christine westphal np msn acns-bc achpn ccrn director/nurse practitioner palliative and restorative...
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Christine Westphal NP MSN
ACNS-BC ACHPN CCRN
Director/Nurse Practitioner
Palliative and Restorative Integrated Services Model (PRISM)
Oakwood Healthcare System
Dearborn, Michigan
A Bridge Over Troubled Waters:Palliative Care in Heart Failure
Objectives
1. Describe the trajectory of heart failure.
2. List three palliative care outcomes in end stage heart failure with related interventions
3. List palliative care resources available to the patient, family and healthcare provider
Definitions Structural or functional
disorder which impacts ability of the heart to eject or fill with blood– Systolic (decreased ejection)
• EF < 40%• Occurs most frequently
– Diastolic (impaired filling)• Impaired relaxation• Ventricular stiffness
Etiology Ischemic cardiomyopathy/CAD 59-70% Non-ischemic cardiomyopathy
– CV Non-CV• Valve disease • Obesity• HTN • Illicit drugs• Atrial fibrillation • Cardiotoxic
medications• Infection • Sleep apnea• Congenital abnormalities • Anemia
Idiopathic dilated cardiomyopathy
Ventricular Dysfunction: Output
Neuroendocrine activation Renin-Angiotensin-Aldosterone Sympathetic Nervous System Vasopressin
Pressure/volume
HR, BP, Myocardial O2 consumptionSodium/water retention/edemaIschemia, dsyrhythmiasDecreased end organ perfusion
Ventricular hypertrophyVentricular remodeling Fibrosis Cell death (apotosis)
Natiuretic Peptides ANP (atrial) BNP (brain)
Attempts to compensate Diuresis Decrease neuroendocrine response
Immune up-regulation Cytokines Tumor necrosis factor Interleukins
Copyright ©2009 American Heart Association
2009 WRITING GROUP ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE, et al. Circulation 2009;119:1977-2016
Recommended Therapy by Stage
Heart Failure Facts Increasing prevalence, particularly in
the elderly 550,000 new cases annually Affects 6-10% of US patients > 65
– Leading cause of Medicare hospitalization > 1 million hospitalizations annually
– 20% of hospitalizations age > 65 >3 billion ED/office visits annually $33 billion spent in 2007
Lloyd-Jones et al (2009) Heart Disease and Stroke Update. Circulation;119;480-486
Heart Failure Society of America (2006) J Card Fail;12;e86-e103.Koelling T et al (2005) Circulation; 111: 179–185Burt C & Schappert S (2004) Vital Health Stat 13; No. 157: 1–70.
Contributing Factors Poor adherence to diet, self-care and
medication recommendations– Lack of understanding– Depression/anxiety/cognitive impairment– Complexity of the plan—multiple co-
morbidities and specialists– Inadequate follow-up/discharge support– Lack of access
• Social and/or financial reasons
Progressive, chronic
Last 6 months end-stage patients spend 1 out of 4 days in hospitalRusso et al (2008) J Card Fail; 14:651-658
End-stage marked by worsening symptoms, functional decline and repeated hospitalizations
Teuteberg et al (2006). J Card Fail; 12: 47-53.
Goldberg & Jessup (2007) Circulation;116:360-362.
Bradley et al (2003). JAMA 289: 730-740.
And Deadly
Cardiac disease is leading cause of death in Michigan2008 Michigan Resident Death File MDCH
2.5 M Medicare recipients 2001-2005 1 year mortality 37%
Curtis et al (2008) Arch Intern Med; 168:2481-88.
About half of patients die within 5 years– Approximately 25% of survive beyond 5 yearsMacIntyre et al (2000) Circulation; 102: 1126-1131Khand et al (2000) J Am Coll Card; 36: 2284-1186
Significant Mortality Indicators If stage IV (D) and with optimal tx, but shows:
– Dobutamine or milrinone dependence– Decompensation despite resynchronization – Frequent AICD firing– Greater than 1.9 hospitalizations/6 months– Not candidate for transplantationKuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach. St.
Louis: Mosby.Hershberger et al (2003) Cardiac Fail; 9: 180-181Albert et al (2002) Cleve Clin Med J. ; 69: 321-328Alla et al ( 2000) Am Heart J ;139: 895-904
Additional Factors Increase Risk
Resting HR >100 Creatinine >2.2 mg/dl Serum NA < 134 after treatment Repeated hospitalization for HF Age >70 Additional serious co-morbidities Dependent for ADL—poor functional statusKuebler, Davis & Moore (2005) Palliative Practices: An Interdisciplinary Approach.
St. Louis: CV Mosby
Living with Heart Failure
“It’s not about death, it’s really about living with a disease…”
Joanne Lynn MD SUPPORT Primary Investigator
Study to Understand Prognoses and Preferences for Treatment (SUPPORT)
Approx 950 heart failure patients with EF < 20%– 68% readmitted within 2 months– 79% experienced a 5 # wt loss in 2 mo– 76% required services for ADL assist– 23% decided to forego resuscitation
Krumholz et al.(1998) Circulation;98:648-655
Living with Serious Illness 90 Million with serious illness annually
70% admitted to hospital in last 6mo– 1:4 inadequate symptom control– 1:3 inadequate emotional support– 1:3 inadequate education on self-care– 1:3 inadequate post-discharge plan
Many died in the hospital• Dartmouth atlas www. Dartmouthatlas .org• Teno et al (2004) JAMA; 29(1):88-93• Covinsky et al (1994) JAMA 272(23): 1838-44.• Commonweath Fund Report (2007)
The Heart Failure Experience
Study comparing HF and lung CA patients HF patients had:
– Less information about illness, prognosis and treatment
– Less involvement in decisions about CPR, ventilation and artificial nutrition
– Frustration with losses and social isolation– Less involvement with palliative care– More stress, distress and less quality of life– Fewer supportive services
Murray et al (2002) Br Med J;325:929-932
“Palliative care should be considered a normal approach to patients with heart failure…”Hauptman et al (2005) Arch Intern Med;165:374-378
What is Palliative Care?
An evidence-based specialty practice that:– Focuses on relief of suffering particularly
for people with serious, life-limiting illnesses
– Helps patients and families to have best quality of life regardless of stage of illness or need for other therapies
– Optimizes function, decision-making and personal growth
Growth of Palliative Care
1998: No PC programs
2008: Over 50% of hospitals with 50 or more beds have a PC program
– Center to Advance Palliative Care, 2008
Oakwood Hospital & Medical Center Dearborn
Detroit Receiving Hospital Providence Hospital St. John Hospital St. Joseph Mercy Ann Arbor St. Joseph Mercy Pontiac Beaumont Hospital Henry Ford Detroit and
Wyandotte University of Michigan
Palliative Care: A Bridge Over Troubled Waters
Communication– Support system– Treatment options/benefits & burdens– Clarify goals, values and preferences– Advance directives & resuscitation status– Match needs and resources
Quality of life– Symptom control– Optimize function– Psycho-social-spiritual support
Satisfaction
Widera & Pantilat (2009) Current Opin Support Pall Care;3:247-251.
Michigan Dignified Death Act
Patients with a life limiting illness must be informed about treatment options including:– Benefits and burdens of treatment– Right to refuse treatment– Palliative care– Pain control– Hospice for patients with terminal
illnessesMichigan Law No. 239 (333.5652)
Palliative Care Impact
Less likely to die in the hospital Experience fewer ICU/CCU admissions
in the last six months of life Spend less time in an ICU/CCU in the
last six months of life – Center to Advance Palliative Care, 2008
Satisfaction
Patient family satisfaction– Relief of symptoms– Improved communication– Smooth access and seamless care
Physician Satisfaction– Collaboration– Saved physician time
PRISM Quality Data 2007-2010
Campbell (2004). Making cents: Cost-effectiveness of palliative care. Presentation
Improved symptom control
50%
60%
70%
80%
90%
100%
Controlled ControlledAnxiety Dyspnea
Non-palliative care
Palliative care
North Kansas CityHospital
SUPPORT Study N=957 HF Patients
92 (10%) died during hospitalization– 43% had dyspnea– 35% had severe pain
865 survivors – 32% had dyspnea– 19% had severe pain
• SUPPORT Principal Investigators (l995). JAMA; 274: 1591-1598
Dyspnea Prevalence
Dx Prevalence%
# Studies N
COPD 90-95 4 372
Heart Dz 60-88 6 948
CA 10-70 20 10,029
AIDS 11-62 2 504
Bausewein C et al (2007). Respir Med; 101(3):399-410Solano, et al. (2006) J Pain Symp Mgt, 31(1):58-69.
Dyspnea Awareness of
uncomfortable breathing– Subjective
“Respiratory distress”– Observed physical and/or
emotional signs
Pathophysiology Increased work of breathing
– Airway constriction– Obstruction: secretions, infections, effusions– Weakness
Chemical– Hypercapnia– Hypoxia
Neuromechanical dissociation– Muscle tension/effort do not match expansion
Thomas and von Guten, (2002) Lancet Onc;3(4):223-228.
Measurements *Numeric Report
*Vertical Dyspnea
Visual Analog Scale
*Borg Scale
Dyspnea Exertion Scale– Level I: Walk w/o SOB to– Level 5: Breathless @ rest
10= Severe distress
0= No distress
•No tool superior to others. All are unidimensional. ACCP (2010)Consensus statement on management of dyspnea in patients with advanced lung or heart disease. Chest; 137(3): 674-691
Asphyxia produces innate, non-voluntary, observable behaviors– Tachycardia– Tachypnea– Accessory muscle use– Paradoxical breathing– Nasal flaring– Fear expressions and behaviors
Campbell ME et al (2010) J Palliat Med. Mar;13(3):285-90.
Campbell ME (2008). J Palliat Med. Jan-Feb;11(1):44-50.
Respiratory Distress Observation Scale
BREATH AIR Bronchospasm
– Albuterol and ipratropium– Steroids
Rales– Limit fluids, evaluate protein– Consider diuretics, ACE-I, other
Effusions– Thoracentesis/catheter
Airway obstruction– Aspiration precaution/suction
Thick secretions– Strong cough? Neb.
Saline/humidity– Thin? Hyoscyamine, atropine
ophthl solution, scopolamine, glycopyrrolate
Hemoglobin low– Transfusion?
Anxiety– Position– Pursed lip breathing– Fan– Music– Massage– Biofeedback– Opioids– Benzodiazepines
Interpersonal issues– Counseling, support
Religious concerns– Spiritual advisor
“Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.” Thomas Sydenham (17th century)
Opioids in Dyspnea
Multiple mechanisms of action– Decrease chemoreceptor response– Decrease anxiety– Increase peripheral vasodilation– Alter perception through afferent pathways
Dosing No one opioid is better than the other Recommended starting p.o.doses (q3-4hrs)
– Morphine sulfate 2.5-5mg– Hydrocodone 2.5-5mg – Oxycodone 2.5-5mg– Hydromorphone 1-2 mg– Codeine 30mg
May start higher in opioid tolerant pts. Titration: 25-50% every 12 hours Convert to sustained release formulas if
available IV: PO 1:3 conversion. Infusions if needed
Nebulized Opioids Theory: action on airway receptors Ambiguous evidence
– Small studies and case reports– 2 RCT report nebulized morphine no better
than saline If trial is warranted:
– Morphine sulfate 2.5-10mg added to 2ml saline (preservative free or non-flavored elixirs) every 4 hours and every 1-2prn
– Hydromorphone 0.25-1mg as aboveWestphal & Campbell AJN (2002) May Supplement 11-15
ACCP (2010) Chest; 137(3): 674-691
Respiratory Arrest!?! Sedation precedes respiratory
suppression Respirations are NOT impacted by
prudent dosing• Improved pulmonary parameters
– Citron et al. Am J Med, 1984
• No difference in duration of survival – Campbell et al. Crit Care Med, 1999; Chan et al. CHEST, 2004)
Respiratory failure Always occurs during dying with or without opioids
• Dead people don’t breathe!
Hypotension?!?
Hypotension most often with IV dosing in the presence of volume depletion and/or in the elderly.
Consider the goals of care.
Oxygen
No studies support use for dyspnea without hypoxemia at rest or min. activity
ACCP (2010). Chest; 137(3): 674-691
Judicious use of bi-pap or c-pap– May benefit cognitively intact pts with
COPD or neurodegenerative disorders. Not for dying pt.
Use of fans or blowing air may be as effective in advanced disease .
– Stimulates facial nerve and non specific
nasal receptors
Galbraith et al J Pain Symp Mgmt 2010; 39(5): 831-838
Spector etal 2007. AACN Adv. Clin Issues; 18(1):48-57
Gallager & Roberts J Pain Pal Care Pharmacotherapy 2004;18(4): 3-15.
Refractory respiratory distress
All previously described interventions fail to relieve patient distress
Complete sedation may be indicated– Benzodiazepines, barbiturates, propofol– Patient and clinician mutually agree to this
approach– May be the only compassionate strategy IF all
other approaches fail
NHPCO Position statement and Commentary on use of palliative sedation in imminently dying terminally ill patients. J Pain Symp Mgmt 2010 39(5): 914-923
Terminal Congestion Explain to family—anticipate as a normal occurrence
Position lateral (“recovery position”) Decrease fluids and feedings
Consider diuretics if pulmonary edema
If oral secretions are excessive--anticholinergics– Scopolamine– Atropine ophthalmic solution 1%– Glycopyrrolate (Robinul)– Hyoscyamine (Levsin)
Pain Up to 41% of patients
experience pain with heart failure
Most pain is general in nature Causes
– Angina– Edema– Osteoarthritis– Diabetic neuropathy
Levenson et al (2000)Am Geriatr Soc
WHO Analgesic Ladder Start at the level of the
pain Avoid NSAIDS-- diuretics
may need to be adjusted Start with PRN and then
consider longer acting scheduled doses
Transdermal difficult to titrate
Stay with same drug Use equianalgesic tables if
converting drugs
Anxiety General Anxiety Disorder (GAD) Affects 2-3% of adults annually Higher in patients with medical
disorders Most common psychiatric
symptom in patients with CV disease
Associated with increased morbidity and mortality
Mueller et al. (2005) Curr Psych Rep; 7: 245-251
Reasons Symptoms
– Dyspnea and pain Medications and lifestyle
– Antihypertensives, steroids– Smoking cessation, caffeine intake or withdrawal
Losses– Role changes– Mobility/ability
Uncertain future– Hospitalizations– Risk of sudden death
Concerns – Family– Finances
Simple Screening
“During the past 4 weeks have you been bothered by feeling anxious or worried most of the time?”
Anxiety Screening Tools MR FISC
– Motor tension, Restlessness, Fatigue, Irritability, Sleep and Concentration impairments
Burke & Wright 2007 Anxiety disorders and medical comorbidities. NY: Jobson Medical Information.
State-Trait Anxiety Inventory www.mindgarden.com
General Anxiety Disorder- 7 Spritzer Arch Int Med 2006;166:1092-1097
Beck Anxiety Inventory www.psychcorp.com
Hospital Anxiety and Depression Scale
www.nfer-nelson.co.uk
Psychotherapy
Cognitive behavior therapy and relaxation showed up to 60% post-treatment recover at 6 months compared with 4% for analytical psychotherapy
Fisher et al (1999) Psychol Med;29:1425-1434
Pharmacology
FDA approved drugs for GAD– Buspirone– Benzodiazepines (situational, short-term)
• Alprazolam
• Diazepam
• Midazolam
– Selective Serotonin Uptake Inhibitors (SSRI)• Paroxetine
• Escitalopram
– Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)• Venlafaxine
Depression Decreased concentration Energy loss/fatigue Pleasure loss (ahedonia) Recurrent thoughts of death Expressions of sadness,
worthlessness, suicide Sleep disturbances Significant weight loss
Heart failure and depression Reported prevalence ranges from 17-58% \ Artininan (2003) AJN; 103(12): 32-42)
Depression is correlated with inability to adjust to decreased functional status
Turvey et al (2006) J CV Nsg; 21(3):178-185)
When severity of depression is controlled for, patients taking antidepressants had a greater incidence of death and hospitalization for cardiovascular events.– Association was independent of the severity of failure– An independent relationship was not established Sherwood A, et al. (2007) Arch Intern Med; 167(4):367–73.
“Are you depressed” Best sensitivity
Best specificity
Best predictive value
Can further clarify using 0-10 scale. – Scores >5 should be assessed by a specialist
Lloyd-Williams M et al (2003). Pall Med (17(1):40-43
Screening Tools Beck Depression Inventory
Beck A & Steer R(1987) San Antonio TX: The Psychological Corp
Hospital Anxiety and Depression Scale Zabora JR (1998). Psycho-oncology. NE: Oxford University Press
Geriatric Depression Scale Koenig H et al (l988). Am Geriatr Soc;36: 699-706.
Pharmacologic Management Selective Serotonin Reuptake Inhibitors
(SSRI) – Citalopram (Celexa), fluoxetine (Prozac),
fuvoxamine (Luvox) ,paroxetine (Paxil), sertraline (Zoloft)
• Little/No anticholinergic effects• Low risk of conduction abnormalities• No orthostatic hypotension• Very little/no sedation• Low seizure risk
Psycho-stimulants May be useful for immediate feelings of
enhanced mood, decreased fatigue and increased appetite
Dextroamphetamine 2.5-5mg daily or methylphenidate 2.5 mg am and noon
Side effects: tremor, tachycardia, psychoses at higher doses
Esper in Kuebler et al (2007) Palliative and End of Life Care. Phil, PA: Saunders
Fatigue and Activity Intolerance
Up to 80% May be associated
with:– Activity intolerance– Malaise– Weakness– Loss of strength– Loss of energy
Impacts quality of life
Fatigue Measurements
Fatigue Symptom Inventory Hann 1998
– Severity, frequency, interference, occurrence
Multidimentional Fatigue and Symptom Scale Stein l998
– General, physical, emotional, mental and vigor
Revised Piper Fatigue Scale Piper l998
– Behavioral, severity, meaning, sensory, cognition and mood
Jacobsen P (2004). J Natl Cancer Inst Mono; 32; 94
Interventions Activity records/energy
conservation Sleep habits
– Mid day 30 minute naps– No evening naps– Stimulus reduction
Medication review Anxiety and depression
management Transfusions/erythropoetin
production Exercise
Davidson et al (2001) Psycho-oncology 10(5):389-397
Pet Therapy Heart failure patients visited by
volunteer-dog team for 12 minutes demonstrated significantly greater decreases in:– Pulmonary artery systolic
pressure– Wedge pressure– Serum epinephrine and nor-epinephrine levels– State anxiety scores
compared to patients who received no visit or a visit by a volunteer only
– Cole et al. (2007)AJCC;16(6):575-588.
Tai Chi Heart failure patients who
participated in supervised Tai Chi classes in addition to usual care demonstrated significantly increased quality of life and distance walked compared to patients who received usual care.
No increases in peak oxygen uptake or adverse outcomes were reported.
Yeh et al (2004) Am J Med;117:541-548.
Massage Systematic review of 20
studies showed massage decreased:– Anxiety– Depression– Pain– Corisol– Catecholamines– Heart rate, blood pressure and
respiratory rate
Field T. (1998) Am Psychol;53:1270-1281
Biofeedback Randomized controlled trial
of 90 HF patients using biofeedback for 6 weeks along with standard care. Patients in the intervention group demonstrated:– 45% decrease in anxiety– 25% decrease in depression
Moser D, et al (1999) Circulation;100:I-99.
Relaxation
Guided progressive relaxation reduced dyspnea in end stage pulmonary disease
Gift AG et al (1992). Nurs Res; 41(4):242-246.
Renfroe KL (1988) Heart Lung; 41(4): 408-413.
ACCP (2010) Chest; 137(3): 674-691
End of Life Care
Refractory dyspnea Terminal pulmonary congestion Terminal delirium Cardiac cachexia and anorexia Inactivation of devices
Hospice Care Palliative care in the last 6
months of life– NYHA III or IV– EF < 20%– Intractable or frequent,
recurrent symptoms despite medical optimization
– Other• Symptomatic arrhythmias,
• History of arrest
• Cardiogenic brain embolism
– Anytime during the illness
– May include curative therapies
– Most often a consult service
– Reimbursed as any other consult
– Usually ends with discharge
– 6 month prognosis – Services covered by Medicare
and most 3rd party payers—excluding room/board
– Therapies for comfort and quality of life including medications
– Admission to service– 13 mo. Bereavement support
National Consensus Project for Quality Palliative Care 2005www.nationalconsensusproject.org
HF and Hospice
HF primary diagnosis for approximately 9% of patients
Mean LOS 60 days (national overall 51.3 days)
Expense of some therapies may preclude use of hospice if hospice was expected to pay for these
Goodlin et al (2005)J Pain Symp Manage;;29(5):525-528
www.nhpco.org
HF Survival and Hospice
Study of 4493 Medicare recipients Hospice vs non hospice Hospice patients with heart failure, lung CA,
pancreatic CA and colon CA had statistically significant longer life compared to non-hospice patients
No statistically significant difference for breast and prostate CA
Connor, S et al (2007)Journal of Pain & Symptom Management. 33(3):238-46.
Information Resources Michigan Hospice and Palliative
Care Organization– www.mihospice.org
Local hospice and palliative care services
Get Palliative Care– www. getpalliativecare.org
National Hospice and Palliative Care Organization– www.nhpco.org
Palliative Care can be…
“It’s not about death, it’s really about living with a disease….
Joanne Lynn MD SUPPORT Primary Investigator