End Stage Heart Failure in Hospice


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Hospice for end stage heart failure patients and the nursing considerations

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  • Dilated Cmy, Ventricular hypertrophy…..hypertrophic Cmy mitral stenosis, pericardial disease
  • NYHA Functional Classification: I-IV. Stage A at high risk w/o heart dz or symptoms, Stage B with structural heart disease w/o S/S HF, Stage C with structural heart dz with prior or current S/S HF, Stage D is refractory.
  • A group of patients whose symptoms limit daily life despite usual rec therapies and for whom lasting remission into less symptomatic dz is unlikely.
  • Cardinal symptom of HF: awareness of breathing at rest or when not expected. Fatigue r/t abn of skeletal muscles & other comorbidities. It promotes a vicious cycle.
  • Any of these therapies may reset the trajectory. Hi risk surgery anticipates there will be residual cardiac dysfunction.PCI: contrast induced nephropathy and 30D mortality increased.Pacing Device/CRT: Contingencies should be made ? ThoracotomyICD: improves survival by aborting lethal arrhythmias but don’t improve functionTemp mech support: may create indefinite dependenceInotropes: clinically significant milestone. Chronic? Goals should be established in advanceRRT: kidney dz increases dramatically. May not extend life in HF.Transplant: Exchange of diseaseVAD…as destination therapy
  • Scientific statement from AHA published 3/12
  • Emotion: Data demonstrates as little as 40 sec of empathetic comments can improve outcomes r/t communication (NURSE): Name the emotion, understand, respect, support the patient, explore the emotion. Depression: rates 4 fold higher in stage D vs A. Associated with impaired cognition interfering with processing. Cognition: Pts have poor understanding of medical interventions. (In pts on statin 38% did not treatment was lifelong and 83% could not id most common side effect). Cognitive decline in 25-5-% of patients. Family Dynamics: Barrier to negotiation. Culture & Religion: Be aware of the influence. Be careful assuming. Language: Subtleties and nuances can be missed with EASL. Family interpreters problematic. Time: Constraints faced by pts and clinicians. Billable visits… Resolving Conflict: Intervention desired may appear discordant with stated goals and medical reality. National culture of entitlement and denial of m/m doesn’t help.
  • Leading cause of inpatient admission in patients 65 and older. HF has a worse prognosis than many common cancers.
  • Pts tend to live variable lengths in continuous state of poor health with intermittent exacerbations.
  • There are many risk calculators: Seattle Heart Failure Model, Heart Failure Survival Score to define prognosis. There are significant underestimates of life expectancy in ambulatory HF.
  • QOL: symptoms, physical function, mental, emotional, social.
  • CSA loss of central drive to resp muscles. OSA functional collapse of pharynx. Poorer prognosis.
  • NSAIDS increase sodium retention and peripheral vasoconstriction
  • Depressed patients have increased hospitalizations and cardiac events. Also increased incidence of ICD shocks.
  • Studies show hospices with deactivation policies in place have more patients with deactivated devices…..
  • No consensus. Practical constraints such as hypotension, renal dysfunction, pill burden…..Should discontinue 1 at a time to assess
  • As HF worsens increased deliveries are certain. Ideally conversations would be had prior to insertion.
  • End Stage Heart Failure in Hospice

    1. 1. ADVANCED HEART FAILURE Dana Kay, MSN, ACNP-BC SHVI/CMC-Main February 2013
    2. 2. HEART FAILURE DEFINITION • A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs ability of the ventricle to fill with or eject blood. • Current patients with HF are older, have more comorbidities and take more medications than in the past. Wong et al 2011
    3. 3. ADVANCED HEART FAILURE • AHF affects 2.4% of adults • 11% of those are > 80 years old • Estimated costs reaching 44.6 billion by 2015 • Therapies slow but infrequently reverse progression
    4. 4. TIME TO INTERACT Any of you with heart failure patient on your service right now?
    5. 5. TYPES OF HEART FAILURE LEFT SIDED RIGHT SIDED (reduced cardiac output) (fluid overload) Systolic Dysfunction: -decreased contractility Diastolic Dysfunction: -abnormal or restrictive ventricular filling -Usually from LV failure
    6. 6. Stage D – Refractory HF requiring specialized interventions (Class IV NYHA) Marked symptoms at rest despite maximal medical therapy GOALS – appropriate measures under Stages A, B, C Options – compassionate end-of-life care/hospice, extraordinary measures including transplant, chronic inotropes, ventricular assist device, experimental surgery or drugs
    7. 7. WHAT IS THE MOST COMMON SYMPTOM IN STAGE D HEART FAILURE? A. Dyspnea B. Fatigue C. Anorexia D. All of the Above
    8. 8. MAJOR INTERVENTIONS TO IMPROVE CARDIAC FUNCTION • High risk cardiac surgery • Temporary mechanical circulatory support • Percutaneous intervention • Renal replacement therapy • Pacing device therapy • Transplantation • Implantable defibrillator • Ventricular assist device • Positive inotropic agents
    9. 9. POTENTIAL BENEFITS OF SAID THERAPY • Improves functional status • Reduces symptoms • Improves hemodynamics • Improves echocardiographic parameters • Improves QOL
    10. 10. SHARED DECISION MAKING • Annual HF review with patients to include current/potential therapies for the anticipated and unanticipated events • Review advanced care decisions on admission to the hospital • Clinical milestones such as hospitalization, ICD shocks should trigger review of the advanced care plan with discussion of treatment options and preferences Circulation 2012
    11. 11. SHARED DECISION MAKING • Discussion should include range of anticipated outcomes and QOL • Therapies that lead to dependence should be weighed carefully • Referral to palliative team should be considered Circulation 2012
    12. 12. BARRIERS TO SHARED DECISION MAKING • Emotional roadblocks • Depression and anxiety • Limitations of cognition, literacy, and numeracy • Family dynamics • Culture and religion • Language differences • Time • Resolving conflict Circulation 2012
    14. 14. COMMON SYMPTOMS EXPERIENCED BY HF AND CANCER PATIENTS Similar to cancer Dyspnea Fatigue Anorexia Cachexia Pain Postural hypotension Anxiety Depression Different from cancer More edema More renal dysfunction More signs of poor perfusion
    15. 15. TIME TO INTERACT What percentage of patients on your service have cancer? Have heart failure or cardiac disease?
    16. 16. PROGNOSIS AND THE ADVANCED HEART FAILURE TRAJECTORY Heart Failure Less Predictable -Loss of functional abilities at onset of diagnosis -Slower decline with repeated hospitalization -Pump failure versus sudden death
    17. 17. PROGNOSIS AND THE ADVANCED HEART FAILURE TRAJECTORY Compared to Cancer Predictable Course -Longer functional abilities before downward slide -Average lifespan of 6 months after begin to decline
    18. 18. PROGNOSIS AND THE ADVANCED HEART FAILURE TRAJECTORY Clinical signs of reduced tissue perfusion: -low MAP -renal insufficiency -poor response to diuretics -lack of improvement with therapy These patients have worse prognosis…..
    19. 19. RISK ESTIMATES IN ADVANCED HEART FAILURE • MDs and RNs always overestimate survival -In prospective cohort of terminally ill patients: 20% accurate 63% optimistic 17% pessimistic **inaccuracy increased the longer the relationship BMJ 2000
    20. 20. PROGNOSIS FOR QUANTITY AND QUALITY OF LIFE ADAPTED FROM SPILKER Direct/Indirect Medical Costs Caregiver Burden Lost Opportunities Survival QOL Outcomes Relevant to Individual Patient
    21. 21. WHEN SHOULD HOSPICE BE CONSIDERED IN AHF? • Frequent hospitalizations • Poor QOL with inability to perform ADLs • Need for intermittent or continuous intravenous support • Consideration of assist devices as destination therapy • Preference for comfort care over life sustaining treatment
    23. 23. BREATHING ASSESSMENT • Have you felt SOB? Do you wake up SOB at night? • Can you speak as much as you want? • What makes breathing easier? • Do you cough? Is it worse than usual? • Do you cough up secretions? • Have you increased your oxygen?
    24. 24. SLEEP ASSESSMENT • Have HF symptoms kept you from sleeping? • Do you sleep in bed or a chair? • Are you able to lay flat in bed? • How many pillows do you use? • Have you recently slept more or less than usual?
    25. 25. DIET ASSESSMENT • Have you recently eaten more salty foods or drank more water than usual? • How often do you eat out? • Have you gained or lost weight recently? • Have you experienced swelling? • How far up your legs do you have edema? • Are your clothes, rings, belt and shoes tighter than one week or one month ago?
    26. 26. MEDICATION ASSESSMENT • Have you taken all prescribed meds? • Did you run out of any medications? • Have you had diarrhea/vomiting? • Have you taken extra diuretic meds? • Have you changed the dose of any meds? • Do you take any OTC meds or herbal supplements?
    27. 27. ACTIVITY ASSESSMENT • How far can you walk? • Can you dress, bathe, prepare food, climb stairs without stopping to rest? • What activities could you do recently but not now because of worsened symptoms? • Have you decreased your activity level?
    28. 28. CONFUSION ASSESSMENT • Do you have difficulty remembering information or feelings of confusion? • Have you had other health problems that may make your heart failure worse?
    29. 29. POSSIBLE EXAM FINDINGS IN HEART FAILURE PATIENTS • Resting tachycardia • Increased respiratory rate • Decreased strength of peripheral pulses • Orthostatic changes in pulse and BP • JVD • Rales • Wheezes • Decreased breath sounds (effusions) • Irregular rhythm • S3 or S4 • Murmurs • Ascites • RUQ pain/tenderness • Cyanosis • Peripheral edema • Muscle wasting
    30. 30. EVIDENCE-BASED TREATMENT ACROSS THE CONTINUUM OF SYSTOLIC LVD AND HF Control Volume Diuretics Renal Replacement Therapy* Improve Clinical Outcomes Aldosterone ACEI -Blocker Antagonist or ARB or ARB CRT  an ICD* HDZN/ISDN* *In selected patients Treat Residual Symptoms Digoxin HFSA 2010
    31. 31. ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACE-I): • Alleviates symptoms, improves clinical status • Enhances overall sense of well-being • Improves duration of exercise • Reduces hospitalization and risk of death • If target doses cannot be reached, intermediate doses should be used Benazepril, Captopril, Lisinopril, Monopril
    32. 32. ANGIOTENSIN RECEPTOR BLOCKERS (ARB): • ARBs if ACE-I intolerant d/t cough or angioedema (valsartan and candesartan) • Reduces hospitalizations and mortality Candesartan, Losartan, Valsartan
    33. 33. ALDOSTERONE ANTAGONISTS: • Reduced risk of death, reduction in HF hospitalization • Improvement in functional class • May help manage volume overload • D/C K supplements and avoid high K foods Spironolactone, Eplerenone
    34. 34. BETA-BLOCKERS: I • Inhibits the adverse effects of the SNS • Lessens symptoms, improve clinical status, reduce risk of death • Begin as soon as LV dysfunction is diagnosed • Initiate at low dose w/gradual increases Atenolol, Metoprolol, Carvedilol
    35. 35. DIGOXIN: • Benefit likely due to neurohormonal mechanism rather than inotropic effect, does not improve survival • No loading dose necessary in SR • Can be used for rate control of AF • New info supports using lower doses and targeting a dig level of 0.5-1ng/ml
    36. 36. DIURETICS: • Loop diuretics (furosemide, bumetanide, torsemide) increase sodium excretion by 20-25% of proximally filtered load • Improves exertion and breathlessness • Thiazides (HCTZ, metolazone) increase sodium excretion 5-10% (preferred in HTN HF secondary more persistent antihypertensive effects) • For optimal synergy, give thiazide 30 min (IV) or 60 min (po) before loop • Monitor K and magnesium closely
    37. 37. ASA & WARFARIN: • ASA if patient has CAD • Warfarin only if other indication such as AF or history/risk of embolic event
    38. 38. NITRATES • Relieve dyspnea Nitroglycerin, Isosorbide
    39. 39. INOTROPES DOBUTAMINE & MILRINONE: • Dobutamine stimulates beta receptors • Increases CO and SV • Milrinone vasodilator via phosphodiesterase inhibition • Decreases afterload and preload, increases CO *As a bridge to transplant or in outpatient setting in pts who could not otherwise be discharged as palliative measure
    40. 40. SYMPTOM MANAGEMENT: FATIGUE • Treat sleep disordered breathing • Central sleep apnea • Obstructive sleep apnea • Treat anemia • Iron • EPO • Aranesp
    41. 41. SYMPTOM MANAGEMENT DYSPNEA Diuretics: Inotropes: Loop diuretics such as Furosemide and Torsemide Dobutamine, Milrinone, Dopamine Thiazide diuretics such as Metolazone Opiods: Morphine Vasodilators such as IV Nesiritide Fentanyl
    42. 42. SYMPTOM MANAGEMENT DYSPNEA • Non pharmacologic: • Dietary sodium restriction • Fluid restriction • Upright positioning in bed, recliner or chair • Utilize fan on face • Oxygen
    43. 43. SYMPTOM MANAGEMENT PAIN • Anti-anginals • Opiods • NSAIDS should be avoided
    44. 44. SYMPTOM MANAGEMENT DEPENDENT EDEMA • Pharmacologic • Loop diuretics • Thiazide diuretics • Non pharmacologic • Dietary sodium restriction • Leg elevation NSAIDS should be avoided • Calf pumping • Rest periods in recumbent position • Compression stockings
    45. 45. SYMPTOM MANAGEMENT ANOREXIA Pharmacologic: Non Pharmacologic: Megesterol acetate Small frequent meals Soft, easy to chew foods Mirtazipine Rest before and after meals Nutritional supplements Entice with favorite foods
    46. 46. SYMPTOM MANAGEMENT ANXIETY/AGITATION/CONFUSION Pharmacologic: Non Pharmacologic: Benzodiazepines HF Education Titrate to effective dose Neuroleptics Advanced care planning Relaxation exercises Haldol Olanzapine Distraction
    47. 47. TIME TO INTERACT Does Hospice of Union County have a deactivation policy? Did you know that 50% of Hospices had an ICD delivery in the last year?
    48. 48. END OF LIFE CARE PLANNING • Should be consistent with patient values, preferences and goals • CLINICIANS SHOULD INITIATE THE CONVERSATION • Deactivation of ICD is desirable avoiding pain/distress • Active discontinuation VAD is often appropriate
    49. 49. DISCONTINUATION OF MEDICATIONS • Medications • Statins • Anti-hypertensives • Coumadin
    50. 50. ICD/CRT-D DEACTIVATION INDICATIONS • Patient/family request • Irreversible cognitive failure • Imminent death • DNR order • Withdrawal anti-arrhythmic drugs
    51. 51. VENTRICULAR ASSIST DEVICE DEACTIVATION • For use as destination therapy • 2 year mortality is 40-50% • Develop acceptable device withdrawal plan www.thoratec..com
    52. 52. DOCUMENTATION FOR DEVICE DISCONTINUATION • Confirm patient has requested the deactivation • Capacity of the patient or surrogate to make decision • Confirm alternative therapies have been discussed • Confirm consequences of deactivation have been discussed • Specific device to be deactivated • Notify family if appropriate
    53. 53. BIBLIOGRAPHY Allen, L, Stevenson, L, Grady, K et al. Decision Making in Advanced Heart Failure: A Scientific Statement From the American Heart Association. Circulation. 2012; 125:1928-1952. Sandesh, D, Abernethy, A, Rogers, J, O’Connor, C. Preferences of People with advanced heart failure-a structured narrative literature review to inform decision making in the palliative care setting. Am Heart J 2012; 164:31319.e5. Morrison, L, Calvin, A, Nora, H, Storey, C. Managing Cardiac Devices Near the End of Life: A Survey of Hospice and Palliative Care Providers. American Journal of Hospice & Palliative Medicine. 2010; 27 (8):545-551. Paul, S, and Glotzer, J. Clinical Evaluation of the Heart Failure Patient. American Association of Heart Failure Nurses. November 2004 on www.aahfn.org.
    54. 54. BIBLIOGRAPHY Kutner, J. An 86-Year-Old Woman With Cardiac Cachexia Contemplating the End of Her Life: Review of Hospice Care. JAMA. 303(4), 27 January 2010: 349-356. www.aha.org www.heartfailureguideline.org