Christine Westphal NP MSN

ACNS-BC ACHPN CCRN

Director/Nurse Practitioner

Palliative and Restorative Integrated Services Model (PRISM)

Oakwood Healthcare System

Dearborn, Michigan

A Bridge Over Troubled Waters:Palliative Care in Heart Failure

Objectives

1. Describe the trajectory of heart failure.

2. List three palliative care outcomes in end stage heart failure with related interventions

3. 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 • Obesity• HTN • Illicit drugs• Atrial fibrillation • Cardiotoxic

medications• Infection • Sleep apnea• Congenital abnormalities • Anemia

Idiopathic dilated cardiomyopathy

Ventricular Dysfunction: Output

Neuroendocrine activation Renin-Angiotensin-Aldosterone Sympathetic Nervous System Vasopressin

Pressure/volume

HR, BP, Myocardial O2 consumptionSodium/water retention/edemaIschemia, dsyrhythmiasDecreased end organ perfusion

Ventricular hypertrophyVentricular remodeling Fibrosis Cell death (apotosis)

Natiuretic Peptides ANP (atrial) BNP (brain)

Attempts to compensate Diuresis Decrease neuroendocrine response

Immune up-regulation Cytokines Tumor necrosis factor Interleukins

Copyright ©2009 American Heart Association

2009 WRITING GROUP ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE, et al. Circulation 2009;119:1977-2016

Recommended Therapy by Stage

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: 179–185Burt 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 co-

morbidities 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 hospitalRusso 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 Michigan2008 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 yearsMacIntyre et al (2000) Circulation; 102: 1126-1131Khand 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 transplantationKuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach. St.

Louis: Mosby.Hershberger et al (2003) Cardiac Fail; 9: 180-181Albert et al (2002) Cleve Clin Med J. ; 69: 321-328Alla 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 statusKuebler, 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;3:247-251.

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

illnessesMichigan 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

50%

60%

70%

80%

90%

100%

Controlled ControlledAnxiety Dyspnea

Non-palliative care

Palliative care

North Kansas CityHospital

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 Prevalence%

# Studies N

COPD 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):399-410Solano, 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

*Vertical Dyspnea

Visual Analog Scale

*Borg Scale

Dyspnea Exertion Scale– Level I: Walk w/o SOB to– Level 5: Breathless @ rest

10= Severe distress

0= No distress

•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

Asphyxia produces innate, non-voluntary, 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.

Respiratory Distress Observation Scale

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 2.5-5mg– Hydrocodone 2.5-5mg – Oxycodone 2.5-5mg– Hydromorphone 1-2 mg– Codeine 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 aboveWestphal & 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.

Oxygen

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 .

– 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% post-treatment 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 2005www.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 non-hospice 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

Palliative Care can be…

“It’s not about death, it’s really about living with a disease….

Joanne Lynn MD SUPPORT Primary Investigator

Like a bridge over troubled waters