
– Focuses on relief of suffering particularly
for people with serious, life-limiting
illnesses
– Helps patients and families to have best
quality of life regardless of stage of illness
or need for other therapies
– Optimizes function, decision-making and
personal growth
Growth of Palliative Care

1998: No PC
programs
 2008: Over 50% of
hospitals with 50 or
more beds have a
PC program
– Center to Advance Palliative
Care, 2008

Oakwood Hospital & Medical
Center Dearborn
 Detroit Receiving Hospital
 Providence Hospital
 St. John Hospital
 St. Joseph Mercy Ann Arbor
 St. Joseph Mercy Pontiac
 Beaumont Hospital
 Henry Ford Detroit and
Wyandotte
 University of Michigan
Palliative Care: A Bridge Over
Troubled Waters

Communication
–
–
–
–
–

Support system
Treatment options/benefits & burdens
Clarify goals, values and preferences
Advance directives & resuscitation status
Match needs and resources
Quality of life
– Symptom control
– Optimize function
– Psycho-social-spiritual support

Satisfaction
Widera & Pantilat (2009) Current Opin Support Pall Care;3:247251.
Michigan Dignified Death Act

Patients with a life limiting
illness must be informed about
treatment options including:
–
–
–
–
–
Benefits and burdens of treatment
Right to refuse treatment
Palliative care
Pain control
Hospice for patients with terminal
illnesses
Michigan Law No. 239 (333.5652)
Palliative Care Impact

Less likely to die in the hospital
 Experience fewer ICU/CCU admissions
in the last six months of life
 Spend less time in an ICU/CCU in the
last six months of life
–
Center to Advance Palliative Care, 2008
Satisfaction

Patient family satisfaction
– Relief of symptoms
– Improved communication
– Smooth access and seamless care

Physician Satisfaction
– Collaboration
– Saved physician time
PRISM Quality Data 2007-2010
Campbell (2004). Making cents: Cost-effectiveness of palliative care. Presentation
Improved symptom control
100%
90%
Non-palliative care
80%
70%
Palliative care
60%
North Kansas City
Hospital
50%
Controlled
Anxiety
Controlled
Dyspnea
Common Symptoms







Dyspnea
Pain
Anxiety
Depression
Fatigue
Edema/anasarca
Anorexia/cachexia
SUPPORT Study
N=957 HF Patients

92 (10%) died during hospitalization
– 43% had dyspnea
– 35% had severe pain

865 survivors
– 32% had dyspnea
– 19% had severe pain
• SUPPORT Principal Investigators (l995). JAMA; 274: 1591-1598
Dyspnea Prevalence
Dx
COPD
Prevalence # Studies N
%
90-95
4
372
Heart Dz
60-88
6
948
CA
10-70
20
10,029
AIDS
11-62
2
504
Bausewein C et al (2007). Respir Med; 101(3):399-410
Solano, et al. (2006) J Pain Symp Mgt, 31(1):58-69.
Dyspnea

Awareness of
uncomfortable breathing
– Subjective

“Respiratory distress”
– Observed physical and/or
emotional signs
Pathophysiology

Increased work of breathing
– Airway constriction
– Obstruction: secretions, infections, effusions
– Weakness

Chemical
– Hypercapnia
– Hypoxia

Neuromechanical dissociation
– Muscle tension/effort do not match expansion
Thomas and von Guten, (2002) Lancet Onc;3(4):223-228.
Measurements
 *Numeric Report
10= Severe distress

*Vertical Dyspnea
Visual Analog Scale

*Borg Scale

Dyspnea Exertion Scale
0= No distress
– Level I: Walk w/o SOB to
– Level 5: Breathless @ rest
•No tool superior to others. All are unidimensional. ACCP (2010)Consensus statement on
management of dyspnea in patients with advanced lung or heart disease. Chest; 137(3): 674-691
Respiratory Distress Observation Scale

Asphyxia produces innate, nonvoluntary, observable behaviors
–
–
–
–
–
–
Tachycardia
Tachypnea
Accessory muscle use
Paradoxical breathing
Nasal flaring
Fear expressions and behaviors
Campbell ME et al (2010) J Palliat Med. Mar;13(3):285-90.
Campbell ME (2008). J Palliat Med. Jan-Feb;11(1):44-50.
Facial Expression: Fear
Campbell, ELNEC 2006
BREATH AIR






Bronchospasm
– Albuterol and ipratropium
– Steroids
Rales
– Limit fluids, evaluate protein
– Consider diuretics, ACE-I, other
Effusions
– Thoracentesis/catheter
Airway obstruction
– Aspiration precaution/suction
Thick secretions
– Strong cough? Neb.
Saline/humidity
– Thin? Hyoscyamine, atropine
ophthl solution, scopolamine,
glycopyrrolate
Hemoglobin low
– Transfusion?



Anxiety
– Position
– Pursed lip breathing
– Fan
– Music
– Massage
– Biofeedback
– Opioids
– Benzodiazepines
Interpersonal issues
– Counseling, support
Religious concerns
– Spiritual advisor
“Among the remedies which it
has pleased Almighty God to
give to man to relieve his
sufferings, none is so universal
and so efficacious as opium.”
Thomas Sydenham (17th century)
Opioids in Dyspnea

Multiple mechanisms of action
– Decrease chemoreceptor response
– Decrease anxiety
– Increase peripheral vasodilation
– Alter perception through afferent pathways
Dosing

No one opioid is better than the other
 Recommended starting p.o.doses (q3-4hrs)
–
–
–
–
–

Morphine sulfate
Hydrocodone
Oxycodone
Hydromorphone
Codeine
2.5-5mg
2.5-5mg
2.5-5mg
1-2 mg
30mg
May start higher in opioid tolerant pts.
 Titration: 25-50% every 12 hours
 Convert to sustained release formulas if
available
 IV: PO 1:3 conversion. Infusions if needed
Nebulized Opioids
Theory: action on airway receptors
 Ambiguous evidence

– Small studies and case reports
– 2 RCT report nebulized morphine no better
than saline

If trial is warranted:
– Morphine sulfate 2.5-10mg added to 2ml
saline (preservative free or non-flavored
elixirs) every 4 hours and every 1-2prn
– Hydromorphone 0.25-1mg as above
Westphal & Campbell AJN (2002) May Supplement 11-15
ACCP (2010) Chest; 137(3): 674-691
Respiratory Arrest!?!
Sedation precedes respiratory
suppression
 Respirations are NOT impacted by
prudent dosing

• Improved pulmonary parameters
– Citron et al. Am J Med, 1984
• No difference in duration of survival
– Campbell et al. Crit Care Med, 1999; Chan et al. CHEST, 2004)

Respiratory failure Always occurs
during dying with or without opioids
• Dead people don’t breathe!
Hypotension?!?

Hypotension most often with IV dosing in the
presence of volume depletion and/or in the
elderly.
 Consider the goals of care.

No studies support use for dyspnea
without hypoxemia at rest or min. activity
ACCP (2010). Chest; 137(3): 674-691

Judicious use of bi-pap or c-pap
– May benefit cognitively intact pts with
COPD or neurodegenerative
disorders. Not for dying pt.

Use of fans or blowing air may be as
effective in advanced disease .
Oxygen
– Stimulates facial nerve and non specific
nasal receptors
Galbraith et al J Pain Symp Mgmt 2010; 39(5): 831-838
Spector etal 2007. AACN Adv. Clin Issues; 18(1):48-57
Gallager & Roberts J Pain Pal Care Pharmacotherapy 2004;18(4): 3-15.
Refractory respiratory distress

All previously described interventions fail to
relieve patient distress

Complete sedation may be indicated
– Benzodiazepines, barbiturates, propofol
– Patient and clinician mutually agree to this
approach
– May be the only compassionate strategy IF all
other approaches fail
NHPCO Position statement and Commentary on use of palliative sedation in
imminently dying terminally ill patients. J Pain Symp Mgmt 2010 39(5): 914-923
Terminal Congestion

Explain to family—anticipate as a normal occurrence

Position lateral (“recovery position”)

Decrease fluids and feedings

Consider diuretics if pulmonary edema

If oral secretions are excessive--anticholinergics
– Scopolamine
– Atropine ophthalmic solution 1%
– Glycopyrrolate (Robinul)
– Hyoscyamine (Levsin)
Pain



Up to 41% of patients
experience pain with heart
failure
Most pain is general in nature
Causes
–
–
–
–
Angina
Edema
Osteoarthritis
Diabetic neuropathy
Levenson et al (2000)Am Geriatr Soc
FLACC Scale
WHO Analgesic Ladder






Start at the level of the
pain
Avoid NSAIDS-- diuretics
may need to be adjusted
Start with PRN and then
consider longer acting
scheduled doses
Transdermal difficult to
titrate
Stay with same drug
Use equianalgesic tables if
converting drugs
Anxiety

General Anxiety Disorder (GAD)
 Affects 2-3% of adults annually
 Higher in patients with medical
disorders
 Most common psychiatric
symptom in patients with CV
disease
 Associated with increased
morbidity and mortality
Mueller et al. (2005) Curr Psych Rep; 7: 245-251
Reasons

Symptoms
– Dyspnea and pain

Medications and lifestyle
– Antihypertensives, steroids
– Smoking cessation, caffeine intake or withdrawal

Losses
– Role changes
– Mobility/ability

Uncertain future
– Hospitalizations
– Risk of sudden death

Concerns
– Family
– Finances
Simple Screening

“During the past 4
weeks have you
been bothered by
feeling anxious or
worried most of the
time?”
Anxiety Screening Tools

MR FISC
– Motor tension, Restlessness, Fatigue, Irritability, Sleep and
Concentration impairments
Burke & Wright 2007 Anxiety disorders and medical comorbidities. NY: Jobson Medical
Information.

State-Trait Anxiety Inventory
www.mindgarden.com

General Anxiety Disorder- 7
Spritzer Arch Int Med 2006;166:1092-1097

Beck Anxiety Inventory
www.psychcorp.com

Hospital Anxiety and Depression Scale
www.nfer-nelson.co.uk
Factors Affecting Adjustment

Symptom control

Attitude and coping skills

Social support
Psychotherapy

Cognitive behavior
therapy and relaxation
showed up to 60% posttreatment recover at 6
months compared with
4% for analytical
psychotherapy
Fisher et al (1999) Psychol Med;29:1425-1434
Pharmacology

FDA approved drugs for GAD
– Buspirone
– Benzodiazepines (situational, short-term)
• Alprazolam
• Diazepam
• Midazolam
– Selective Serotonin Uptake Inhibitors (SSRI)
• Paroxetine
• Escitalopram
– Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
• Venlafaxine
Depression







Decreased concentration
Energy loss/fatigue
Pleasure loss (ahedonia)
Recurrent thoughts of death
Expressions of sadness,
worthlessness, suicide
Sleep disturbances
Significant weight loss
Heart failure and depression

Reported prevalence ranges from 17-58% \
Artininan (2003) AJN; 103(12): 32-42)

Depression is correlated with inability to adjust to
decreased functional status
Turvey et al (2006) J CV Nsg; 21(3):178-185)

When severity of depression is controlled for,
patients taking antidepressants had a greater
incidence of death and hospitalization for
cardiovascular events.
– Association was independent of the severity of failure
– An independent relationship was not established
Sherwood A, et al. (2007) Arch Intern Med; 167(4):367–73.
“Are you depressed”

Best sensitivity

Best specificity

Best predictive value

Can further clarify using 0-10 scale.
– Scores >5 should be assessed by a specialist
Lloyd-Williams M et al (2003). Pall Med (17(1):40-43
Screening Tools

Beck Depression Inventory
Beck A & Steer R(1987) San Antonio TX: The Psychological Corp

Hospital Anxiety and Depression Scale
Zabora JR (1998). Psycho-oncology. NE: Oxford University Press

Geriatric Depression Scale
Koenig H et al (l988). Am Geriatr Soc;36: 699-706.
Pharmacologic Management

Selective Serotonin Reuptake Inhibitors
(SSRI)
– Citalopram (Celexa), fluoxetine (Prozac),
fuvoxamine (Luvox) ,paroxetine (Paxil),
sertraline (Zoloft)
•
•
•
•
•
Little/No anticholinergic effects
Low risk of conduction abnormalities
No orthostatic hypotension
Very little/no sedation
Low seizure risk
Psycho-stimulants

May be useful for immediate feelings of
enhanced mood, decreased fatigue and
increased appetite

Dextroamphetamine 2.5-5mg daily or
methylphenidate 2.5 mg am and noon

Side effects: tremor, tachycardia, psychoses
at higher doses
Esper in Kuebler et al (2007) Palliative and End of Life Care. Phil, PA: Saunders
Fatigue and Activity Intolerance

Up to 80%
 May be associated
with:
–
–
–
–
–

Activity intolerance
Malaise
Weakness
Loss of strength
Loss of energy
Impacts quality of life
Fatigue Measurements

Fatigue Symptom Inventory Hann 1998
– Severity, frequency, interference, occurrence

Multidimentional Fatigue and Symptom Scale
Stein l998
– General, physical, emotional, mental and vigor

Revised Piper Fatigue Scale Piper l998
– Behavioral, severity, meaning, sensory, cognition
and mood
Jacobsen P (2004). J Natl Cancer Inst Mono; 32; 94
Interventions


Activity records/energy
conservation
Sleep habits
– Mid day 30 minute naps
– No evening naps
– Stimulus reduction




Medication review
Anxiety and depression
management
Transfusions/erythropoetin
production
Exercise
Davidson et al (2001) Psycho-oncology
10(5):389-397
Think outside the box!
Pet Therapy

Heart failure patients visited by
volunteer-dog team for 12
minutes demonstrated
significantly greater decreases
in:
– Pulmonary artery systolic
pressure
– Wedge pressure
– Serum epinephrine and
nor-epinephrine levels
– State anxiety scores
compared to patients who
received no visit or a visit by a
volunteer only
–
Cole et al. (2007)AJCC;16(6):575-588.
Tai Chi


Heart failure patients who
participated in supervised
Tai Chi classes in addition
to usual care
demonstrated significantly
increased quality of life
and distance walked
compared to patients who
received usual care.
No increases in peak
oxygen uptake or adverse
outcomes were reported.
Yeh et al (2004) Am J Med;117:541-548.
Massage

Systematic review of 20
studies showed massage
decreased:
–
–
–
–
–
–
Anxiety
Depression
Pain
Corisol
Catecholamines
Heart rate, blood pressure and
respiratory rate
Field T. (1998) Am Psychol;53:1270-1281
Biofeedback

Randomized controlled trial
of 90 HF patients using
biofeedback for 6 weeks
along with standard care.
Patients in the intervention
group demonstrated:
– 45% decrease in anxiety
– 25% decrease in depression
Moser D, et al (1999) Circulation;100:I-99.
Relaxation

Guided progressive
relaxation reduced
dyspnea in end stage
pulmonary disease
Gift AG et al (1992). Nurs Res; 41(4):242-246.
Renfroe KL (1988) Heart Lung; 41(4): 408-413.
ACCP (2010) Chest; 137(3): 674-691
Continuum of Care
Office Community In Patient Out Patient Home Care Hospice
End of Life Care
Refractory dyspnea
 Terminal pulmonary congestion
 Terminal delirium
 Cardiac cachexia and anorexia
 Inactivation of devices

Hospice Care

Palliative care in the last 6
months of life
– NYHA III or IV
– EF < 20%
– Intractable or frequent,
recurrent symptoms despite
medical optimization
– Other
• Symptomatic arrhythmias,
• History of arrest
• Cardiogenic brain embolism
– Anytime during the
illness
– May include curative
therapies
– Most often a consult
service
– Reimbursed as any
other consult
– Usually ends with
discharge
– 6 month prognosis
– Services covered by Medicare
and most 3rd party payers—
excluding room/board
– Therapies for comfort and
quality of life including
medications
– Admission to service
– 13 mo. Bereavement support
National Consensus Project for Quality Palliative Care 2005
www.nationalconsensusproject.org
HF and Hospice

HF primary diagnosis for approximately 9% of
patients
 Mean LOS 60 days (national overall 51.3
days)
 Expense of some therapies may preclude use
of hospice if hospice was expected to pay for
these
Goodlin et al (2005)J Pain Symp Manage;;29(5):525-528
www.nhpco.org
HF Survival and Hospice

Study of 4493 Medicare recipients
 Hospice vs non hospice
 Hospice patients with heart failure, lung CA,
pancreatic CA and colon CA had statistically
significant longer life compared to nonhospice patients
 No statistically significant difference for breast
and prostate CA
Connor, S et al (2007)Journal of Pain & Symptom Management. 33(3):238-46.
Information Resources

Michigan Hospice and Palliative
Care Organization
– www.mihospice.org

Local hospice and palliative
care services

Get Palliative Care
– www. getpalliativecare.org

National Hospice and Palliative
Care Organization
– www.nhpco.org
“It’s not about death, it’s really
about living with a disease….
Joanne Lynn MD
SUPPORT Primary Investigator
Palliative Care can be…
Like a bridge over troubled
waters