This document discusses palliative care options for patients who are not candidates for transcatheter aortic valve replacement (TAVR). It defines palliative care as active treatment to improve quality of life for patients with diseases that cannot be cured. Palliative care differs from hospice in that hospice care is for terminally ill patients expected to live less than 6 months. The document outlines the roles of an interdisciplinary palliative care team in symptom management and exploring treatment strategies for end-stage cardiac patients. It emphasizes determining patient-centered goals of care and providing shared decision making.

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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

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TAVR Turndown: Now What?
Palliation (ALWAYS)
Hospice and Other Options (Sometimes)

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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.

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Nkomo V et al. Lancet. 2006:368;1005-11.

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Swetz and Mansel, Cardiol Clin 2013.

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Cardiac disease course (HF and AS)
Goodlin et al. J Card Fail. 2004:54;200-9.

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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

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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

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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.

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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!”

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Palliative Care & Hospice
Palliative Care
Hospice
Comfort
Care

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Curative or disease-
targeted care%
Clinical
Effort
0
100
time
deathterminal phase
bereavement
Palliative care
Emerging Model for End-of-Life Care

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Frailty and Outcomes

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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.

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Frailty and Outcomes
• “frailty index, but not established risk scores,
was predictive of functional decline”
Schoenenberger et al. Eur Heart J. 2013

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Goals of Care

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Patient-centered Outcomes:
Determining the Goals of Care
Allen L et al. Circulation 2012 Apr 17;125(15):1928-52

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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

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Ways to Providing Patient-Centered
Care
Shared Decision Making and Programatic Opportunities

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Thanks to Dr.
Megan Coylewright,
copyrighted,
publications in
progress.

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Thanks to Dr.
Megan Coylewright, copyrighted,
publications in progress.

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Thanks to Dr.
Megan Coylewright,
copyrighted, publications in
progress.

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Copyright © by European Society of Cardiology
Sandra Lauck et al. Eur J Cardiovasc Nurs 2014;13:177-184

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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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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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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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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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Questions & Discussion
swetz.keith@mayo.edu
Palliative Care
Hospice
Comfort
Care