This document provides information on continuing education credit for completing an advanced cardiac disease training. It states that learners must complete an evaluation to receive a certificate of completion and participate in the entire activity, as partial credit is not available. It then lists the accredited organizations that provide credit for various specialties, such as physicians, nurses, social workers, and nursing home administrators. Exceptions to credit eligibility for certain specialties are also noted for some states.

1. Advanced Cardiac Disease

2. CME Provider Information
Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for
a specialty not listed below, it is your responsibility to contact your licensing certification board to
determine course eligibility for your licensing certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and
VITAS® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmecy Education (ACPE), and the American Nurses
Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation
Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.

3. VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board
of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists
through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved by the Illinois Division of Profession Regulation for: Licensed Nursing
Home Administrators and Illinois Respiratory Care Practitioners.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2018 – 06/06/2021.
Social workers completing this course receive 1.0 continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH:
No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
06-2019
CE Provider Information

4. To leverage evidence-based data and case studies to understand hospice
eligibility and benefits for patients with advanced cardiac disease (ACD)
who have a prognosis of ≤ 6 months.
Goal

5. By the end of this presentation, you should be able to:
• Recognize the burden association with heart failure
• Identify patients with advanced heart failure who are eligible for hospice
• Comprehend evidence-based research supporting hospice eligibility
for patients with heart failure
• Understand the role of advanced technologies in end-of-life care
Objectives

6. • Heart disease is the #2 cause of death
in the US in 2020 (COVID-19 is #1).
Heart disease is followed by lung
disease, stroke, and Alzheimer’s
disease/dementia1
• About 655,000 Americans die from
heart disease each year—that’s
1 in every 4 deaths2
• Every year, about 805,000
Americans have a heart attack2
• 30-day post-discharge mortality for
Medicare beneficiaries with heart failure
is 8.7%. Heart failure patients also
experience more post-discharge visits
to the ED3
• According to projections, 8 million
Americans will experience heart failure
by 20304
Heart Disease in the US
1COVID-19 Results Briefing: the United States of America. (2020). Institute for Health Metrics and Evaluation. December 4, 2020.
Retrieved from https://www.healthdata.org/sites/default/files/files/Projects/COVID/briefing_US_20201204.pdf
2US Centers for Disease Control and Prevention. (2020). Heart Disease Facts. Retrieved from: https://www.cdc.gov/heartdisease/facts.htm
3Khera, R., et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort
study of Medicare beneficiaries in the United States. British Medical Journal, 368:6831.
4Riley J., et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure;4:81-87.

7. • In 2018, circulatory/heart disease
(not including stroke) was the second
largest principal diagnosis for patients
enrolled in hospice.1
• Although heart disease is more
common, those with heart disease are
less likely to receive hospice services
than patients with cancer.1
Attributable Causes of Cardiovascular Mortality
1NHPCO. (2020). Facts and Figures: Hospice Care in America.
2American Heart Association. 2020. Heart Disease and Stroke Statistics - 2020 Update. Circulation, 141; e139-e596.
Other, 17.6%
Coronary Heart
Disease, 42.6%
Stroke, 17%
Heart
Failure*,
9.4%
High Blood
Pressure,
10.5%
Diseases of the
Arteries, 2.9%
Percentage of deaths attributable to
cardiovascular disease (2017)2

8. The Burden of Heart Failure
Healthcare System
• 1 million annually, additional
2 million contributory diagnoses,
80% hospitalized in the last
6 months of life
• Hospital readmission 21.4%
within 30 days
• Almost 50% of patients die
within 5 years of HF diagnoses
Benjamin, E., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation. 2019;139:e56–e528.
Riley, J., et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure, 4:81-87.
Wordingham, et al. (2016). Complex care options for patients with advanced heart failure approaching end of life. Current Heart Failure Reports, 13;20-29.
Khera, R., et al. (2018). Association of HRRP with mortality during acute hospitalization. JAMA Network Open, 1(5), e182777-e182777.
• Mortality and hospitalization
– Within 4-10%
– 28 days: 10.4%
– 1 year: 29.5%
– 5 years: 45%
• 1 in 8 deaths has HF listed on the
death certificate

9. The Burden of Heart Failure (cont.)
Benjamin, E., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation. 2019;139:e56–e528.
Riley, J., et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure, 4:81-87.
Wordingham, et al. (2016). Complex care options for patients with advanced heart failure approaching end of life. Current Heart Failure Reports, 13;20-29.
Khera, R., et al. (2018). Association of HRRP with mortality during acute hospitalization. JAMA Network Open, 1(5), e182777-e182777.
Patient and Caregiver
• 32.4 hours of care per week for
average 48.9 months
• Risks include depression, strain,
anxiety, poor QOL, worsening health
Financial
• In 2012, total cost estimated to be
$30.7 billion, more than 50% attributed
to patients in the last 6 months of life
• By 2030, total cost will increase by
127%, to $69.8 billion, amounting
to ~$244 for every US adult
Increased Prevalence
• 6.2 million (up from 5.7 million in 2013)
in the US
• Approximately 1 million new cases
each year
• Projected increase > 8 million people
by 2030 (46% increase)

10. Heart Disease Prevalence
American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035
Percent
of
US
Population
Projected Prevalence of Stated Disease (2015-2035)
CHD CHF Stroke
Any CVD

11. The Burden of Heart Failure on the US Health System (cont.)
Adapted from American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
Current 2035
Total Direct
(Medical) Costs
$318
billion
$749
billion
Total Indirect
Costs
$237
billion
$368
billion
Projections – CVD Direct and
Indirect Costs Through 2035
$0
$50
$100
$150
$200
$250
2015 2035
Billions
of
Dollars
Projected CVD Direct and Indirect Costs Through 2035 by Condition
Direct. Indirect
CHD CHF Stroke Other

12. The Burden of Heart Failure – Symptoms1
1Bekelman, D., et al. (2009). Symptom burden, depression, and spiritual well-being: a comparison of
heart failure and advanced cancer patients. Journal of General Internal Medicine, 24(5), 592-598.
2Riley, J., et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure, 4:81-87.
Outcome
Heart Failure
Low EF
Heart Failure
Normal EF
Advanced
Cancer
Number of Physical
Symptoms
9.4 8.7 8.7
Depression Score 3.6 4.3 3.2
Spiritual Well-Being 35.2 36.3 39.1
Most Common and High-Distress Symptoms of Heart Failure2
Physical problems:
• Shortness of breath
• Feeling drowsy/tired
Psychological problems:
• Worrying
• Feeling irritable
• Pain
• “I don't look like myself”
• Feeling sad
• Feeling nervous

13. • Approximately 34.2 million Americans have provided unpaid
care to an adult age > 50 in the last 12 months
• 39% of caregivers leave their job to have more time to care
for a loved one
• 1 in 10 experience a catastrophic financial burden due to
cumulative out-of-pocket healthcare expenses
• Caregivers who provide care and report strain had a
mortality risk 63% higher than those who were not strained
The Burden of Heart Failure on the Family
National Alliance for Caregiving and AARP (2015). Caregiving in the US 2015.

14. The Burden of Heart Failure on the Family (cont.)
Multidimensional Burden
• Increased responsibilities
and tasks
• Social isolation
• Financial strain
• Loss of former identity
• Decreased quality of life
Physical Health
• Neglected management
of own health
• Fatigue
• Sleep disruption
• Increased mortality
Psychological Health
• Anxiety
• Depression
• Hypervigilance
• PTSD symptoms
• Coping
Rewards
• Accomplishment
• Satisfaction
• Meaning
Known Relationship-Level Outcomes
• Communication challenges
• Concealment of symptoms/feelings
• Conflict or resentment
• Effects on relationship quality
(strengthened or stressed)
• Changes in sexual
relationship (couples)
Known Caregiver Influence
on Patient Outcomes
• Increased quality of life
• Adherence
• Increased physical function
• Emotional well-being
• Decreased healthcare utilization
Kitko, L., et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and
Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020). Family Caregiving for
Individuals with Heart Failure. Circulation. 2020;141:e864–e878. DOI: 10.1161/CIR.0000000000000768

15. Clinical Course of Heart Failure
Mclluennan, C., et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352.
Transition to Advanced Heart Failure
• Oral therapies
• A time for many major decisions
• Consider MCS and/or
transplantation (if eligible)
• Consider inversion of care plan
to one dominated by a palliative
approach, which may involve
formal hospice
Clinical course
Traditional care: including
disease-modifying therapies
Palliative care: including
symptom management

16. NYHA Class Patient Symptoms – Functional Capacity
I
No limitation of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, or dyspnea (shortness of breath).
II
Slight limitation of physical activity. Comfortable at rest. Ordinary physical
activity results in fatigue, palpitation, or dyspnea
(shortness of breath).
III
Marked limitation of physical activity. Comfortable at rest. Less than ordinary
activity causes fatigue, palpitation, or dyspnea.
IV
Unable to carry on any physical activity without discomfort. Symptoms of heart
failure at rest. If any physical activity is undertaken, discomfort increases.
Heart Failure Classification - Symptoms
American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-
failure/classes-of-heart-failure

17. Class Objective Assessment
A
No objective evidence of cardiovascular disease. No symptoms and no
limitation in ordinary physical activity. High risk for developing heart failure.
B
Objective evidence of minimal cardiovascular disease. Mild symptoms and
slight limitation during ordinary activity. Comfortable at rest.
C
Objective evidence of moderately severe cardiovascular disease. Marked
limitation in activity due to symptoms, even during less-than-ordinary activity.
Comfortable only at rest.
D
Objective evidence of severe cardiovascular disease. Severe limitations.
Experiences symptoms even while at rest. Advanced heart failure.
Heart Failure Classification - Objective
The focus here is objective identification of disease. Someone may have severe cardiac disease but minimal symptoms: Class D heart
failure, Functional Status II.
Criteria Committee, New York Heart Association Inc. Diseases of the Heart and Blood Vessels. (1964).
Nomenclature and Criteria for diagnosis, 6th edition. Little, Brown and Co.

18. HF Outcomes by Type
Gotsman, I., et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022.

19. HF Functional Status and Survival
PPS
Score
Ambulation
Activity and
Evidence
of Disease
Self-Care Intake
Conscious
Level
60 Reduced
Unable to do
hobby/housework
Significant disease
Occasional
assistance
necessary
Normal
or
reduced
Full
or
confusion
50
Mainly
sit/lie
Unable to do
any housework
Extensive disease
Considerable
assistance
required
40
Mainly
in bed
Unable to do
most activities
Extensive disease
Mainly
assistance Full or
drowsy
+/-
confusion
30
Totally
bedbound
Unable to do
any activities
Extensive disease
Requires
total care
• Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible
Creber, R., et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure.
ESC Heart Failure, 6(2), 371-378.

20. HF Places of Death
• More patients are dying at
home over time, yet the
majority continue to die in
hospitals and nursing homes;
many are not able to receive
support from hospice services
• Patients and families
continue to report dying at
home as a priority. Hospice
best affords the opportunity
to achieve this goal
Al-Kindi, S., (2017). Where patients with heart failure die: trends in location of death of patients with heart failure in the United States.
Journal of Cardiac Failure, 23(9), 713-714.
0%
5%
10%
15%
20%
25%
30%
35%
40%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Inpatient Emergency Room Home Hospice Nursing Home/LTAC

21. Hospice Eligibility Guidelines for ACD
• NYHA Class III if any of the following
symptoms are present during
less-than-normal activity
(only comfortable at rest):
– Fatigue
– Palpitations
– Angina or dyspnea
• NYHA Class IV as manifested by
any of the following symptoms:
– Dyspnea and/or other symptoms
at rest or minimal exertion
– Inability to carry out physical
activity without dyspnea and/or
other symptoms
– If physical activity is undertaken,
symptoms worsen
• Patient is optimally treated for heart
disease or maximally treated and
not pursuing surgical options

22. Hospice Eligibility Guidelines for ACD (cont.)
• Significant/supporting comorbidities:
– Hypertension
– Diabetes
– Coronary artery disease
– Prior myocardial infarction
– Valvular heart disease
• Indicators of poor prognosis:
– Renal dysfunction
– Cachexia
– Valvular regurgitation
– Ventricular arrhythmias
– Low left ventricular ejection
fractions (LVEF)
– Elevated B-type natriuretic
peptides (BNP)
– Low serum sodium
– Marked left ventricular dilatation
– Syncope and near-syncope

23. • Hospice admission guidelines are independent of labs and EF
• The question to ask oneself: “Would I be surprised if the
patient were to die in the next year? 6 months?”
Key indicators for a hospice referral:
• Decrease in function
• Increase in patient symptoms and distress
• Frequent/increased utilization of medical
care, especially hospitalization and ED visits
• Start the conversation
Hospice Eligibility Guidelines for ACD (cont.)
Creber, R., et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure;
6:371-378.

24. • Determine goals of care – what is important?
• Manage symptoms holistically
– Psychosocial interventions
– Nonpharmacologic interventions
– Medications
• Avoid suffering and prolongation of dying
• Achieve a sense of control
• Relieve burdens
• Strengthen relationship with loved ones
The Role of Hospice in ACD

25. Pharmacologic Interventions as Heart Failure Progresses
Class Name Indication Adverse Effects Comments
Aldosterone Blocker Spironolactone NYHA III or IV
• Hyperkalemia
• Renal dysfunction
Monitor hyperkalemia
ACE Inhibitor
Enalapril
Lisinopril
Ramipril
HF Stage B-D
• Hyperkalemia
• Renal dysfunction
• Hypotension Angioedema
• Cough First line for systolic HF
Beta-Blockers Carvedilol
Metoprolol
• Fatigue
• Hypotension
• Depressed mood
ARBs
Losartan
Valsartan
Candesartan
• Hyperkalemia
• Renal dysfunction
• Hypotension
Substitution for ACE
inhibitors, not with ACEI
Loop Diuretics
Furosemide
Torsemide
Bumetanide
Volume overload
• Renal dysfunction
• Frequent urination
• Increase thirst
IV or Sub Q admin
Cardiac Glycosides Digoxin
Symptomatic
HF after 1st line
• Cardiac arrythmias
• Ventricular hypertrophy
• Nausea
• Delirium
Monitor toxicity closely
This slide outlines appropriate treatment of heart failure. A patient’s intolerance to an escalation of medications or a need to have
medications de-escalated are indications of progressive disease and decompensation, and should trigger a discussion about hospice
eligibility and appropriateness.

26. • 76-year-old female with 3
hospitalizations in the past 6 months
for HF exacerbations and recent
fall due to syncope. Discharged to
home from hospital; now at PCP for
follow-up visit with her daughter
– PMH: NYHA Class III HF, HFpEF,
hypertension, COPD,
dementia, recent syncope;
recent LV EF 48%
– Stays in bed or recliner most of the
time; difficulty bathing and dressing
– Antihypertensives have been
de-escalated due to hypotension
– Current medications: ACE inhibitor,
oxygen, nebulizers
– Dyspneic, anxious, diffuse muscle
wasting
– BP 92/64, HR 108 bpm, RR 22,
pulse ox 93% 2L NC, afebrile
• Goals-of-care (GOC) conversation
Case of AF

27. • No hospital
• Minimal tests
• Improve shortness of breath
• Continue to live at home
• Live as long as possible
Elements Important to Goals-of-Care Conversation, Shared
Decision-Making
Allen, L. A., et al. (2012). Decision making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation, 125(15), 1928-1952.
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Outcomes
Relevant to
Individual
Patient
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social

28. • PCP refers AF to VITAS for
hospice care after GOC
discussion with support
from daughter
• Is AF hospice-eligible?
Yes. Why?
– NYHA Class III with dyspnea
on minimal exertion
– PPS 50%
– Frequent hospitalizations
for HF
– History of hypertension,
now hypotensive and
unable to tolerate optimized
medical therapy
– Weight loss/cachexia
– Oxygen-dependent with COPD
– Recent syncopal episode
– Tachycardia at rest
– Progressive fatigue
Case of AF (cont.)

29. Association of Hospice Admission with Rehospitalization
Kheirbek, R., et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure.
Circulation: Heart Failure, 8(4), 733-740.
• 41% of the heart failure patients who died
within six months of hospital discharge and
did not receive hospice services had at
least one rehospitalization within 30 days
prior to death
• Only 5% of heart failure patients who
died within 6 months and were admitted
to hospice were rehospitalized within
30 days
• Findings suggest that only 10% of
1,790 patients who died within 6
months after hospital discharge
received hospice referral
Patients Who Received Hospice Had Significantly
Lower 30-Day All-Cause Readmission Rates

30. Comprehensive Services
Service VITAS Home Health
Eligibility • Physician-certified prognosis
< 6 months, if disease runs its
normal course
• Hospice prognosis must be
re-certified periodically
• Patient agrees to palliative,
not curative, plan of care
• Plan of care determined by initial and
ongoing doctor/team assessment,
combined with patient/family wishes
• Not required to be homebound
• Must require skilled level
of care and a specific plan
of care confirming need,
frequency, and duration
of visits
• Skilled nursing care
need must be re-certified
periodically
• As skilled needs change,
approved services change
• Must be homebound, except
for short durations
Length of Care Unlimited number of visits based
on patient need, if prognosis
remains 6 months or less
• Limited number of visits
• Must document progress within
the length of service allowed
Medications
Included
VITAS provides Rx and OTC
medications related to hospice
diagnosis at no charge to the patient
Medications are not covered
under the Medicare Home
Health Benefit
Service VITAS Home Health
Palliative Care
Physician Support
Yes No
Nurse Visit Frequency
Unlimited based
on patient need
Diagnosis-driven
RT/PT/OT/Speech Yes Yes
Equipment Included Yes No
After-Hours Staff
Availability
Yes No
Levels of Care 4 Levels Home
Care Plan Review Weekly Variable
Targeted Disease-Specific
Program(s)
Yes Variable
Bereavement Support Yes No

31. Patients’ and Clinicians’ Barriers to Hospice
Misinformation
Communication
breakdown
Discomfort around
EOL issues
Treatment
discontinued
in hospice
Disease has
unpredictable trajectory
Patient overestimates
survival
Patient experiences
frequent exacerbations
Hospitalized HF patient
lacks DNR status
Patient misunderstands
hospice
Prognostication
proves challenging

32. • AF is admitted to VITAS and placed
on Routine Level of Care; her
symptoms and quality of life improve
with palliative interventions
– RN visits weekly, hospice aide
visits twice weekly
• 7 weeks later, AF develops increased
dyspnea overnight, daughter calls
Telecare for help. VITAS RN visits
to assess and treat AF
• AF placed on Intensive Comfort Care®
;
physician visits to assess and evaluate
– Diuresis with SQ Lasix and careful
titration of cardiac medications
– Increased oxygen and low-dose
morphine for dyspnea/air hunger
• 4 days later, symptoms are
improved and AF returns to
Routine Level of Care
Case of AF (cont.)

33. Case of AF (cont.)
• After 2 months of well-managed
care, AF again develops worsening
dyspnea, accompanied by decreased
level of consciousness and poor
oral intake
• AF placed on Intensive Comfort Care®
for symptom management
• Medications are titrated for comfort
• VITAS physician, RT, SW, and
chaplain visit AF
• After a total of 109 days of care at
home, AF dies comfortably with her
daughter by her side

34. Advanced Cardiac Interventions
Advanced, aggressive interventions may be
appropriate to palliate symptoms of ACD.
These may include:
• Parenteral diuretics
• IV inotropes
• Pacemaker or Cardiac
resynchronization therapy (CRT)
• Ventricular assist device (VAD)
Defibrillator – not palliative

35. Advanced Interventions – Parenteral Diuretics
Afari, M., et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review.
Heart Failure Reviews, 24(3), 309-313.
• Diuretics can be administered IV or SQ
• SQ diuretics can eliminate the need for an IV
for patients at home
• Similar outcomes between SQ and IV
– Similar diuresis
– No difference in rehospitalizations
• Dosing can be continuous infusion or intermittent
• Limited data in severely obese and end-stage kidney disease
• Local side effects can occur – stinging, burning, swelling

36. Advanced Interventions – Inotropes
• IV inotropes can be used for symptom control in select patients with advanced
heart failure on optimal medical management and who are not candidates for
mechanical circulatory support or transplant
– Improved NYHA Class – Functional Capacity
– No association with mortality
– No association with hospital readmission
– ICD shock
• Hospice will provide inotropes when appropriate, as they palliate symptoms
Ginwalla, M., et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616.

37. Advanced Interventions – Inotropes (cont.)
Ginwalla, M. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448.
Name
Mechanism
of Action
Primary
Effects
Maintenance
Dose
Benefits
Risks/
Adverse
Effects
Significant
Adverse
Reaction
Indications for
Discontinuation
Dobutamine
Stimulates
Beta-1 and
Beta-2 receptors
Inotropic and
chronotropic
2-20
mcg/kg/min
Slows heart rate and
strengthens
cardiac contractility
Reduces sinoatrial
firing rate
Reduces atrial
fibrillation and
ventricular flutter
Increases ejection
fraction
Decreases pulmonary
congestion
Tachycardia
Dizziness
Nausea and
vomiting
Anorexia
Blurred
vision
Interacts with
many meds
and most
OTC drugs
• PVC’s
• Palpitations
• Headache
• Nausea
Side effects
outweigh benefits
Refractory to inotrope
Tolerance
Develop HF symptoms
Patient request-requires
goals of care discussion
Milrinone
Phosphodiesterase
III Inhibitor
Inotropic,
arterial and
venous
dilation
0.375-0.75
mcg/kg/min
• Arrhythmias
• Hypotension
• Angina
• Hypokalemia

38. Case of MJ
• 26 y/o with idiopathic cardiomyopathy (EF 15%)
• Not a transplant or LVAD candidate
• Traveled from Atlanta to Chicago to visit family
• Increased shortness of breath and swelling
• Poor insight into condition, eats chips and fast food
• ICU care for dobutamine initiation and titration
• Relative stabilization of condition
• Cardiologist states “nothing more can be done”

39. • Be with mother in her house
• Be with kids as much as possible
• Help family as much as possible
• Improve shortness of breath
• Live as long as possible
Elements Important to Goals-of-Care Conversation
Allen, L., et al. (2012). Decision making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation, 125(15), 1928-1952.
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Outcomes
Relevant to
Individual
Patient
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social

40. • Cardiologist is involved
• Requires more permanent central venous access
• Fixed/maintenance dose, no active up-titration
• No previous hypersensitivity to inotropes
• Patient/family agreeable to hospice plan of care
– No monitors, not a bridge to transplant or LVAD
– Typically discharged on continuous care for transition
Home Hospice Inotropic Therapy: Considerations

41. • Admitted to VITAS on Intensive Comfort Care®
• Electricity issues developed and needed to be
transferred to inpatient unit
• Died comfortably 7 days after enrollment
– Intense family support
– High-risk bereavement plan
Case of MJ (cont.)

42. Case of RZ
• 73 y/o male with advanced HF
• Mechanical circulatory support
with LVAD
• Developed infection and on
suppressive antibiotics for
several weeks
• Clot started to form despite
anticoagulation therapy
• Patient functional status declined;
now can ambulate only a few steps
• Hospitalized and then transferred
to LTAC for continued, aggressive,
life-prolonging interventions,
yet decline continued
• Palliative care consult for
goals of care

43. • Get home
• Be with wife and dogs
• Improve shortness of breath
• Die when unable to communicate
Elements Important to Goals-of-Care Conversation
Allen, L., et al. (2012). Decision making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation, 125(15), 1928-1952.
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Outcomes
Relevant to
Individual
Patient
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social

44. • In a study of 14,072 hospitalized older adults discharged to LTAC:
– Median survival 8.3 months, 55% deceased at 1 year
– 47.1% achieved recovery, with plateau at 9 months
– Median time of remaining life spent in an inpatient
faciltiy was > 65%
– More than one-third died in an inpatient setting
– 16% enrolled in hospice, with median 10 hospice days
– Prognosis worse for patients ≥ 85 and those admitted
with primary respiratory diagnosis
LTAC and Hospice
Makam, A., et al. (2019). The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries.
JAGS, 67(11). https://doi.org/10.1111/jgs.16106

45. Hospitalized older adults
discharged to LTAC:
• 8.3-month median survival
• Patients ≥ 85: 4-month
median survival
– Spent 97.7% of remaining
days as an inpatient
• Patients with respiratory Dx
– 5.3-month median survival,
spent 88.8% of remaining
days as an inpatient
LTAC and Hospice (cont.)
Makam, A., et al. (2019). The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries.
JAGS, 67(11). https://doi.org/10.1111/jgs.16106

46. 1Harrington, L., et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
2Balla, C., et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65:37-34.
Type Indication Benefits Burdens Comments/Reasoning
Pacemakers/
CRTs
Both:
• Symptomatic bradycardia
• 2○ or 3○ heart block
CRT only:
• NYHA Class III and IV
• Certain Class II patients
Improves:
• Symptoms of heart disease
• Quality of life
• Cardiac function
All:
• Battery lifespan
• Infection (rare)
• Malfunction (rare)
• Poorer outcomes1:
– Typically placed in patients who
are > 90 y/o, renal failure, active
malignancy, connective tissue
disorder, dementia
cerebrovascular disease,
AICD only:
• Risk of traumatic death
Life expectancy of years
Rare to discontinue–may result
in acute HF exacerbation
Not palliative
Recommend to deactivate when
patient has advanced illness
Defibrillators/
AICDs
High risk of life-threatening
arrhythmias
Delivers shock
to convert to normal rhythm
Fewer hospitalizations
VADs
(LVAD, RVAD,
BiVAD)
Advancing HF despite
maximal medical therapy–
Bridge to transplant/
decision/recovery or
destination therapy
Improves:
• HF symptoms
• Quality of life
Complications:
• Stroke
• Infection
• Sepsis/pneumonia
• Serious bleeds
• Pump malfunction (rare)
External battery must always
be connected
LVAD does not improve 1-yr
survival but does show significant
symptom benefit over OMM
after 1 yr
Improved survival with
continuous flow2:
• 78% at 1 yr
• 45% at 4 yrs
Advanced Mechanical Interventions (cont.)

47. Trajectories After LVAD Implantation
DeFilippis, E. et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
Journal of the American Geriatrics Society, 67(11), 2410–2419. https://doi.org/10.1111/jgs.16105

48. Clinical Scenarios Leading to LVAD Discontinuation
Brush, S., et al. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist device.
The Journal of Heart and Lung Transplantation, 29(12), 1337-1341.
• Catastrophic complications of the LVAD or LVAD failure
– Stroke, sepsis, and multi-organ failure
• Poor quality of life despite LVAD
– Chronic infections, hemodialysis, poor functional status
• Comorbid conditions
– Cancer, dementia, etc.

49. Case of RZ (cont.)
• Recognizes has only days left to live
• Concerned about family well-being
• Would prefer to be at home with his wife and dogs
• Beginning to develop shortness of breath and some confusion
• Hospice nurse trained in device deactivation
• Communication with cardiology team

50. • Patient went home on Intensive Comfort Care®
• Did well for 3 days; then became more confused and unconscious
• Per goals-of-care conversation, LVAD deactivated when unconscious
– Symptoms controlled beforehand; meds available
– IDT team present
– Nurse deactivated LVAD
• Patient died 5 minutes later
Case of RZ (cont.)

51. • Deactivation can occur at home
– Address family concerns about hospice’s knowledge of LVADs
• Hospice nurse/physician trained on device deactivation
– Includes silencing of alarm
• Survival after deactivation ranges from minutes to a few days
– Explain the heterogeneity of survival time to family
– Average time to death with device deactivation: 20 minutes
LVAD Discontinuation
Brush, S., et al. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist device.
The Journal of Heart and Lung Transplantation, 29(12), 1337-1341.

52. Questions

53. Afari, M. E., et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart failure
reviews, 24(3), 309-313.
Al-Kindi, et al. (2017). Where patients with heart failure die: trends in location of death of patients with heart failure in the
United States. Journal of Cardiac Failure, 23(9), 713-714.
Allen, L. A., et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association.
Circulation, 125(15), 1928-1952.
American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/
heart-failure/what-is-heart- failure/classes-of-heart-failure
American Heart Association. (2020). Heart Disease and Stroke Statistics - 2020 Update. Circulation, 141; e139-e596.
Balla, C., et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65: 37-43.
Bekelman, D., et al. (2009). Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced
cancer patients. Journal of General Internal Medicine, 24(5), 592-598.
Benjamin E., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation, 139(10):e56–528.
Brush, S., et al. (2010). End-of-life decision making and implementation in recipients of a destination left ventricular assist
device. The Journal of Heart and Lung Transplantation, 29(12), 1337-1341.
References

54. COVID-19 Results Briefing: the United States of America. (2020). Institute for Health Metrics and Evaluation. December 4, 2020.
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Creber, R., et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients
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Criteria Committee, New York Heart Association Inc. Diseases of the Heart and Blood Vessels. (1964).
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DeFilippis, E. et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
Journal of the American Geriatrics Society, 67(11), 2410–2419. https://doi.org/10.1111/jgs.16105
Ginwalla, M. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448.
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Harrington, L., et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
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References

55. Khera, R., et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national
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