Heart Failure Palliative Care Perspectives

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Heart Failure- Palliative Care Perspectives

• Dr Paul Paes
• Consultant in Palliative Medicine

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Content

• Palliative needs of patients with heart failure
• Models of service
• Referral criteria
• Palliative Management of Heart Failure
• Death planning

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COMPARISON WITH CANCER

• Worse survival rates than many cancers
• 40 of cancer patients receive palliative care
  input
• lt4 of heart failure patients receive palliative
  care

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What are the palliative care needs of patients
with heart failure?

• Literature suggests that patients dying from
  heart failure have sustained unrelieved physical
  and psychological issues
• They have a poor quality of life
• They have little understanding of their
  condition, its management or implications
• Services are poorly co-ordinated
• There is a large burden for carers
• They believe healthcare professionals are
  reluctant to talk about prognosis and dying- this
  limits their care and their choices

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Lets think. There was one study, not randomised
though, but it did suggest laughter could bring
on angina. Lets cut that out from now and your
ECG should improve.
Ive stopped smoking, drinking, salt, fat but I
still feel awful. There must be something else?
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Symptom issues

• Physical problems
• weakness/ fatigue (80)
• pain (78)
• dyspnoea (61)
• anorexia (43)
• constipation (37)
• nausea and vomiting (32)
• Cognitive problems
• depression (59)
• anxiety (43)
• confusion/ memory problems (27)

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Models of service
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Principles

• Most palliative care is not carried out by
  palliative care specialists, but done by primary
  care or secondary care teams
• The same applies to heart failure
• New services need to complement existing
  services, meet unmet need and be responsive to
  patients and carers needs

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Responsive services
Im sorry, weve stopped home visits. When you
feel well again, come and see me in clinic.
DOCTOR
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Current services/models/ideas

• Co-operation/ discussion/ study days
• Education initiatives
• Complementary therapies
• Bereavement support
• Tools- Primary care standards, Care of the dying
  pathway, Preferred Place of Care
• Support/ rehabilitation programmes
• Advice
• MDT meetings

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• Referral to community/hospital specialist
  palliative care team- doctors, Clinical Nurse
  specialists, social worker, physiotherapist,
  occupational therapist
• Day care
• Joint clinics
• In-patient respite- nursing homes, hospices
• Community respite- professionals, volunteers
• In-patient care

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When to refer
The Beginning Of
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Possible referral triggers

• NYHA III or IV patients
• Recurrent hospital admissions
• Would you be surprised if this patient were to
  die in the next 6-12 months?
• Any patient who has had a DS1500 form for
  attendance/disability living allowance completed
  because of their heart failure
• Patients opting for symptomatic treatment only
• Any circumstances where further hospital
  admission is not considered to be the best option
  for the patient

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Pragmatic criteria

• Physical symptoms despite maximum tolerated
  therapy
• Complex psychological/social/ spiritual issues
• Patients choosing symptomatic treatment only
• The threshold will vary depending on the skills
  of the local teams- as palliative skills improve
  in community and cardiology teams the threshold
  for referral will rise

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NB

• A referral to palliative care is not dependent
  on a particular prognosis. The key is whether
  they have a palliative care need. The prognosis
  may determine the management but it does not
  affect the need.

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Obstacles to overcome

• Mutual suspicion and lack of knowledge about each
  others and our own skills
• Lack of joint working
• Worries about prognosis
• Capacity issues
• Image of palliative care

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live and let die poster 002 home gt bond posters
gt live and let die posters gt poster 002
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Palliative management

• With any symptom/problem
• Assess and work out the cause
• Reverse what can be reversed
• Maximise treatment for heart failure or other
  condition that may be contributing as long as
  medication tolerated
• Treat the symptom

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ER, 65 year old man

• PMH Cardiac arrest 2002 due to MI- long stay
  in CCU and hospital post-discharge significant
  impairment Type 2 diabetes Multiple
  admissions for chest pain/ breathlessness

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• Medication Aspirin 150mg
  od Bisoprolol 1.25mg daily Perindopril
  2mg daily Furosemide 80mg bd Simvastatin
  20mg od
• ISMN 20mg bd
• Referred because wanting to die/ avoid going back
  into hospital

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Assessment

• Symptoms
• cough- related to ACE-I- switched to ACE-II
• constipation- dehydration/decreased mobility-
  laxatives, diet
• nausea- electrolyte disturbance, constipation-
  sort out constipation, anti-emetic eg.
  haloperidol
• urinary frequency- related to timing of
  diuretics- given once a day
• generalised pain- related to oedema and reduced
  mobility- paracetamol/ NSAID (monitoring
  renal function)

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• chest pain- clear plan re angina medication
• breathlessness- variety of causes-
• maximise heart failure medication, nitrates
• trial of low dose opiates/ benzodiazepines
• breathing techniques, exercise
• relaxation/anxiety management
• lifestyle/environmental adjustments
• oxygen assessment
• oedema-
• review of diuretics/ heart failure medication,
  leg elevation, skin care
• fatigue- poor sleep, low mood, renal impairment-
• addressing sleep issues, treatment of
  depression,
• dietary advice, exercise
• depression- anti-depressant, psychological
  approaches

23

• Psychologically
• -never got over initial event and impact lost
  family business, role, financial problems
  alongside traumatic experience in hospital
• -no real enjoyment of life socially isolated,
  given up smoking/ alcohol, low fat diet, had been
  advised to stop activities that may cause stress
• -frequent hospital admissions
• -felt as though alive but not living
• -scared about how he would die

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• Management
• -listening
• -information needs
• -review of life/lifestyle
• -goal setting
• -addressing fears about future
• -addressing financial concerns
• -emotional/financial legacy
• -carers to help with ADLs
• -day hospice, complementary therapies
• -death planning

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Death planning

• It is good to have an end to journey towards,
  but it is the journey that matters, in the end.
  Ursula Le Guin

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Challenges

• Symptoms- breathlessness chest pain
• Resuscitation
• Professional back-up
• Psychological barriers
• Documentation

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• Breathlessness
• -maintain heart failure medication as long as
  possible
• -low dose opioids
• -sub-lingual lorazepam as required
• -breathing techniques/relaxation
• When no longer able to swallow tablets
• -buccal/sl/td nitate, benzodiazepine, opiate
• -injectable opiate, midazolam, anti-secretory
  drug, ?frusemide, ?nitrate
• -oxygen
• -breathing techniques/relaxation/support

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• Chest pain
• -nitrates
• -opiates as before
• For both symptoms, there need to be clear
  instructions to follow, written and shared with
  others.
• When injectable drugs are used, dosages need to
  be clear and a decision made re who is going to
  give them- professional/carer
• Other drugs as per protocols

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• Resuscitation
• -clear discussion, decision and documentation
• -defibrillators
• Professional back-up
• -management plan to give as much control to
  patient and family stating when to seek help and
  who to contact within primary care, secondary
  care, palliative care with relevant telephone
  numbers
• -Carer availability

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• Psychological barriers -does the patient and
  carer want death to occur at home
  (memories) -fears about process, support,
  back up
• Documentation
• -once the plan is agreed between the patient
  and professional, it needs to be clearly
  documented. That document needs to be with the
  relevant teams, out of hours service and above
  all PATIENTS and their carers

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The experience of heart failure
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Final Thoughts

• -Patients with heart failure suffer considerably
  -General palliative care can be delivered by most
  healthcare professionals, with a shift of mindset
• Although the world is full of suffering, it is
  also full of the overcoming of it. Helen
  Keller
  Palliative care will not get rid of the
  suffering but may help people to overcome it