Tavr turndown now what palliation, hospice and other options

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TAVR Turndown: Now What? Palliation, Hospice and Other Options Keith M. Swetz, MD, MA, FACP, FAAHPM Consultant, Department of Medicine, Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, MN Associate Professor of Medicine, Mayo Clinic College of Medicine

Controversies in Treatment for Advanced Cardiovascular Disease: Tough Choices ACC.15 San Diego Convention Center, Room 5A Sunday, March 15, 2015; 1230-1345hr


TAVR Turndown: Now What? Palliation (ALWAYS) Hospice and Other Options (Sometimes)


Objectives

• Define comprehensive palliative care and how it differs from hospice.

• Explain the emerging models for end-of-life care for patients with advanced structural heart disease, and, in diseases with uncertain prognosis (like advanced heart disease), what a palliative care approach might look like.

• Describe the role of palliative care in symptom management and explore treatment strategies for the end-stage cardiac patient.


Nkomo V et al. Lancet. 2006:368;1005-11.


Swetz and Mansel, Cardiol Clin 2013.


Cardiac disease course (HF and AS)

Goodlin et al. J Card Fail. 2004:54;200-9.


What is Palliative Care?

• Active, total care of patients whose diseases are not fully responsive to curative treatment

• Symptom control is top concern

• Achieve best quality of life for patients and families

• Affirms life, regards dying as a normal process

• Neither hastens nor postpones death


How is Palliative Medicine practiced and

palliative treatments delivered?

• Comprehensive management by interdisciplinary team

• Medical, nursing, social work, spiritual ministers, and others

• Enhance comfort and improve quality of life

• No specific therapy is excluded

• Continual assessment of treatment goals


What is hospice and how does it differ

from Palliative Care?

• Hospice—palliative care to terminally ill patients, providing support services to family and caregivers, 24/7, in the home or facility-based setting

• Palliative care can begin when symptoms begin, in a disease process that cannot be cured

• Hospice is a specific type of palliative care provided when a patient is terminally ill (i.e. life expectancy < 6 mos.)

• There are certain Medicare rules that often govern hospice care, while palliative care is not subject to these rules.


Why is this distinction important?

• If one thinks palliative care and hospice are the same thing, and that a patient has to be imminently dying before they qualify for service, then symptoms may not be addressed until it’s too late

Palliative care ≠ hospice ≠ nothing we can do ≠ death

• “There’s nothing more we can do….”

• “We may not be able to cure you, but there is ALWAYS something we can do!”


Palliative Care & Hospice

Palliative Care

Hospice

Comfort

Care


Curative or disease-

targeted care %

Clinical

Effort

0

100

time death terminal phase

bereavement

Palliative care

Emerging Model for End-of-Life Care


Frailty and Outcomes


Why Important with TAVR?

• Frailty is a major driver of why TAVR is done.

• Patients have other needs for curative or disease directed therapies.

• Challenging to know if standard frailty assessment tools valid for this population

• Question if frailty increase risk of short-term morbidity after TAVR, versus higher risk with cardiac surgery

Afilalo et al. JACC. 2004:63;757-8.


Frailty and Outcomes

• “frailty index, but not established risk scores, was predictive of functional decline”

Schoenenberger et al. Eur Heart J. 2013


Goals of Care


Patient-centered Outcomes:

Determining the Goals of Care

Allen L et al. Circulation 2012 Apr 17;125(15):1928-52


Kaldjian and Goals of Care

• Cure

• Live longer

• Improve/maintain health

• Make comfortable

• Accomplish life goals

• Provide support for family caregivers

• Understanding diagnosis/prognosis

• Other or all equally important


Ways to Providing Patient-Centered Care

Shared Decision Making and Programatic Opportunities


Thanks to Dr.

Megan Coylewright,

copyrighted,

publications in

progress.


Thanks to Dr.

Megan Coylewright, copyrighted,

publications in progress.


Thanks to Dr.

Megan Coylewright,

copyrighted, publications in

progress.


Figure 1. Conceptual model for the integration of best end-of-life care

in the care of severe aortic stenosis. Adapted from Jaarsma et al., Eur J Heart Failure 2009;11: 433–443.




Table 1. Models of functional status assessment in transcatheter heart valve

(THV) programs.




Table 3. Survey of referring physicians after referral for palliative approach for

the management of severe aortic stenosis.




Quill TE, Abernethy AP. N Engl J Med 2013;368:1173-1175.

“We hope that every medical field

will define a set of basic palliative

skills for which they will be primarily

responsible and distinguish them

from palliative care challenges

requiring formal consultation. Such a

model might be better and more

sustainable than our current system,

as we strive to make high-quality

health care available to all

Americans.”


Questions & Discussion

[email protected]

Palliative Care

Hospice

Comfort

Care

Tavr turndown now what palliation, hospice and other options

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