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Tavr turndown now what palliation, hospice and other options
1.
©2011 MFMER |
slide-1 TAVR Turndown: Now What? Palliation, Hospice and Other Options Keith M. Swetz, MD, MA, FACP, FAAHPM Consultant, Department of Medicine, Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, MN Associate Professor of Medicine, Mayo Clinic College of Medicine Controversies in Treatment for Advanced Cardiovascular Disease: Tough Choices ACC.15 San Diego Convention Center, Room 5A Sunday, March 15, 2015; 1230-1345hr
2.
©2011 MFMER |
slide-2 TAVR Turndown: Now What? Palliation (ALWAYS) Hospice and Other Options (Sometimes)
3.
©2011 MFMER |
slide-3 Objectives • Define comprehensive palliative care and how it differs from hospice. • Explain the emerging models for end-of-life care for patients with advanced structural heart disease, and, in diseases with uncertain prognosis (like advanced heart disease), what a palliative care approach might look like. • Describe the role of palliative care in symptom management and explore treatment strategies for the end-stage cardiac patient.
4.
©2011 MFMER |
slide-4
5.
©2011 MFMER |
slide-5 Nkomo V et al. Lancet. 2006:368;1005-11.
6.
©2011 MFMER |
slide-6
7.
©2011 MFMER |
slide-7 Swetz and Mansel, Cardiol Clin 2013.
8.
©2011 MFMER |
slide-8 Cardiac disease course (HF and AS) Goodlin et al. J Card Fail. 2004:54;200-9.
9.
©2011 MFMER |
slide-9 What is Palliative Care? • Active, total care of patients whose diseases are not fully responsive to curative treatment • Symptom control is top concern • Achieve best quality of life for patients and families • Affirms life, regards dying as a normal process • Neither hastens nor postpones death
10.
©2011 MFMER |
slide-10 How is Palliative Medicine practiced and palliative treatments delivered? • Comprehensive management by interdisciplinary team • Medical, nursing, social work, spiritual ministers, and others • Enhance comfort and improve quality of life • No specific therapy is excluded • Continual assessment of treatment goals
11.
©2011 MFMER |
slide-11 What is hospice and how does it differ from Palliative Care? • Hospice—palliative care to terminally ill patients, providing support services to family and caregivers, 24/7, in the home or facility- based setting • Palliative care can begin when symptoms begin, in a disease process that cannot be cured • Hospice is a specific type of palliative care provided when a patient is terminally ill (i.e. life expectancy < 6 mos.) • There are certain Medicare rules that often govern hospice care, while palliative care is not subject to these rules.
12.
©2011 MFMER |
slide-12 Why is this distinction important? • If one thinks palliative care and hospice are the same thing, and that a patient has to be imminently dying before they qualify for service, then symptoms may not be addressed until it’s too late Palliative care ≠ hospice ≠ nothing we can do ≠ death • “There’s nothing more we can do….” • “We may not be able to cure you, but there is ALWAYS something we can do!”
13.
©2011 MFMER |
slide-13 Palliative Care & Hospice Palliative Care Hospice Comfort Care
14.
©2011 MFMER |
slide-14 Curative or disease- targeted care% Clinical Effort 0 100 time deathterminal phase bereavement Palliative care Emerging Model for End-of-Life Care
15.
©2011 MFMER |
slide-15 Frailty and Outcomes
16.
©2011 MFMER |
slide-16 Why Important with TAVR? • Frailty is a major driver of why TAVR is done. • Patients have other needs for curative or disease directed therapies. • Challenging to know if standard frailty assessment tools valid for this population • Question if frailty increase risk of short-term morbidity after TAVR, versus higher risk with cardiac surgery Afilalo et al. JACC. 2004:63;757-8.
17.
©2011 MFMER |
slide-17 Frailty and Outcomes • “frailty index, but not established risk scores, was predictive of functional decline” Schoenenberger et al. Eur Heart J. 2013
18.
©2011 MFMER |
slide-18 Goals of Care
19.
©2011 MFMER |
slide-19 Patient-centered Outcomes: Determining the Goals of Care Allen L et al. Circulation 2012 Apr 17;125(15):1928-52
20.
©2011 MFMER |
slide-20 Kaldjian and Goals of Care • Cure • Live longer • Improve/maintain health • Make comfortable • Accomplish life goals • Provide support for family caregivers • Understanding diagnosis/prognosis • Other or all equally important
21.
©2011 MFMER |
slide-21 Ways to Providing Patient-Centered Care Shared Decision Making and Programatic Opportunities
22.
©2011 MFMER |
slide-22 Thanks to Dr. Megan Coylewright, copyrighted, publications in progress.
23.
©2011 MFMER |
slide-23 Thanks to Dr. Megan Coylewright, copyrighted, publications in progress.
24.
©2011 MFMER |
slide-24 Thanks to Dr. Megan Coylewright, copyrighted, publications in progress.
25.
©2011 MFMER |
slide-25 Copyright © by European Society of Cardiology Sandra Lauck et al. Eur J Cardiovasc Nurs 2014;13:177-184
26.
©2011 MFMER |
slide-26 Figure 1. Conceptual model for the integration of best end-of-life care in the care of severe aortic stenosis. Adapted from Jaarsma et al., Eur J Heart Failure 2009;11: 433–443. Copyright © by European Society of Cardiology Sandra Lauck et al. Eur J Cardiovasc Nurs 2014;13:177-184
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slide-27 Table 1. Models of functional status assessment in transcatheter heart valve (THV) programs. Copyright © by European Society of Cardiology Sandra Lauck et al. Eur J Cardiovasc Nurs 2014;13:177-184
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slide-28 Table 3. Survey of referring physicians after referral for palliative approach for the management of severe aortic stenosis. Copyright © by European Society of Cardiology Sandra Lauck et al. Eur J Cardiovasc Nurs 2014;13:177-184
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slide-29 Quill TE, Abernethy AP. N Engl J Med 2013;368:1173-1175. “We hope that every medical field will define a set of basic palliative skills for which they will be primarily responsible and distinguish them from palliative care challenges requiring formal consultation. Such a model might be better and more sustainable than our current system, as we strive to make high-quality health care available to all Americans.”
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slide-30 Questions & Discussion swetz.keith@mayo.edu Palliative Care Hospice Comfort Care
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