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Palliative Medicine in Cardiovascular Disease
Transcript of Palliative Medicine in Cardiovascular Disease
A heart-to-heart talk I want to change the way
palliative care When you are communicating a new concept, especially one which challenges old assumptions, it is important to: Define terms
Use small words and short sentences
Repeat as necessary The goal is to improve quality of life for the patient and their family. Definitions:*
(I"ll apologize in advance. I can't use small words
unless I do it ) like this. Specialized care for people with serious illness.
this type of care is focused on providing patients with relief from the symptoms, pain and stress of a serious illness-whatever the diagnosis. What is the Goal? Who does Palliative Care? Palliative care is provided by a team of doctors, nurses and other specialists who work with a patient's other doctors to provide an extra layer of support. When is it Appropriate? Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Palliative Care Principles "...comprehensive, interdisciplinary care, focusing on promoting quality of life for patients living with a serious, chronic or terminal illness, and for their families assuring physical comfort and psychosocial support."
-J Pall Med, 1999;1:73-81 What Palliative Care is NOT A mutually exclusive alternative to life-prolonging, restorative care
A mere sequel to failed intensive care Palliative Care Improves Quality RCT simultaneous standard cancer care with palliative care co-management from diagnosis vs. control of standard cancer care only: Improved QOL (FACT-L 98 vs. 91.5, p<0.03)
Reduced depression (HAD 16% vs. 38%, p<0.01; PHQ-9 4% vs 17%, p<0.04)
Reduced "aggressiveness" (chemo > 14 d before death, no hospice care or hospice <3 d before death) of care (33% vs 54%, p<0.05)
Improved survival (11.6 mos. vs 8.9 mos., p<0.02) Temel et al. Early palliative care for patients with non-small-cell lung cancer. NEJM2010; 363:733-42. What We Know: Public and Professional
Misconceptions Washing hands prevents the spread of infection. This has changed practice. Indiscriminate use of antibiotics leads to the development of resistant organisms. This has changed practice. Palliative Medicine improves survival and quality of life. Why hasn't this
changed practice??? Current - Palliative care is linked to "end-of-life" in the minds of the public, professionals, and policy makers
- This is the major barrier to ensuring access to high quality medical care for persons with serious and advanced illness. Near-term solutions - Public awareness; provider awareness; insurer awareness, and policy-maker awareness Hospice:Palliative Care::ACLS:Cardiology Palliative care ≠ hospice. The discipline of palliative care began with a focus almost exclusively on end-of-life care.
But...it was re-conceptualized. Palliative Medicine in Cardiovascular Disease: presented by Stanley Hall, FNP It was recognized that patients with life limiting illnesses, and their families, experience MULTIPLE domains of distress throughout the course of illness A heart-to-heart talk Significant symptoms and psychosocial distress BEGIN during treatments intending to extend life or to cure potentially life-limiting illness...so, why not start palliative care at the same time? Palliative Care Goals Strengthen
patient/family/physician communication and decision making Assure coordinated care
multiple settings Palliative Care Goals Relief of suffering Palliative Care is... pain and symptom management
application of Bioethics/Law community resources/hospice
psychosocial and family care
after-death care an integrative model, in which palliation occurs while life-prolonging therapies are administered
Palliative therapies gradually expand as illnesses progress
hospice is administered according to the patient's wishes or when the harm of their therapies outweighs their benefits Conceptual Shift The World Health Organization modified its definition of palliative care in 2002 to state that palliative care should be provided "early in the course of illness, in conjunction with other therapies that are intended to prolong life." -Goodlin, Sarah J. J Am Coll Cardiol. 2009; 54(5):386-396. doi:10.1016/j.jacc.2009.02.078 (previous 4 slides inclusive) An Amicable Separation palliative medicine is trying to engage with patients who have serious illness EARLY in those illnesses
in other words: For the past 10 years,
we've been swimming upstream... but there are still some Beariers What is palliative care? In summation Traditional medical models view the curing of disease and the providing of comfort care as mutually exclusive
That is so 2001. It has been 10 years since 2002, and in the interim, every major medical specialty has adopted a similar consensus statement regarding palliative care. It's time to put those consensus
statements into practice! More
definitions Treatment effort which is directed toward the cure, or against the cause, of injury or disease. There is, or should be, an expectation of benefit. Care attentive assistance to those in need Treatment ≠ Care although the terms are often used interchangeably, there is an important distinction Treatments have some expectation that they will be beneficial to the patient
may be started when they seem necessary
may be efficacious
may be futile
may be stopped when they are not achieving desired results, or when they result in an intolerable burden of suffering Care is always provided regardless of whether there is active treatment This is important! knowing the distinction and making the distinction when you speak to patients, is critical! Please! Don't ever say or imply by word or deed or omission that... "There is nothing more we can do." If treatments are failing, SAY that the treatment is not achieving the desired result and that:
You recommend that it be stopped, and
You recommend that anything which is still contributing to comfort, to function, or to any other goals of care to be continued...including other treatments you may want to try.
You will still care for the patient, and may bring in some other experts to help you. This discussion will segue nicely With the interactions you have had since the patient first came in, describing the variable course and the progressive nature of heart failure, the risk of sudden cardiac death, the necessity of establishing goals of care, advance directives, completing/updating a POST, ruling out sleep disorder… Wait! Here's another item: Neither is lying. Many patients with life-threatening disease tell interviewers that they have never had a discussion with their care provider which included prognosis. Here's an item Most providers say they have—and document that they have—this type of conversation with their patients. ? A lot of the time, patients don’t hear or process bad news, especially on the first pass.
A majority of providers (especially cardiologists) think that their patients are smart, and understand what they are told.
Sometimes patients smile and nod politely when they get Jargoned, and haven’t the faintest clue what you are really saying…. The Consultation Reasons to consider a Palliative Care Consultation Unaddressed spiritual or psychosocial issues Frequent ED visits or admissions for same diagnosis Prolonged LOS without evidence of improvement or with poor prognosis Team/Patient/Family need
help with complex decision making
and goals of care discussions If You: Wouldn’t be surprised to hear that your patient died in the next six months;
Have noted disease progression despite the patient receiving standard-of-care;
Know the patient/family are having issues with symptom management, end-of-life issues or just aren’t quite ready for hospice yet…
And you haven’t done it already,
You should consult Palliative Care. Survival in Heart Failure “A consequence of advances in the treatment of heart attack is a growing group of patients at risk for the occurrences of heart failure.” Claude Lenfant, M.D.
NHLBI Survival in Heart Failure cont. In 1950-1969, 70% of men died within 5 years of being diagnosed with heart failure; in 1990-1999, that figure dropped to 59% Deaths from heart failure decreased
on average by 12% per decade
for women and men The Burden of Advanced Heart Failure Deaths due to heart failure increased by 28% between 1994 and 2004, while the overall national death rate decreased by 2% over that same interval End stage heart failure has one of the largest effects on quality of life of any advanced disease ~5% of patients with heart failure have end-stage disease which is refractory to treatment The Burden of Advanced Heart Failure More than 5 million Americans
have heart failure with a yearly incidence
estimated at >500,000
Deaths due to heart failure in 2004 (284,365)
exceeded those due to lung cancer,
breast cancer, prostate cancer and
HIV/AIDS combined Symptom Burden in Advanced Heart Failure Dyspnea: 60-88% Fatigue: 42-82% Pain: 41-77% Did you know? Patients with advanced heart failure can have a symptom burden equal to, or exceeding, that of patients with advanced cancer. Challenges in the Treatment of Heart Failure Substantial Symptom Burden
Difficulty with Prognosis
Coordination of Care Illness Impact Trajectory Dyspnea in CHF Diuretics After load reduction (nitrates) Inotropes Opiates Pain in CHF Common and often
under-treated in end
stage heart failure antianginals
with vitamin D repletion
opiates Fatigue in CHF Treat underlying cause (thyroid dysfunction, depression, dehydration, etc.)
Methyphenidate Consensus Recommendations National Institute for Clinical Excellence (NICE-UK): “The palliative needs of patients and caregivers should be identified, assessed and managed at the earliest opportunity” ACC/AHA Heart Failure Guidelines: Palliative care or hospice referral is recommended for end stage heart failure (Level of Evidence 1A) Cardiologists are already experts in palliative medicine: Most of the medical interventions they provide are palliative, rather than curative in nature, and a good deal of their time is invested in managing symptoms. So, you may be wondering, "What is the relationship between Cardiology and Palliative Medicine?" That's easy... You, Batman. We Robin. What does Palliative Care look like in Heart Failure? In a heart failure patient, good palliative care
includes aggressive symptom management. This
can include: pacemakers
participation in clinical trials.
Inotropes and certainly includes maximal medical management of their underlying heart disease…and hence their distressing symptoms…most of the time right up to the point of death. Active participation of cardiologists and cardiology staff contributes substantially to the patient’s symptom relief; Because many, if not most, of their symptoms are a feature of their heart failure. Explain that Palliative medicine is NOT end-of-life care. HOSPICE is end-of-life care Hospice is a special type of palliative medicine. It is our end game. If a patient is engaged in palliative care and progresses to end-stage disease, segué into hospice should be seamless, expected, and atraumatic for the patient and family. The Role of Palliative Care The Course of a Life-Limiting Illness A more comprehensive view, specialized to the trajectory of, and interventions in, heart failure: What palliative medicine adds to
standard cardiology care is: Location, Location,
Location Frequency Social Work Cardiac and vascular patients can
be seen by Palliative Care between
their scheduled sub-specialist visits. This gives more opportunity for assessment, for teaching, for reinforcement of the plan of care, and for managing symptoms. We have the capability to visit patients in their homes. We have social work native to our service, which is available in both inpatient and outpatient venues; Broad Focus Heart failure is seldom the only thing wrong with the patient. Management of symptoms, patient/family education, and goals of care may vary among the patient's diagnosis Time. We’re not limited by the constraints of a 15-minute office visit
We can meet with the patient and the family and take the time needed to answer questions, ensure their knowledge about their treatment, and to:
Reinforce the information/instructions they have already received from Cardiology. What occurs in a Palliative Care Consultation? 1. What is the consult question? symptom control
decision making, goal setting
counseling/support 2. Chart Review 3. Staff Interview: physician, nurse, social worker, chaplain, others What occurs in a Palliative Care
Consultation? (Cont.) 4. Patient/Family Interview Symptom assessment
Disposition planning 5. Communication with primary team: Symptom management plan and negotiation—define who is in charge?
Change care plan to meet patient-defined goals
Triage for additional services 6. Family Meeting-if needed for goal setting and /or information sharing 7. Transition if dying: Where, and with whom? 8. When an inpatient is discharged, Palliative Medicine
service will provide a
Palliative Discharge Summary detailing
PM interventions and what the plan is for follow up. Don’t think of palliative medicine
as just another link in a chain. Think of us as one of the strands of your rope; a constant presence from end to end. Palliative Medicine ≠ Hospice By conflating Palliative medicine with hospice, referrals are often not made until the patient is end-stage, noncompliant, or problematic in some other way. Continuous involvement of Palliative Medicine can make the patient’s and family’s transitions from stage to stage of illness much smoother and less traumatic. On to the end game... Palliative care consultations increase referrals to hospice and result in earlier referrals to hospice. Timely referrals to Hospice: Result in better symptom control, which yields
Better quality of life for the patient, which yields
Better quality of life for the caregivers, AND
Fewer episodes of critical care at the end of life, and, when it comes,
A better quality of death. Late referrals to hospice correlate with: lower overall
lower satisfaction with hospice services
more unmet needs
lack of awareness about what to expect at time of death
more concerns about coordination of care, and... lower confidence in participating in patient care at home
more episodes of hospitalization It's time to do a little... Make Palliative Care
of your patient care. Everybody