Palliation for Congestive Heart Failure Patients

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Palliation for Congestive Heart Failure Patients

• Dr. Glen Drobot and Estrellita Estrella-Holder,
  clinical nurse specialist
• Heart Failure Clinic
• St. Boniface General Hospital
• Hospice Palliative Care Manitoba Conference
  September 12, 2008

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Objectives

• Define heart failure (HF), end stage HF
• Define palliative care
• Review methods to assess prognosis in HF patients
• Outline measures for palliation of end-stage HF
  patients

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Definition of Heart Failure

• Heart Failure is a clinical syndrome where
• Heart and circulation are unable to meet the
  demands of the body
• Includes situations where metabolic demands are
  elevated (i.e. high output HF from anemia)
• Or only able to do so at an abnormally elevated
  diastolic volume

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Stages of Heart Failure

• American College of Cardiology defines stages of
  heart failure
• Differs from New York Heart Association classes
  of symptoms (I IV)
• Akin to stages of renal disease
• Stage A high risk for developing HF
• Stage B asymptomatic LV dysfunction
• Stage C past or current symptoms of HF
• Stage D end-stage HF

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Stages of Heart Failure

• Progressive nature of LV dysfunction
• Progress in one direction due to cardiac
  remodeling
• Patient can move between NYHA classes

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• Stage A emphasizes preventability
• Stage B is asymptomatic LV dysfunction

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• typical patient is in Stage C
• Increasing numbers of patients with Stage D
• Palliation is appropriate

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Scope of the problem of HF

• 1 in 100 Canadians suffer from HF
• Prevalence steadily increased since 1970
• Most common cause for hospitalization among
  patients over age 65
• HF contributes to 9 of all deaths in Canada

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Palliative Care (WHO)

• Approach that improves the quality of life of
  patients and families facing life-threatening
  illness
• Prevention and relief of suffering
• Early identification and assessment
• Treatment of pain and other problems physical,
  psychosocial and spiritual

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Palliative Care and HF

• Emphasizes goal of improving quality of life (not
  necessarily quantity)
• Decrease symptoms
• Reduce rates of hospital admissions
• Both Canadian and American HF guidelines have
  sections devoted to end-of-life issues

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Prognosis of HF

• Difficult to predict time of death
• Challenging in HF due to
• Cyclical nature of disease
• Complexity of care
• Recent advances, especially in the area of
  medical devices
• Implantable defibrillators
• Biventricular pacemakers (cardiac
  resynchronization)

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Prognosis of HF

• Mechanism of death in HF
• Sudden cardiac death
• Brady- or tachyarrhythmias
• Progressive heart failure
• Varies depending on NYHA class
• NYHA class II higher risk of sudden death or
  drop
• NYHA class IV increasing dyspnea/ orthopnea,
  decreased BP LOC or drown

Arnold et al. CCS Can J Cardiol 2006
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Predicting Mortality in HF

• Risk stratification for in-hospital mortality in
  acutely decompensated HF (ADHF)
• ADHERE American registry of HF patients from
  263 community and teaching hospitals totaling
  65,000 hospitalizations
• Identified 3 variables urea, creatinine, and
  systolic blood pressure
• Divided into low risk (mortality 2),
  intermediate risk (5-12), and high risk (22)

Fonorow et al. JAMA 2005
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30-day and 1-year Mortality in HF

• Retrospective study of 4000 patients presenting
  with HF in Ontario, divided between derivation
  and validation cohorts
• Newly admitted patients with a primary diagnosis
  of heart failure
• Baseline characteristics
• Mean age 76
• Females 50
• EF
• Prior MI 37 AFib 29

Lee et al. JAMA 2003
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30-day Mortality in HF
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1-year Mortality in HF
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Case of Mr. K.

• 60-year-old male
• Ischemic cardiomyopathy, EF 20, AFib
• DM 2 x 10 years
• Some degree of hepatic cirrhosis
• Systolic BP 100 mm Hg, RR 20
• Initial investigations
• Na 130, urea 25
• Hgb 143 g/L

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Mr. K. acute decompensation HF

• Urea 15
• BPsys
• Creatinine
• Intermediate-high 12.4 for that hospital
  admission
• Calculated risk score 33 mortality _at_ 30 d.
• and 78 mortality _at_ 1 year!

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Limitations of Studies

• Probabilities HF can be a very unpredictable
  syndrome
• Latter study uses data performed on initial
  hospitalization for HF
• Prognosis is only one component of care? patients
  want symptom control and generally want to leave
  hospital

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General Measures in End-stage HF

• Meticulous identification and control of fluid
  retention, including avoidance of certain
  medications
• NSAIDs, celecoxib
• non-dihydropyridine CCBs (verapamil, diltiazem if
  low EF)
• Thiazolidinediones (TZDs) (rosiglitazone,
  pioglitazone)
• Metformin in chronic kidney disease
• Most antiarrythmics (? risk sudden death)

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General Measures in End-stage HF

• Referral of patients to HF program with expertise
  in management of refractory HF
• Options for end-of-life care discussed with
  patients and family
• Patients with refractory HF and ICDs should
  receive information about the option to
  inactivate defibrillation
• (continuous IV positive inotrope)
• (cardiac transplant, LV assist device)

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Management of Fluid Status

• Many patients have symptoms of congestion (versus
  low-output, ie. fatigue)
• Increasing doses of loop diuretic
• Addition of 2nd diurectic, eg. Metolazone
• Hospitalization for IV medications
• Accept elevations of urea creatinine
• Discharge after stable/effective diuretic regimen
  established
• Close to euvolemia

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Step-wise Approach
Hauptman and Havranek. Arch Intern Med 2005
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Step-wise Approach
Hauptman and Havranek. Arch Intern Med 2005
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Evidence for general measures?

• Guidelines provide levels of evidence for many
  aspects of medical management
• Paucity of recommendations/data for many aspects
  of care
• Palliation of dyspnea and fatigue
• Treatment of depression
• Communication re advance care planning, course
  of illness

Goodlin et al. J Card Failure 2004
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Evidence for specific measures?

• Oxygen therapy
• No studies in advanced HF
• Small studies in mild-moderate, stable HF
• Variable improvement in symptoms
• More than just correction of hypoxemia
• Adverse effects
• Restriction of activities
• Psychological dependence to have oxygen on at all
  times
• Hypercapneic respiratory failure
• Difficult to withdraw when not needed

Booth et al. Resp Med 2003
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Evidence for specific measures?

• Opiates
• Commonly used in palliative care for pain and
  dyspnea
• Studied in acute LV dysfunction, but less so in
  chronic setting
• Morphine has sedative, hemodynamic, neurohormonal
  and ventililatory effects
• Small cross-over study showed improvement in
  breathlessness after 4 days of morphine 5mg qid,
  with increased sedation constipation

Johnson et al. Eur J Heart Failure 2001
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Back to Mr. K.

• Frequent hospitalizations for dyspnea
• Rapid accumulation of ascites
• Persistent large (R) pleural effusion
• Variable degree of renal insufficiency
• Admitted about 75 of the time over past 3 months
• What would your approach be?

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Plans with Mr. K.

• Expressed desire to have everything done on a
  few occasions
• Wife and daughter (who is a nurse) didnt agree
  with this approach, but respected his decision
• HF clinic physician and ward physician ? frank
  discussion about probable lack of benefit with
  resuscitation given poor prognosis
• Agreed to change from ACP plan 4 ? 3

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Plans with Mr. K.

• Elective abdominal paracentesis to decrease
  chance of hospitalization
• Home O2 therapy at 2L for mild hypoxemia
• Plan to consult pain and symptom control clinic
  readdress goals of therapy
• Progressive renal insufficiency
• Discussed palliative care and the program
• Passed away at home

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Mr. M.

• 72-year-old male with DM 2, ESRD on CAPD,
  ischemic cardiomyopathy
• Admitted with a fall about 3 weeks earlier
• No evidence of fracture
• Basically, bed-bound entire admission
• Problems of hypotension vs. enough volume removal
• Has an implantable cardiac defibrillator (ICD)

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Mr. M. - continued

• What do you do with the ICD?

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Mr. M. - continued

• Retrospective study, n 232 people with ICDs who
  died over 5 year period
• Able to contact 136 next-of-kin, of which 100
  participated
• Discussion of deactivation of ICD occurred in
  only 27/100 cases
• Usually discussion occurred in last few days of
  life
• Family report that 8 patients received a shock in
  last few minutes of life

Goldstein et al. Ann Int Med 2004
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Mr. M. - continued

• Spoke with family and patient about deactivation
  of defibrillator function of ICD
• Emphasized not turning off the patient
• Highlighted that dont want patient to suffer a
  shock near the end of life
• The procedure is painless
• Mentioned possibility of dying an arrhythmic
  death

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Summary

• Most patients progress to later stages of
  symptomatic HF
• Prognosis may be difficult to determine, as very
  fluctuating course
• Frequent reassessment of goals of therapy is
  necessary
• Palliative care does not preclude ongoing,
  intensive management of HF

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Bibliography

• Bekelman DB et al. Defining the role of
  palliative care in older adults with heart
  failure. Int J Card 2007 125 183-90.
• Booth S et al. The use of oxygen in the
  palliation of breathlessness. A report of the
  expert working group of the scientific committee
  of the association of palliative medicine. Resp
  Med 2003 98 66-77.
• Johnson MJ et al. Morphine for relief of
  breathlessness in patients with chronic heart
  failure a pilot study. Eur J Heart Failure
  2001 4 753-6.
• Johnson MJ. Management of end stage cardiac
  failure. Postgrad Med J 2007 83 395-401.

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Bibliography

• Fonorow GC et al. Risk stratification for
  in-hospital mortality in acutely decompensated
  heart failure. JAMA 2005 293(5) 572-80.
• Goldstein NE et al. Management of implantable
  cardioverter defibrillators in end-of-life care.
  Ann Int Med 2004 141 835-8.
• Lee DS et al. Predicting mortality among patients
  hospitalized for heart failure derivation and
  validation of a clinical model. JAMA 2003
  290(19) 2581-7.
• http//www.ccort.ca/CHFriskmodel.asp

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Bibliography

• Charette SL. The next step palliative care for
  advanced heart failure. J Am Med Dir Assoc 2006
  11(1) 63-4.
• Goodlin SJ et al. Consensus statement palliative
  and supportive care in advanced heart failure. J
  Card Failure 2004 10(3) 200-9.
• Pantilat SZ, Steimle AE. Palliative care for
  patients with heart failure. JAMA 2004 291(20)
  2476-82, e1.
• Hauptman PJ, Havranek EP. Integrating palliative
  care into heart failure care. Arch Intern Med
  2005 165 374-8.