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Orlando, Florida – October 7-9, 2011
Approach to End-of-Life in Heart Failure
Rami Kahwash, MDAssistant Professor in Internal medicine
Division of Cardiovascular MedicineSection of Heart Failure/Transplant
The Ohio State University
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The Burden of Advanced Heart Failure
More than 5 million Americans have heart failure
Yearly incidence estimated to be > 500.000
The number of deaths due to heart failure (284.365) exceeds the deaths due to lung cancer, breast cancer, prostate cancer and HIV/AIDS combined ( 2004)
Deaths due to heart failure increased by 28 % from 1994 to 2004
Circulation. 2008;117:e25-e146
WWW.cdc.gov/uscs
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Economic Impact of Heart Failure
Yearly costs of heart failure was roughly $ 30 billions in 2006 Average mean hospital stay length is 6 days> 1/3 of the patients admitted for > 5 daysNearly half of the hospitalizations of heart failure exceed Medicare diagnosis-related group reimbursement
Cicrulation.2006;113:285-e151
Am Heart J. 2008;155:978-985.el.
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4
NCHS 2006
2581
242315
5048120
831
21101 138 165
85
560
0
200
400
600
800
1,000
<45 45-54 55-64 65-74 75-84 85+ Total
Ages
Deat
hs in
Tho
usan
ds
CVD Cancer
CVD Deaths vs. Cancer Deaths by Age (US)
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MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF). LANCET. 1999;353:2001-07.
Severity of Heart FailureModes of Death
12%12%
24%24%
64%64%
CHFCHFOtherOtherSuddenSuddenDeathDeath
n = 103n = 103
NYHA IINYHA II
26%26%
15%15%
59%59%n = 103n = 103
NYHA IIINYHA III
56%56%
11%11%
33%33%
n = 27n = 27
NYHA IVNYHA IV
CHFCHFOtherOtherSuddenSuddenDeathDeath
CHFCHFOtherOtherSuddenSuddenDeathDeath
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Stages of Heart Failure and Treatment Options
Jessup, M. et al. N Engl J Med 2003;348:2007-2018
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When to consider advanced therapies?
What define stage D?
•Intolerance of beta-blockers•Intolerance of ACE-I / ARB’s•Recurrent hospitalizations specially if on optimal medical therapies/CRT•Inotropes use/dependant•Hyponatremia•Progressive renal insufficiency•BUN> 40•SBP < 110•BNP or NT-proBNP >5 X normal
What Define End Stage Clinically?• Intolerance of beta-blockers• Intolerance of ACE-I / ARB’s• Recurrent hospitalizations specially if on optimal medical
therapies/CRT• Inotropes use/dependant• Hyponatremia• Anemia• Progressive renal insufficiency• BUN> 40• SBP < 110• BNP or NT-proBNP >5 X normal
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Stage D Heart Failure
Refractory symptoms despite optimal medical and device therapy5 % of patients with heart failure*Eend stage heart failure has one of the larges effect on QOL of any advanced diseasePalliative care relive symptoms, improves patient satisfaction and decreases the costs of careRecommended by ACC/AHA guidelines as A1**
* Costanzo et al, (ADHERE), Am Heart J. 2008
**Hunt et al, Circulation. 2005
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Palliative Care Movement
Started in mid 1970s as a grassroots community hospice movement aimed at caring for cancer patients in their homes
Added to Medicare benefits in 1982
> 50 % of patients enrolled in hospice have cancer as primary diagnosis and only 12 % has CV disease*
*Fox e et al, JAMA. 1999
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Non-hospice Care Model
Aimed at improving QOL and supporting patients and the families of patients with serious chronic illnesses in whom prognosis is uncertain or may be measured in yearsBased on patient and family needs, independent of prognosisLife prolonging therapies are continued
Hospice Care Model
Aimed to provide pain & suffering relief to terminal patients
Based on patient prognosis
Life prolonging therapies are d/c
Palliative Care
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Model for Palliative Care
Jaarsma T et al. Eur J Heart Fail 2009;11:433-443
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Communication in End-Stage Heart FailureNot Doing a Good Job!
37 % of patients are aware of poor prognosis 8 % of patients and 44 % of family members were told by physician that the time is short36 % of patients die alone
Early approach:Discuss advance directives Appoint healthcare proxy decision makerDiscuss cardiopulmonary resuscitation options
McCarthy M et al, J R Soc Med. 1997
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Example of Effective Dialogue
“Some of my patients tell me that if they were permanently comatose or severely brain injured and unable to recognize or interact with loved ones, they would want care focused only on making sure they were comfortable. Other patients of mine tell me they would want all life-prolonging technologies, no matter how brain damaged they were. Which would you choose?”
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Trajectories of decline.
Jaarsma T et al. Eur J Heart Fail 2009;11:433-443
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Impact of Palliative Care on Clinical Outcome
Improve patient and family satisfaction with care and symptoms management *Patient who receive in-home palliative care are more likely to die at home which is consistent with the expressed wishes of most patients **Improves patient well-being and dignity ( less burden on the their families).Addresses patient spiritual and emotional needsProvides better access to community support services ***
*Gade G et al, J Palliative Med.2008
**Conner SR et al, J Pain Symptoms Manage.2007
***Cassaret D et al, J Am Geriatr soc. 2008
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Impact of Palliative Care on Mortality?Comparing Hospice and Non-hospice Patient Survival Among Patients Who Die Within a Three-Year Window
Retrospective analysis of Medicare beneficiaries
Survival CHF:(402 vs. 321 days).
Conner SR et al, J Pain Symptoms Manage.2007
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Impact of Palliative Care on Healthcare Costs
Decrease the number of procedures or interventions performed near the end of life *Decrease the length of stay in inpatient wards **Decrease hospital indirect costs including pharmacy and imaging ***A study in 1995 showed that enrollment in hospice resulted in reduction in mean Medicare cost per heart failure patient from 53 K to 46 K +
* Field BE et al, chest. 1089
**Lilly et al, Am J Med. 2000
***Bruera et al, J Palliat Med. 2000
+Pyenson B et al, J Pain Symptoms Manage. 2004
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Morrison, R. S. et al. Arch Intern Med 2008;168:1783-1790.
Mean direct costs per day for patients who died and who received palliative care consultation on hospital days 7, 10, and 15 compared with mean direct costs for usual care patients matched by
propensity score
The palliative care patients had an adjusted net savings of $4908 in direct costs per admission (P = .003) and $374 in direct costs per day (P < .001).
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End-of-Life Care
Medical therapy discontinuation: if it will improve QOL ( BB, ACE I, ARB)Inotropes (dobutamine vs. Milrinone)ICD deactivation ( discuss early, explain how ICD works, keep Brady therapy, keep CRT).VAD deactivation:challenging, group discussion (patient, family, CT surgeons, HF specialists, palliative care specialist)best to establish advanced directives prior to implant that outline conditions under which he or she desires the device to be turned off
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End-of-Life Considerations
ACC/AHA Guidelines , 2009 focused update
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End-of-Life Considerations
Aggressive procedures performed within the final days of life (including intubation and implantation of a cardioverterdefibrillator in patients with NYHA functional class IV symptoms who are not anticipated to experience clinical improvement from available treatments) are not appropriate.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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“ No one wants to die. Even people who want to go to heaven don’t want to die to get there. And yet, death is the destination we all share. No one have ever escaped it, and that is how it should be, because death is the single best invention of life. It is life’s change agent. It clears out the old to make the new”
1955-2011
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Thank You