Palliative care in heart failure

1. National Hospice and Palliative Care Organization’s
Palliative Care Resource Series
PALLIATIVE CARE FOR HEART FAILURE PATIENTS:
PRACTICAL TIPS FOR HOME BASED PROGRAMS
Parag Bharadwaj, MD
Anjali Chandra, MD
Donna Stevens, BS
Ernst R. Schwarz, MD, PhD

2. INTRODUCTION
 More than 5 million people suffer from heart failure (HF) in the
US
 Half the people who develop HF die within 5 years of
diagnosis
 HF has a high symptom burden
 Palliative care intervention provides comfort and optimization
of treatment plan and goals

3. OVERVIEW
 HF
 Definition
 Pathophysiology
 Clinical Features
 Disease Management
 Palliative Care in HF Patients at Home

4. DEFINITION OF HEART FAILURE
 HF is a pathophysiologic condition in which the efficiency
of the myocardium is reduced through damage and
overloading, resulting in decreased cardiac output (CO)
and circulatory failure
 Characterized by recurrent decompensation and
persistent symptoms

5. RELEVANT PATHOPHYSIOLOGY
 Heart fails to pump adequate blood to meet the requirements
of the metabolizing tissues
 Types
 Systolic HF
Impaired contractile function of the heart with reduced ejection
fraction (EF)
EF < 40% might indicate systolic HF
 Diastolic HF
Impaired ventricular filling during relaxation phase
Normal EF of 55 – 60%

6. CLINICAL FEATURES
 Predominant Symptoms
 Shortness of Breath
 Exceptional Dyspnea
 Orthopnea
 Paroxysmal Nocturnal Dyspnea
 Acute Pulmonary Edema
 Pain around the chest and other parts of the body is under
diagnosed

7. CLINICAL FEATURES
 Other Common Signs and Symptoms:
 Fatigue
 Weakness
 Weight Gain
 Nausea and Bloating
 Sexual Dysfunction
 Insomnia
 Lack of Concentration
 Cognitive Decline
 Memory Loss
 Muscle Wasting
 Cachexia

8. DISEASE MANAGEMENT
 Non-Pharmacological Interventions
 Exercise
 Diet
 Sodium Restriction
 Fluid Restriction
 Nutrition

9. DISEASE MANAGEMENT
 Pharmacological Interventions
 Diuretics
 Vasodilator
 Inotropes
 Beta Adrenergic Receptor Blockers
 Angiotensin-Converting Enzyme Inhibitors (ACEIs)
 Angiotensin II Receptor Blockers (ARBs)
 Supplemental Oxygen

10. DISEASE MANAGEMENT
 Invasive Strategies
 Electrophysiologic Intervention Devices: CRT and pacemakers
 Ventricular Assist Device (VAD)
 Revascularization Procedures: CABG and PCI
 Valvular Surgery: valve replacement or repair, ventricular
restoration

11. PALLIATIVE CARE FOR HF PATIENTS AT HOME
 Meeting the patients’ needs at home lessens the patient and
caregiver burden and prevents avoidable hospital admissions
 Delivery of this type of care requires intense planning and
care coordination between all involved medical specialties
and additional support
 Team involved includes Palliative Care, Primary Care,
Cardiology, as well as some additional community partners
such as Home Care, Parish Nurses and Area Agency on Aging

12. CLINICAL: AREAS OF FOCUS
 Vital Signs, with special attention to:
 Oxygen Saturation
 5th vital sign - pain
 Physical Exam
 Labored Breathing
 Fluid Overload
Jugular Venous Distention (JVD)
Auscultation of Lungs: Crackles
Pedal Edema

13. CLINICAL: AREAS OF FOCUS
 Weight and Fluid Input/Output
 Weight Gain – Fluid Overload
 Input should be less than output
 Insensible Water Loss: 600 – 900ml/day
 Functional Status (use one tool consistently)
 Suggest Palliative Performance Scale (PPS)
 Monitor for change – fluid overload, progression of disease
 Prognostic implications

14. CLINICAL: AREAS OF FOCUS
 Screening for Symptoms (use one tool consistently)
 Suggest Edmonton Symptom Assessment Scale (ESAS)
 Medication Reconciliation
 Assess ability to manage medications
 Ensure understanding, purpose and importance of each
medication
 Ensure adequate supply of medication to optimize compliance

15. CLINICAL: AREAS OF FOCUS
 Hardware Check (pacemakers, ICDs)
 Relevance of the devices in relation to goals needs to be
revisited on a regular basis
 Intravenous Inotrope Infusions
 Requires higher level of maintenance
 Fixed dose, usually not titrated

16. CLINICAL: AREAS OF FOCUS
 VADs and Post Transplant Patients
 Experienced multi-disciplinary team must be involved in
management
 Protocols placed in advance, including turning off the device at
home
 Review of Records
 Essential to know baseline of clinical parameters in order to
identify significant changes

17. CLINICAL: AREAS OF FOCUS
 Any changes in the areas of focus will require a more
thorough assessment to determine changes needed in
the home regimen or to escalate care to the next level,
such as setting up an appointment with the cardiologist
or transfer to the hospital
 All changes should be implemented in collaboration with
the HF service

18. ADDITIONAL NEEDS ASSESSMENT: AREAS OF
FOCUS
 Emotional and Financial Support Screening
 Request social worker follow-up, if needed, in addition to routine
social worker visits
 Spiritual Needs Screening
 Request chaplain visit, if needed, in addition to routine chaplain
visits
 Caregiver Screening
 Ensure social worker and chaplain support to caregiver(s)
 Monitor for burnout

19. PATIENT GOALS: AREAS OF FOCUS
 Care plan and patient goals should be reviewed frequently
with the patient and caregiver to ensure the appropriate
care is being delivered
 Every patient should have an advance directive completed,
preferably a POLST (Physician Orders for Life Sustaining
Treatment)
 Any changes should be promptly reflected in the document
 Documents should be readily available to patient, caregiver and
paramedics (if called)

20. PATIENT GOALS: AREAS OF FOCUS
 Depending on the patient’s clinical status, options and
goals should be readdressed on a regular basis
Informing the patient and the caregiver of options,
including hospice, is necessary

21. REVIEW AND EDUCATION: AREAS OF FOCUS
 Any changes in the treatment plan should be given to the
patient and caregiver in writing and reviewed with them
during the visit
 Before leaving the patients’ residence, patients and/or
caregivers should be instructed to call the palliative care
service with any questions or concerns. A back-up plan
must be in place when the service is not available.
 Ideally, a call to the primary physician/cardiologist should
be made from the patient’s home during every visit and
the plan of care should be reviewed

22. OPERATIONAL
 Outline scope of practice of each team member
 Optimization of care requires team function as one unit
with team members being able to rely on each other
 Routine Interdisciplinary Team (IDT) meetings are
essential

23. OPERATIONAL
 Role delineation is vital
Meet with primary care colleagues and the cardiology
team to establish parameters
 Strong relationship with cardiology and primary care is
essential
Involve all specialties during regular patient care
meetings
Operational communication is vital for discussing
changes such as protocols and practice personnel

24. OPERATIONAL
 Emergency strategy needs to be set up
Off-work hours plan needs to be in place if your
service is not 24/7
 Clinical and operational data, patient/family satisfaction
and referring entity satisfaction should be collected and
reviewed routinely
 Additional support from cardiology is essential if
palliative care becomes involved with VAD patients

25. OPERATIONAL
 Expected Outcomes
 Improved continuity and quality of care
 Decrease in ER visits and hospitalizations
 Increased adherence to patient goals
 Improved patient and provider satisfaction

26. SUMMARY: LESSONS LEARNED AND BEST
PRACTICES
 A well-coordinated team is required, preferably with a
shared electronic medical record
 Frequent team meetings allow other insights and
techniques; each home setting is unique and requires
attention and respect for the environment
 Focus should be on keeping the patient comfortable and
meeting patient/family goals, versus just avoiding
hospitalizations. Some hospitalizations may be
appropriate

27. SUMMARY: LESSONS LEARNED AND BEST
PRACTICES
 Prevention and preventative plans are vital
 Home is where the heart is; figuring out how to eliminate
obstacles for patients is part of the terrain
 Social interactions and being able to give to others in
some way is good medicine

28. SUMMARY: LESSONS LEARNED AND BEST
PRACTICES
 An office nurse coordinator who will work with the
palliative care provider(s) and triage phone calls, provide
clinical input, assist with care coordination and manage
referrals maximizes the providers’ time
 Relationships develop in a different way when in the
home; resiliency and self-care must be part of this work