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Advanced Cardiac Disease

This document provides comprehensive details regarding a continuing education program focused on advanced cardiac disease, including eligibility requirements for various healthcare professionals seeking credits. It emphasizes the significant burden of heart disease in the U.S., outlining statistics related to mortality, hospitalization, and impacts on patients and caregivers. Additionally, it covers the guidelines for hospice eligibility and the role of palliative care in managing advanced cardiac conditions.

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Advanced Cardiac Disease
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 Pharmacy 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.
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
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
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 through evidence-based research • Understand palliative interventions for patients with advanced cardiac disease • Understand the role of advanced technologies in end-of-life care Objectives
• Heart disease is the #1 cause of death in the US, with nearly 634,000 deaths in 2020, followed by cancer and COVID-191 • 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 ED2 • In 2018, 6 million Americans had heart failure; by 2030, that number is expected to rise to 8 million.3 Heart Disease in the US 1Ahmad, et al. (2020) The Leading Causes of Death in the US for 2020. JAMA. 2021;325(18):1829–1830. 2Khera, 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. 3Alonso, et al. (2021) "Heart Disease and Stroke Statistics—2021 Update." Circulation (143) e00-e00. Percentage Breakdown of US Deaths Attributable to Cardiovascular Disease, 20184 42.1% 17.4% 9.6% 11% 2.9% 17.4% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Coronary Heart Disease Stroke Heart Failure* High Blood Pressure Diseases of the Arteries Other Percent of Total CVD Deaths
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
Heart Disease as Primary Hospice Diagnosis • In 2019, circulatory/heart disease (excluding stroke) was the second most common principal diagnosis for patients enrolled in hospice, with over 150,000 Medicare decedents receiving care • The median length of hospice care received by this population was <25 days • The most common hospice diagnoses were Alzheimer’s/dementia, and Parkinson’s Heart Disease and Hospice 1NHPCO. (2021). Facts and Figures: Hospice Care in America.
The Burden of Heart Disease on the US Health System 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
• 80% with HF are hospitalized in the last 6 months of life • Hospital readmission is 21.4% within 30 days • Almost 50% of patients die within 5 years of HF diagnosis • Out-of-hospital (OOH) cardiac arrest has a10.5% survival to hospital discharge • In-hospital cardiac arrest 26.7% survival to discharge. • 30-day mortality after AMI is 13.6%2 Heart Failure Hospital Utilization in the Last Year of Life 1Benjamin, et al. (2019) “Heart disease and stroke statistics—2019 update: a report from the American Heart Association.” Circulation 139.10 (2019): e56-e528. 2Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1):89-94. • The number of hospitalizations and days hospitalized prior to death are displayed for 486 decedents with at least a full year of follow-up from heart failure diagnosis until death 0 50 100 150 200 250 300 350 331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30 Number of Hospitalizations Days Prior to Death Hospitalizations Days in Hospital • Healthcare utilization increases as patients near the end of life • Hospitalizations are most common among home patients and those with multiple comorbidity, such as PVD, DM, COPD On a new ACD F/U Aid
Most common symptoms of heart failure2: Shortness of breath, pain, feeling drowsy/tired, worry, irritability, feeling sad, being nervous The Burden of Heart Failure on Patients – Symptoms 1Bekelman, 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, et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure, 4:81-87. 3Alpert, et al. (2017). Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev,22:25-39. Outcome1 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 Common (and easily missed) symptoms3: pain, dyspnea, depression, nausea, constipation, anorexia, fatigue
• Approximately 41.8 million Americans have provided unpaid care to an adult age > 50 in the last 12 months • Those in high-intensity caregiving situations more often report high physical strain (29%) and higher emotional stress (49%) The Burden of Heart Failure on the Family National Alliance for Caregiving and AARP (2020). Caregiving in the US 2020. As a result of providing care to your [relation], have you ever experienced any of these financial Things? 2020 Base: Caregivers of Recipient Age 18+ (n=1,392) Note: Respondents may select more than one response; results add to greater than 100 percent Top Financial Impacts as a Result of Caregiving 15% 19% 22% 23% 28% 34% 45% Borrowed money from family or friends Left your bills unpaid/paid them late Use up your personal short-term saving Took on more debt Stopped saving 2+ financial impacts Any of these % Yes
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, 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
Clinical Course of Heart Failure Mclluennan, 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
Class 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
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: Functional Status II, Class D heart failure. 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.
18.7 15.1 11.9 9.1 6.8 5 3.6 2.9 2.3 1.7 1.2 0.8 3.3 2.8 2.6 1.8 1.3 1 4 3.4 2.6 2.2 1.5 0.9 0 2 4 6 8 10 12 14 16 18 20 65-69 70-74 75-79 80-84 85-89 ≥90 Median Survival in Years Median Survival Stratified by Age Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients HF Outcomes by Type 1Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022. 2Shah, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486. On the ACD DSA
Isolation in Heart Disease Lee, et al. (2021). Social Isolation and All-Cause and Heart Disease Mortality Among Working-Age Adults in the United States: “The 1998–2014 NHIS–NDI Record Linkage Study.” Health Equity. 5.1; 750-761. Cumulative Mortality Incidence Function for US Adults Aged 18–64
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, 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. On the ACD DSA
Hospice Eligibility Guidelines for ACD NYHA Class III as manifested by any of the following symptoms during less-than-normal activity: • Fatigue • Palpitations • Angina or dyspnea • Plus significant comorbidities 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
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
• 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.)
• 76-year-old female compliant with cardiologist and PCP follow-ups. PMH: NYHA Class III HF, HFpEF, LV EF 48%, AFIB, hypertension, COPD, dementia – Weight loss >5% over past month, diffuse muscle wasting – Current medications: diuretics, ACE inhibitor, oxygen, nebulizers – BP 92/64, HR 108 bpm, RR 22, pulse ox 93% 2L NC, afebrile – In the last 6 months, AM has had increased visits to office due to intensifying HF symptom burden and recent fall. – Symptoms of SOB, fatigue, and palpitations worsen despite a recent visit to the cardiologist and optimal medical management Case of AM
• AM is referred to home health but is unable to tolerate PT due to dyspnea and fatigue • During PT visit the following week, she develops chest pain and SOB, sent to the hospital • She is admitted to the ICU for HF exacerbation and requires ventilator and pressors • After 10 days, she undergoes trach and PEG and is transferred to long-term acute care (LTAC) still on ventilator • After 3 weeks, she develops sepsis due to UTI, transferred to the hospital, then returns to LTAC still intubated • After 2 more weeks, daughter opts for comfort care and AM undergoes compassionate withdrawal of ventilator support and dies in the LTAC AM Pathway 1 – Missed Opportunities
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 for the Older Adult Makam, 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
• In a study of 14,072 hospitalized older adults discharged to LTAC: – Median survival 8.3 months, 57% deceased at 1 year – 47.1% achieved recovery, with plateau at 9 months – Median time of remaining life spent in an inpatient facility was > 65% – More than one-third died in an inpatient setting Long-term Acute Care (LTAC) for the Older Adult Makam, 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 – Only 16% enrolled in hospice, with median 10 hospice days – Prognosis worse for patients ≥ 85 and those admitted with primary respiratory diagnosis – Older adults discharged from hospital to LTAC don’t get to go home.
• 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
Pharmacologic Interventions for Heart Failure 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
Other Cardiac Medications: • Entresto – angiotensin receptor neprilysin inhibitor (ARNi) • Corlanor/Ivabradine • Soluble guanylate cyclase (sGC) stimulators • Farxiga//dapagliflozin • Pulmonary hypertension medications Pharmacologic Interventions for Heart Failure
• AM’s symptoms worsen after cardiology appointment despite adjustment of medications • Daughter calls 911, and she is admitted to the hospital for HF exacerbation (NYHA Class IV) • AM receives IV diuresis for SOB and congestion; meds readjusted • Symptoms improve somewhat, and AM is discharged home with home health and PT, stating she never wants to return to the hospital • 3 days later AM continues with SOB, congestion, and is not improving with PT Case of AM – Pathway 2 Hospice and Timely Prognostication
• Instead of returning to the hospital, daughter gets an urgent telehealth visit with the cardiologist, who advises another change in her HF regimen and reaches out to the primary care physician • They have a GOC discussion with AM and her daughter, and AM is referred to VITAS for hospice care at home • She is admitted that same day Case of AM – Pathway 2 Hospice and Timely Prognostication
• 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, 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
• Is AF hospice-eligible? Yes. Why? – NYHA Class III or IV with dyspnea on minimal exertion – AFIB, COPD, O2 dependent and Dementia – Hypotensive and unable to tolerate optimized medical therapy for HF – Functional decline, progressive fatigue with tachycardia at rest, recent fall, and not improving with PT – Recurrent heart failure exacerbations despite frequent follow up with cardiologist and PCP, and ongoing titration of cardiac medication regimen – Increased health care utilization for HF including hospitalizations Case of AM – Pathway 2 Hospice and Timely Prognostication On the ACD DSA
Association of Hospice Admission With Rehospitalization Kheirbek, 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 6 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 On the ACD DSA
Comprehensive Services VITAS Palliative Care Home Health Eligibility Requirements Prognosis required: ≤ 6 months if the illness runs its usual course Prognosis varies by program, usually life-defining illness Prognosis not required Skilled need not required Skilled need not required Skilled need required Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care Length of Care Unlimited Variable Limited, with requirements Homebound Not required Not required Required, with exceptions Targeted Disease-Specific Program ✓ Variable Variable Medications Included ✓ X X Equipment Included ✓ X X After-Hours Staff Availability ✓ X X RT/PT/OT/Speech ✓ X ✓ Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis Palliative Care Physician Support ✓ Variable X Levels of Care 4 1 1 Bereavement Support ✓ X X
• Unpredictable trajectory • Patient overestimates survival • Physicians overestimate survival • Frequent exacerbations • Hospitalized HF patient lacks DNR status • Patient misunderstands hospice • Physicians misunderstand hospice • Prognostication proves challenging • “Treatments are discontinued in hospice” Discomfort around EOL issues Communication breakdown Misinformation Patients’ and Clinicians’ Barriers to Hospice
• During her 3 ½ months of well-managed care by VITAS, AM has two episodes of symptom exacerbation with increased dyspnea, decreased level of consciousness, and poor oral intake • Each time, AM is placed on Intensive Comfort Care® for symptom management in the comfort of her home with her daughter at bedside • SQ Lasix is provided for congestion • Cardiac medications, O2, and opioids titrated for SOB and comfort • VITAS physician, RT, SW, and chaplain visit AM • After a total of 111 days of care at home, AM dies comfortably with her daughter by her side with VITAS staff in attendance Case of AM Pathway 2 Hospice and Timely Prognostication
Advanced Cardiac Interventions in Hospice Advanced, aggressive interventions may be appropriate to palliate symptoms of ACD in hospice. These may include: • Parenteral diuretics • IV inotropes • Pacemaker or cardiac resynchronization therapy (CRT) • Ventricular assist device (VAD) Defibrillator – not palliative
Advanced Interventions – Parenteral Diuretics Afari, 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 or intermittent infusion • Limited data in severely obese and end-stage kidney disease • Local side effects can occur: tinging, burning, swelling
Advanced Interventions – Inotropes Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. • IV inotropes may be used for palliation of symptoms in select patients with advanced HF on optimal medical management and who are not candidates for MCS or transplant – Improve NYHA Class – Functional Capacity – No association with mortality – No association with hospital readmission – May increase risk of ICD shock
Advanced Interventions – Inotropes (cont.) Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. Considerations for hospice: • Hospice may provide inotropes to palliate symptoms with ongoing assessment • Cardiologist should be involved • Requires more permanent central venous access • Fixed dose, no active up-titration • Patient/family agreeable to hospice plan of care: no cardiac monitor • Typically admitted to hospice on continuous care
Advanced Interventions – Inotropes (cont.) Ginwalla et al. (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 Patient request (requires goals of care discussion) Refractory to inotrope/ Tolerance Develop HF symptoms Milrinone Phosphodiesterase III Inhibitor Inotropic, arterial and venous dilation 0.375-0.75 mcg/kg/min • Arrhythmias • Hypotension • Angina • Hypokalemia
1Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin. 2Balla, 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 Mechanical Interventions
Trajectories After LVAD Implantation DeFilippis, 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 1 Preimplantation advanced care planning Inpatient support, symptom management Review of progress and goals of care, symptom management Triggered revisiting of goals of care Bereavement support 1 2 3 4 5
• Caring for a patient with a VAD is fundamentally no different than caring for a patient without a VAD • Hospice team trained in VAD- specific symptom management, differences in physical exam, technical concerns • Hospice and cardiology teams collaborate closely • Address any patient and family concerns VADs and Hospice
VAD Deactivation Brush, 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. • Although the majority of VAD patients die with their VAD still functioning, elective discontinuation is a treatment option, decision made with treatment teams • Clinical indications for VAD deactivation – Complications of the VAD or VAD failure – Poor quality of life despite VAD – Advanced comorbid conditions • Can occur at home or inpatient unit – Clinical and psychosocial team involvement with patient and family – Survival after deactivation ranges from minutes to days (average survival 20 minutes)
Questions
Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart failure reviews, 24(3), 309-313. Ahmad FB, et al. (2020) The Leading Causes of Death in the US for 2020. JAMA. 2021;325(18):1829–1830. Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1), 89-94. 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. Alonso et al. (2021) "Heart Disease and Stroke Statistics—2021 Update." Circulation (143) e00-e00. Alpert, A., et al. (2017). Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev, 22:25-39. 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. References
Brush, 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. Creber, 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. 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. DeFilippis, 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, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448. Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022. Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin. Kheirbek, 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. Khera, et al. (2018). Association of HRRP with mortality during acute hospitalization. JAMA Network Open, 1(5), e182777-e182777. References
Khera, 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 Kitko, 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 Lee, et al. (2021). Social Isolation and All-Cause and Heart Disease Mortality Among Working-Age Adults in the United States: The 1998–2014 NHIS–NDI Record Linkage Study." Health Equity. 5.1; 750-761. Makam, 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 Mclluennan, et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352. National Alliance for Caregiving and AARP. Caregiving in the US 2020. NHPCO. (2021). Facts and Figures: Hospice Care in America. Riley, et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure;4:81-87. Shah, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology 70.20: 2476-2486. References
Advanced Cardiac Disease

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Advanced Cardiac Disease

  • 1.
  • 2.
    CME Provider Information SatisfactoryCompletion 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 Pharmacy 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 programsare 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-baseddata 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 endof 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 through evidence-based research • Understand palliative interventions for patients with advanced cardiac disease • Understand the role of advanced technologies in end-of-life care Objectives
  • 6.
    • Heart diseaseis the #1 cause of death in the US, with nearly 634,000 deaths in 2020, followed by cancer and COVID-191 • 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 ED2 • In 2018, 6 million Americans had heart failure; by 2030, that number is expected to rise to 8 million.3 Heart Disease in the US 1Ahmad, et al. (2020) The Leading Causes of Death in the US for 2020. JAMA. 2021;325(18):1829–1830. 2Khera, 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. 3Alonso, et al. (2021) "Heart Disease and Stroke Statistics—2021 Update." Circulation (143) e00-e00. Percentage Breakdown of US Deaths Attributable to Cardiovascular Disease, 20184 42.1% 17.4% 9.6% 11% 2.9% 17.4% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Coronary Heart Disease Stroke Heart Failure* High Blood Pressure Diseases of the Arteries Other Percent of Total CVD Deaths
  • 7.
    Heart Disease Prevalence AmericanHeart 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
  • 8.
    Heart Disease asPrimary Hospice Diagnosis • In 2019, circulatory/heart disease (excluding stroke) was the second most common principal diagnosis for patients enrolled in hospice, with over 150,000 Medicare decedents receiving care • The median length of hospice care received by this population was <25 days • The most common hospice diagnoses were Alzheimer’s/dementia, and Parkinson’s Heart Disease and Hospice 1NHPCO. (2021). Facts and Figures: Hospice Care in America.
  • 9.
    The Burden ofHeart Disease on the US Health System 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
  • 10.
    • 80% withHF are hospitalized in the last 6 months of life • Hospital readmission is 21.4% within 30 days • Almost 50% of patients die within 5 years of HF diagnosis • Out-of-hospital (OOH) cardiac arrest has a10.5% survival to hospital discharge • In-hospital cardiac arrest 26.7% survival to discharge. • 30-day mortality after AMI is 13.6%2 Heart Failure Hospital Utilization in the Last Year of Life 1Benjamin, et al. (2019) “Heart disease and stroke statistics—2019 update: a report from the American Heart Association.” Circulation 139.10 (2019): e56-e528. 2Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1):89-94. • The number of hospitalizations and days hospitalized prior to death are displayed for 486 decedents with at least a full year of follow-up from heart failure diagnosis until death 0 50 100 150 200 250 300 350 331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30 Number of Hospitalizations Days Prior to Death Hospitalizations Days in Hospital • Healthcare utilization increases as patients near the end of life • Hospitalizations are most common among home patients and those with multiple comorbidity, such as PVD, DM, COPD On a new ACD F/U Aid
  • 11.
    Most common symptomsof heart failure2: Shortness of breath, pain, feeling drowsy/tired, worry, irritability, feeling sad, being nervous The Burden of Heart Failure on Patients – Symptoms 1Bekelman, 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, et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure, 4:81-87. 3Alpert, et al. (2017). Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev,22:25-39. Outcome1 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 Common (and easily missed) symptoms3: pain, dyspnea, depression, nausea, constipation, anorexia, fatigue
  • 12.
    • Approximately 41.8million Americans have provided unpaid care to an adult age > 50 in the last 12 months • Those in high-intensity caregiving situations more often report high physical strain (29%) and higher emotional stress (49%) The Burden of Heart Failure on the Family National Alliance for Caregiving and AARP (2020). Caregiving in the US 2020. As a result of providing care to your [relation], have you ever experienced any of these financial Things? 2020 Base: Caregivers of Recipient Age 18+ (n=1,392) Note: Respondents may select more than one response; results add to greater than 100 percent Top Financial Impacts as a Result of Caregiving 15% 19% 22% 23% 28% 34% 45% Borrowed money from family or friends Left your bills unpaid/paid them late Use up your personal short-term saving Took on more debt Stopped saving 2+ financial impacts Any of these % Yes
  • 13.
    The Burden ofHeart 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, 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
  • 14.
    Clinical Course ofHeart Failure Mclluennan, 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
  • 15.
    Class Functional Capacity I Nolimitation 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
  • 16.
    Class Objective Assessment A Noobjective 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: Functional Status II, Class D heart failure. 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.
  • 17.
    18.7 15.1 11.9 9.1 6.8 5 3.6 2.9 2.3 1.7 1.2 0.8 3.3 2.8 2.6 1.8 1.3 1 4 3.4 2.6 2.2 1.5 0.9 0 2 4 6 8 10 12 14 16 18 20 65-6970-74 75-79 80-84 85-89 ≥90 Median Survival in Years Median Survival Stratified by Age Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients HF Outcomes by Type 1Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022. 2Shah, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486. On the ACD DSA
  • 18.
    Isolation in HeartDisease Lee, et al. (2021). Social Isolation and All-Cause and Heart Disease Mortality Among Working-Age Adults in the United States: “The 1998–2014 NHIS–NDI Record Linkage Study.” Health Equity. 5.1; 750-761. Cumulative Mortality Incidence Function for US Adults Aged 18–64
  • 19.
    HF Functional Statusand 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, 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. On the ACD DSA
  • 20.
    Hospice Eligibility Guidelinesfor ACD NYHA Class III as manifested by any of the following symptoms during less-than-normal activity: • Fatigue • Palpitations • Angina or dyspnea • Plus significant comorbidities 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
  • 21.
    Hospice Eligibility Guidelinesfor 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
  • 22.
    • Hospice admissionguidelines 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.)
  • 23.
    • 76-year-old femalecompliant with cardiologist and PCP follow-ups. PMH: NYHA Class III HF, HFpEF, LV EF 48%, AFIB, hypertension, COPD, dementia – Weight loss >5% over past month, diffuse muscle wasting – Current medications: diuretics, ACE inhibitor, oxygen, nebulizers – BP 92/64, HR 108 bpm, RR 22, pulse ox 93% 2L NC, afebrile – In the last 6 months, AM has had increased visits to office due to intensifying HF symptom burden and recent fall. – Symptoms of SOB, fatigue, and palpitations worsen despite a recent visit to the cardiologist and optimal medical management Case of AM
  • 24.
    • AM isreferred to home health but is unable to tolerate PT due to dyspnea and fatigue • During PT visit the following week, she develops chest pain and SOB, sent to the hospital • She is admitted to the ICU for HF exacerbation and requires ventilator and pressors • After 10 days, she undergoes trach and PEG and is transferred to long-term acute care (LTAC) still on ventilator • After 3 weeks, she develops sepsis due to UTI, transferred to the hospital, then returns to LTAC still intubated • After 2 more weeks, daughter opts for comfort care and AM undergoes compassionate withdrawal of ventilator support and dies in the LTAC AM Pathway 1 – Missed Opportunities
  • 25.
    Hospitalized older adults dischargedto 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 for the Older Adult Makam, 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
  • 26.
    • In astudy of 14,072 hospitalized older adults discharged to LTAC: – Median survival 8.3 months, 57% deceased at 1 year – 47.1% achieved recovery, with plateau at 9 months – Median time of remaining life spent in an inpatient facility was > 65% – More than one-third died in an inpatient setting Long-term Acute Care (LTAC) for the Older Adult Makam, 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 – Only 16% enrolled in hospice, with median 10 hospice days – Prognosis worse for patients ≥ 85 and those admitted with primary respiratory diagnosis – Older adults discharged from hospital to LTAC don’t get to go home.
  • 27.
    • Determine goalsof 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
  • 28.
    Pharmacologic Interventions forHeart Failure 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
  • 29.
    Other Cardiac Medications: •Entresto – angiotensin receptor neprilysin inhibitor (ARNi) • Corlanor/Ivabradine • Soluble guanylate cyclase (sGC) stimulators • Farxiga//dapagliflozin • Pulmonary hypertension medications Pharmacologic Interventions for Heart Failure
  • 30.
    • AM’s symptomsworsen after cardiology appointment despite adjustment of medications • Daughter calls 911, and she is admitted to the hospital for HF exacerbation (NYHA Class IV) • AM receives IV diuresis for SOB and congestion; meds readjusted • Symptoms improve somewhat, and AM is discharged home with home health and PT, stating she never wants to return to the hospital • 3 days later AM continues with SOB, congestion, and is not improving with PT Case of AM – Pathway 2 Hospice and Timely Prognostication
  • 31.
    • Instead ofreturning to the hospital, daughter gets an urgent telehealth visit with the cardiologist, who advises another change in her HF regimen and reaches out to the primary care physician • They have a GOC discussion with AM and her daughter, and AM is referred to VITAS for hospice care at home • She is admitted that same day Case of AM – Pathway 2 Hospice and Timely Prognostication
  • 32.
    • 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, 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
  • 33.
    • Is AFhospice-eligible? Yes. Why? – NYHA Class III or IV with dyspnea on minimal exertion – AFIB, COPD, O2 dependent and Dementia – Hypotensive and unable to tolerate optimized medical therapy for HF – Functional decline, progressive fatigue with tachycardia at rest, recent fall, and not improving with PT – Recurrent heart failure exacerbations despite frequent follow up with cardiologist and PCP, and ongoing titration of cardiac medication regimen – Increased health care utilization for HF including hospitalizations Case of AM – Pathway 2 Hospice and Timely Prognostication On the ACD DSA
  • 34.
    Association of HospiceAdmission With Rehospitalization Kheirbek, 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 6 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 On the ACD DSA
  • 35.
    Comprehensive Services VITAS PalliativeCare Home Health Eligibility Requirements Prognosis required: ≤ 6 months if the illness runs its usual course Prognosis varies by program, usually life-defining illness Prognosis not required Skilled need not required Skilled need not required Skilled need required Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care Length of Care Unlimited Variable Limited, with requirements Homebound Not required Not required Required, with exceptions Targeted Disease-Specific Program ✓ Variable Variable Medications Included ✓ X X Equipment Included ✓ X X After-Hours Staff Availability ✓ X X RT/PT/OT/Speech ✓ X ✓ Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis Palliative Care Physician Support ✓ Variable X Levels of Care 4 1 1 Bereavement Support ✓ X X
  • 36.
    • Unpredictable trajectory •Patient overestimates survival • Physicians overestimate survival • Frequent exacerbations • Hospitalized HF patient lacks DNR status • Patient misunderstands hospice • Physicians misunderstand hospice • Prognostication proves challenging • “Treatments are discontinued in hospice” Discomfort around EOL issues Communication breakdown Misinformation Patients’ and Clinicians’ Barriers to Hospice
  • 37.
    • During her3 ½ months of well-managed care by VITAS, AM has two episodes of symptom exacerbation with increased dyspnea, decreased level of consciousness, and poor oral intake • Each time, AM is placed on Intensive Comfort Care® for symptom management in the comfort of her home with her daughter at bedside • SQ Lasix is provided for congestion • Cardiac medications, O2, and opioids titrated for SOB and comfort • VITAS physician, RT, SW, and chaplain visit AM • After a total of 111 days of care at home, AM dies comfortably with her daughter by her side with VITAS staff in attendance Case of AM Pathway 2 Hospice and Timely Prognostication
  • 38.
    Advanced Cardiac Interventionsin Hospice Advanced, aggressive interventions may be appropriate to palliate symptoms of ACD in hospice. These may include: • Parenteral diuretics • IV inotropes • Pacemaker or cardiac resynchronization therapy (CRT) • Ventricular assist device (VAD) Defibrillator – not palliative
  • 39.
    Advanced Interventions –Parenteral Diuretics Afari, 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 or intermittent infusion • Limited data in severely obese and end-stage kidney disease • Local side effects can occur: tinging, burning, swelling
  • 40.
    Advanced Interventions –Inotropes Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. • IV inotropes may be used for palliation of symptoms in select patients with advanced HF on optimal medical management and who are not candidates for MCS or transplant – Improve NYHA Class – Functional Capacity – No association with mortality – No association with hospital readmission – May increase risk of ICD shock
  • 41.
    Advanced Interventions –Inotropes (cont.) Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. Considerations for hospice: • Hospice may provide inotropes to palliate symptoms with ongoing assessment • Cardiologist should be involved • Requires more permanent central venous access • Fixed dose, no active up-titration • Patient/family agreeable to hospice plan of care: no cardiac monitor • Typically admitted to hospice on continuous care
  • 42.
    Advanced Interventions –Inotropes (cont.) Ginwalla et al. (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 Patient request (requires goals of care discussion) Refractory to inotrope/ Tolerance Develop HF symptoms Milrinone Phosphodiesterase III Inhibitor Inotropic, arterial and venous dilation 0.375-0.75 mcg/kg/min • Arrhythmias • Hypotension • Angina • Hypokalemia
  • 43.
    1Harrington, et al.(2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin. 2Balla, 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 Mechanical Interventions
  • 44.
    Trajectories After LVADImplantation DeFilippis, 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 1 Preimplantation advanced care planning Inpatient support, symptom management Review of progress and goals of care, symptom management Triggered revisiting of goals of care Bereavement support 1 2 3 4 5
  • 45.
    • Caring fora patient with a VAD is fundamentally no different than caring for a patient without a VAD • Hospice team trained in VAD- specific symptom management, differences in physical exam, technical concerns • Hospice and cardiology teams collaborate closely • Address any patient and family concerns VADs and Hospice
  • 46.
    VAD Deactivation Brush, etal. (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. • Although the majority of VAD patients die with their VAD still functioning, elective discontinuation is a treatment option, decision made with treatment teams • Clinical indications for VAD deactivation – Complications of the VAD or VAD failure – Poor quality of life despite VAD – Advanced comorbid conditions • Can occur at home or inpatient unit – Clinical and psychosocial team involvement with patient and family – Survival after deactivation ranges from minutes to days (average survival 20 minutes)
  • 47.
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    Brush, 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. Creber, 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. 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. DeFilippis, 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, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448. Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022. Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin. Kheirbek, 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. Khera, et al. (2018). Association of HRRP with mortality during acute hospitalization. JAMA Network Open, 1(5), e182777-e182777. References
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    Khera, R., etal. (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 Kitko, 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 Lee, et al. (2021). Social Isolation and All-Cause and Heart Disease Mortality Among Working-Age Adults in the United States: The 1998–2014 NHIS–NDI Record Linkage Study." Health Equity. 5.1; 750-761. Makam, 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 Mclluennan, et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352. National Alliance for Caregiving and AARP. Caregiving in the US 2020. NHPCO. (2021). Facts and Figures: Hospice Care in America. Riley, et al. (2017). Palliative Care in heart failure: facts and numbers. ESC Heart Failure;4:81-87. Shah, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology 70.20: 2476-2486. References