Improving the care of patients dying of heart failure

1
Improving the care of patients dying of heart
failure

• Andrea Lees
• Heart Failure Liaison Nurse
• Monklands Hospital
• February 2006

2

• Heart failure is an increasingly common problem
  and much can be done to relieve its symptoms and
  prolong life.
• Indeed HF produces greater suffering and is
  associated with a worse prognosis than many
  cancers.

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Worsening Heart Failure

• LV progressively dilates
• Recurrent episodes of decompensation
• Dyspnoea and oedema increase
• Drugs become less effective
• Renal function deteriorates

4
Common symptoms of end-stageheart failure

• Breathlessness
• Pain
• Abdominal fullness
• Nausea
• Early meal satiety
• Palpitations/racing heart
• Easily fatigued,leg weakness,lack of
  energy,persistent cough,weight loss,sleep
  problems,memory problems,oedema
• Pleural effusion
• Anorexia
• Cachexia
• ascites

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Do we contribute to this malaise?

• Over diuresis/fluid restriction?
• Digoxin toxicity
• Ace inhibitor induced cough
• Beta-blocker induced malaise
• Opiate related constipation

6
Depression

• Major depression in 26
• Minor depression in 32
• Koenig et al
  1988
• Increase in mortality
• Readmissions are raised

7

• Heart failure patients are much more likely to
  die in hospital than are cancer patients.
• They are also more likely to receive invasive
  interventions in the last three days of life.

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• Patients with heart failure have special
  palliative care needs,but palliative measures for
  treating the symptoms of end stage heart failure
  have been largely ignored .
• A formal disease management program for heart
  failure should include palliative care.

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Why have heart failure patients been underserved?

• Constraints on access to resources
• Wide variation in funding base
• Heavy reliance on UK cancer based charities
• Cardiologists/palliative care professionals do
  not normally interact
• Existing services may be overwhelmed
• Poorly defined disease trajectory

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End of life (terminal) care

• When a patient is expected to die in the near
  future.
• Turning away from active treatment..concentrating
  on relief of symptoms and support for both
  patient and family
• 
  Saunders C

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What should be done now-if not sooner?

• Discuss prognosis and prospects of improvement
  with patients/carers
• Discuss important related issues
• Use established symptom control protocols
• Consider working with the Gold Standard Framework

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Dying of Heart Failure

• Response to therapy?
• Symptom Relief Complete Partial None
• Pain 23 34
  34
• Dyspnoea 36 39
  24
• McCarthy et al,J.Roy.Coll.Phys.Lond,(30)325,1996

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Compared to lung cancer

• Cardiac patients received less health,social and
  palliative care services and care was often
  poorly coordinated. Murray 2002
• Most people with heart failure do not understand
  the cause or prognosis of their disease and
  rarely discuss end of life issues with their
  carers Murray 2002

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Trajectory of Dying
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Reasons for difficulties in predicting prognosis

• Numerous clinical scenarios
• Unpredictable response to treatment
• High incidence of sudden death
• Concerns that
• A) precipitant may be overlooked
• B) alternative drug combinations may help

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Practical Clinical Approach

• Progressive oedema,renal failure or hyponatraemia
  with no reversible cause.
• Deterioration despite optimal therapy
• Patient wishes. .Ward,Heart 2002,
  87294-298
• Intuitive Approach
• Would I be surprised if the patient died
• over the next 12 months

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Therapeutic approaches often denied heart failure
patients

• Adequate alleviation of symptoms related to the
  primary diagnosis/other conditions
• Acknowledgment of disease-specific barriers to
  predicting outcome
• Emphasis on quality of life
• Early discussion on prognosis/patient views
• A strategy for transition from curative to
  supportive care

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• Currently cardiovascular disease accounts for
  only 1.6 of referrals for specialist palliative
  care.

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• It is unrealistic to expect the wider needs for
  palliative care to be met by expanding the
  workforce of specialists in palliative care
• It is more likely that a solution will be found
  by expanding the knowledge and skills of health
  professionals generally.
• WHO
  2004
• 
  

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House of CommonsHealth CommitteePalliative
CareFourth Report of Session 2003-2004

• Recognised inequity of access to palliative care
  for non-cancer patient
• Accepted that much of the care for those with
  cancer was transferable
• Proposed the NICE guidelines on supportive and
  palliative care for adults with cancer as the
  benchmark for developing this support

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What does general palliative care involve

• NICE in 2004 suggested the following
• Assessment of patient and carer need for support
• Information to patients and carers known as
  signposting
• Co-ordination in and out of hours and across
  boundaries
• Basic levels of symptom control
• Psychological,social,spiritual and practical
  support
• Open and sensitive communication
• Referral to specialist palliative care when
  necessary

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• Managed frameworks of care include the Gold
  Standard Framework(GSF) and the Liverpool Care
  Pathway(LCP).
• They were both developed as tools to organise
  and improve the care of people with advanced
  cancer.Where they have been introduced to a care
  setting,health professionals have also used them
  for people with advanced non-malignant diseases
  such as heart failure.

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Coronary Heart Disease Collaborative

• CHF NYHA III or IV
• Patient thought to be in last year of life by the
  care team
• Patient has repeated hospital admissions with
  symptoms of HF
• Pt has difficult physical/psychological symptoms
  despite optimal tolerated therapy

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Liverpool Care Pathway

• The patient is bed bound
• Semi comatose
• Only able to take sips of fluid
• No longer able to take tablets

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Liverpool Care Pathway

• Does not preclude continuation of conventional
  medications.
• Doesnt accelerate death
• Is not euthanasia
• It does provide optimum comfort and support for
  the patient and carers.

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Opiates in the treatment of heart failure
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Morphine for heart failure

• Dyspnoea much improved especially pnd.
• No adverse effect with nausea,BP,sedation or
  respiratory rate.
• Johnson MJ et al.EHJ
  2002
  

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• Essential for acute LVF
• Regularly used long term in lung cancer
• Fears of tolerance,dependence and withdrawal
  problems are unfounded.
• Should be prescribed as in palliative care
  protocols

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Lanarkshire

• Managed Clinical Network for non malignant
  palliative care.
• Working with GPs and district nurses
• Out of hours nursing care.
• Appropriate referrals to specialist palliative
  care and use of hospice
• Palliative care guidelines for symptom relief

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Conclusion

• Good care at the end of life should be a
  universal right and not just reserved for those
  with cancer.