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When are Cardiac Patients Hospice Appropriate
This document discusses when cardiac patients are appropriate for hospice care. It provides background on heart failure prevalence and costs in the US. It describes the stages and classifications of heart failure as well as common causes. Advanced cardiac disease greatly impacts quality of life and functional status. Hospice can improve outcomes for these patients by managing symptoms, preventing hospitalizations, and providing psychosocial support. Three case scenarios are presented that demonstrate key factors qualifying patients for hospice, such as frequent hospitalizations, poor prognosis, and declining functional status.
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When are Cardiac Patients Hospice Appropriate
- 1. When are CardiacPatients Hospice Appropriate?
- 2. Objectives • Understand theimpact of cardiac disease on patients, families and the health care system • Discuss the basic function of the heart and causes of cardiac disease • Identify patients with cardiac disease appropriate for hospice services
- 3. Objectives (Cont.) • Understandthe benefits of hospice for patients, their families, and referral sources • Learn strategies to engage physicians & referral sources in discussions about hospice for this patient population and overcome barriers to hospice referral
- 4. Heart Failure inthe U.S.: It Is Common • Prevalence: 5 million People – Yearly incidence >500,000 – 50% who develop HF die within 5 years – Causes more deaths per year than lung, breast, prostate cancer & HIV/AIDS combined (~285,000) – 75% of patients with heart failure are over 65 years old – 10% of patients have advanced disease
- 5. Heart Failure inthe U.S.: High Personal and Financial Costs • Significant impact on QOL – Chronic, progressive, terminal illness: – 1994-2004, national death rate 2%, but deaths due to CHF by 28% – Despite being the leading cause of death, patients w/ cardiac conditions = only 10% of hospice referrals & admissions
- 6. Heart Failure inthe U.S.: High Personal and Financial Costs • Financial burden: $30 billion in 2006 – High cost of medications, compromises med adherence – Freq. MD visits, hospitalizations, ICU stays – Leading cause of hospitalization > 65 years old – COMMON CAUSE OF REHOSPITALIZATION, – Under scrutiny via ACA, penalties for readmission – FERTILE Ground to get hospital administration to help identify triggers for referral
- 7. Causes of CardiacDisease • What can go wrong? – Atherosclerosis: Hardening of the arteries, prevents adequate oxygen delivery to the heart muscle – Valvular insufficiency: Heart valves won’t close, causing blood to leak back into the chamber, dilating and weakening it; – Valvular stenosis: Valves won’t open properly, causing blood to be trapped in the chamber and to not get out to the lungs and body
- 8. Causes of CardiacDisease • What can go wrong? – Atherosclerosis: Hardening of the arteries, prevents adequate oxygen delivery to the heart muscle – Valvular insufficiency: Heart valves won’t close, causing blood to leak back into the chamber, dilating and weakening it; – Valvular stenosis: Valves won’t open properly, causing blood to be trapped in the chamber and to not get out to the lungs and body
- 9. Causes of CardiacDisease (Cont.) – Cardiomegaly: Enlargement of the heart caused by too much pressure (hypertension, valve failure) or injury (heart attacks) – Arrhythmia: Abnormal rhythms – can be caused by the walls stretching – Cardiomyopathy: Any disease of the heart muscle itself
- 10. Causes of CardiacDisease (Cont.) – Infections: Pericarditis (covering of the heart), endocarditis (inner lining of the heart) and myocarditis (the muscle of the heart) – Uncontrolled Chronic conditions HTN and Diabetes:
- 11. • Disease ofthe heart muscle that decreases the heart’s ability to pump blood • End pathway of all cardiac injury that leads to heart failure • Types of Cardiomyopathy – Ischemic Cardiomyopathy – Non-Ischemic Cardiomyopathy • Dilated Cardiomyopathy (Most common post MI) • Hypertrophic Cardiomyopathy (Htn, Genetic) • Restrictive Cardiomyopathy Cardiomyopathy
- 12. Updated Terminology for HeartFailure • HFrEF: Heart Failure with reduced Ejection Fraction (EF<50%) – Previously was called systolic dysfunction – Patients have reduced amount of blood leaving heart that leads to heart failure symptoms – Can be systolic or diastolic in nature
- 13. Updated Terminology for HeartFailure (Cont.) • HFpEF: Heart Failure with preserved Ejection Fraction (EF>50) – Previously was called diastolic heart dysfunction – Can be from ischemic and/or chronic conditions – Patients get thickening of heart muscle that decreases size of heart chamber and amount of blood delivered to body, but on imaging ejection fraction looks normal – Patients who have symptomatic HF with normal EF
- 14. The Stages ofHeart Failure: NYHA Classification • Class I: (mild) No limitation of physical activity. Does not cause undue fatigue, palpation, or dyspnea • Class II: (mild) Slight limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpation, or dyspnea
- 15. The Stages ofHeart Failure: NYHA Classification (Cont.) • Class III: (moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpation, or dyspnea • Class IV: (severe) Unable to carry out of physical activity. Without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased
- 16. The New Classification ofHeart Failure • Stage A: No limitation of physical activity. Patients at high risk for heart failure without structural heart disease. – Patients with: Hypertension, Atherosclerosis, Diabetes, obesity, metabolic syndrome, or Cardio- toxin exposure. – Treatment Goals: prevention and disease directed therapies of chronic diseases to decrease risk.
- 17. The New Classification ofHeart Failure (Cont.) • Stage B: No limitation of physical activity. Structural heart disease without signs of heart failure. – Patients with: Previous MI, Cardiac remodeling like LVH and al low ejection fraction, and asymptomatic valvular disease – Goal: Continued medical management to prevent further disease progression including medications and defibrillator if appropriate
- 18. The New Classification ofHeart Failure (Cont.) • Stage C: Limitation of physical activity. Patient with structural heart disease and current or previous symptoms of heart. – Patients with: Any for of heart disease with SOB and fatigue, and/or reduced exercise tolerance. – Goal: Optimize medical therapy to decrease symptoms and dietary salt restriction
- 19. The New Classification ofHeart Failure (Cont.) • Stage D: (severe) Unable to carry out any physical without discomfort. Symptoms of Cardiac insufficiency at rest despite optimal medical therapy. • Patients who are recurrently hospitalized or those who cannot be safely discharged from hospital without special interventions
- 20. The New Classification ofHeart Failure (Cont.) – Goals: Optimize medical therapy to decrease symptoms and dietary salt restriction – Options: Quality EOL Care/Hospice, and extraordinary measures including transplant, bridging LVAD, and Destination LVAD
- 21. The Impact ofAdvanced Cardiac Disease • Physical Symptoms – dyspnea/shortness of breath – pain – edema – fatigue – insomnia – anorexia/cachexia – constipation – confusion • Psychosocial issues – Depression – Anxiety – Increased dependence – Frequent hospitalization – Lack of awareness & understanding of disease progression/dying process End-stage Heart Failure has one of the greatest effects on quality of life of any advanced illness
- 22. Impact of Advanced CardiacDisease • Silver Tsunami is here! – 2011 1st Baby Boomer began turning 65 – Medicare Usage will be 47-80 million people by 2030 – They live with multiple chronic conditions with variable control • DM, HTN, COPD, and Dementia • This Stresses the entire health system! • Puts Patients at risk for Readmission
- 23. Impact of Advanced CardiacDisease (Cont.) • Mean Cost for last 2 years of life $156,168 – 78% of this cost is Inpatient – 25% of last 6M of life spent in hospital
- 24. Impact of Advanced CardiacDisease (Cont.) • Hospital Readmission Reduction Program – Reduction in all cause readmissions by AMI, CHF, and PNA to patients who readmit within 30 days – Penalties to Medicare Billing • 2013: 1% • 2014: 2% • 2015: 3% • And don’t forget sequestration!
- 25. Palliative Care &Hospice Improve Clinical Outcomes • Patients with advanced cardiac disease & their families experience: – Overall satisfaction with their care – Symptom control, QOL – Unnecessary, invasive procedures and interventions near EOL • Chance of dying at home
- 26. Palliative Care &Hospice Improve Clinical Outcomes • Chance of dying at home – Improved communication with health care providers – Earlier referral to hospice may actually prolong survival (avg. 81 days for CA pats) Adler, ED. Palliative care in the treatment of advanced heart failure. Circulation 2009 120(25): 2597-606.
- 27. Patient Eligibility: Advanced CardiacDisease – NYHA Class III or IV or Stage D: (moderate-severe) Class III: Marked Limitation of physical activity. Comfortable at rest. Minimal exertion causes fatigue, palpation, or dyspnea. – Class IV Stage D: Unable to carry out any physical activity without discomfort. Dyspnea, angina, palpations at rest. “Bed to chair” existence.
- 28. Patient Eligibility: Advanced CardiacDisease • “Optimally treated” or maximized with diuretics, vasodilators, ACE inhibitors, or inotropes. • Co-morbid risk factors: HTN, DM, CAD, CM, MI, COPD • Poor prognostic indicators: cachexia, renal dysfunction (increased creatinine), O2 requirement (SpO2 < 88%), symptomatic arrhythmia, EF < 20%, history of cardiac arrest and/or syncope
- 29. Patient Eligibility: Advanced CardiacDisease • Frequent ED visits and/or hospitalizations Clinical judgment may be more accurate than NHPCO guidelines (Freund 2012)
- 30. Chronic Illness andFunctional Dependence at EOL • Pattern of precipitous decline is seen in end stage cancer • Higher level of functional impairment and more gradual decline in non-cancer end stage processes • 40% of decedents with DM, CHF, COPD and CVA had ADL impairment on year prior to death Age Adjusted ADL Scores by Month before Death 0 0.5 1 1.5 2 2.5 3 3.5 12 11 10 9 8 7 6 5 4 3 2 1 0 Month before Death ADLScore Teno, J.M., Weitzen, S., Fennell, M.L., & Mor, V. (2001). Dying trajectory in the last year of life: Does cancer trajectory fit other diseases? Journal of Palliative Medicine, 4 (4), 457-464. Cance r COPD CHF
- 31. Activities of DailyLiving • Dependence in three or more is related to increased mortality – Bathing – Dressing – Toilet – Transfer – Continence – Feeding
- 32. Mariell Jessup, MDFACC University of Pennsylvania, September 5, 2005 “There is a failure to recognize that end-stage heart CHF patients frequently come in and out of the hospital over and over again and suffer a lot with really no impact on their ultimate survival.”
- 33. Benefits of HospiceCare for Patients with Advanced Cardiac Disease • Regular assessment by skilled clinicians who will provide cardiac case management: monitor vital signs, improve medication & dietary compliance, proactive intervention to prevent crises before they occur • Access to skilled clinicians 24 hours/day through Telecare program can prevent emergency department visits, after-hours calls to the physician office, recurrent hospitalizations and death in an ICU
- 34. Benefits of HospiceCare for Patients with Advanced Cardiac Disease (Cont.) • Availability of higher levels of care at an Inpatient Unit or with Intensive Comfort Care for exacerbation management
- 35. Benefits of HospiceReferral for Advanced Cardiac Disease • Cardiac & other symptom management medications are covered and delivered directly to the home, including IV therapies if clinically indicated • Oxygen is provided to all hospice patients as needed, regardless of pulse oximetry testing, as well as durable medical equipment (DME, HME)
- 36. Benefits of HospiceReferral for Advanced Cardiac Disease (Cont.) • Assistance in meeting increasing care needs through in-home care • Counseling & psychosocial support to patients and their families as the cope with a chronic & progressive, yet ultimately terminal illness
- 37. Utilizing Hospice Services forand Advanced Heart Failure PatientClinicalStatus Inpatient Hospice or Intensive Comfort Care for exacerbation management Time Hospice Enrollment Routine Hospice Care
- 38. Why Do Cardiac PatientsReadmit? • Very vulnerable during periods of exacerbation of disease that are more frequent and persistent
- 39. • Old HabitsDie Hard and their HF is looked at as a chronic disease - The hospital has become their safety net! - For years they have gone to hospital and gotten better! • Reality Their Progressive TERMINAL disease is now unstable and highly symptomatic - Edema, SOB, progressive debility, muscle wasting, and poor response to medications. Why Do Cardiac Patients Readmit?
- 40. • Elicit Needs,then Introduce Hospice as a Solution to the Patient’s Concerns, Prevention of Readmission – Note that the admission criteria do NOT depend on labs or Ejection Fraction! • Would it surprise you if the patient were to die in the next 6M? • ADL deterioration, pt distress, frequent hospitalization and ED visits are the key for referral • In the following cases, identify the key factors for referral
- 41. Myths Create Barriersto Hospice Referrals for Cardiac Patients • Hospice is only for patients with cancer • Hospice is only for patients who are actively dying • All treatment is discounted when a patient elects hospice • DNR status is required for all hospice patients • The patient who lives longer that 6 months will be discharged • The physician must be certain that the patient’s life expectancy is 6 months
- 42. Case Scenario 1:Mrs. G • 78 y.o. hospitalized for the 3rd time in 2 mos for exacerbation of CHF Sxs • ABG slightly worse, BiPAP initiated • Severe edema, cough, can only speak a few words at a time and pauses to catch her breath • Mrs. G hates coming to the hospital, but does not know how else to “feel better” • Daughter feels “overwhelmed” by her mother’s increased needs, reports Mom “sometimes runs out of her medicines”
- 43. Case Scenario 2:Mr. K • 59 y.o. with long history of cardiomyopathy • Admitted to the hospital 1 mo ago w/ severe dyspnea (SOB); EF=10%, started on IV Lasix and Milrinone • SOB improved, now able to transfer from bed to chair; cannot wean off IV Milrinone • Pt understands his illness in progressing and would like to be home spending time with his family
- 44. Case Scenario 3:Mrs. W • 71 y.o. with history of CAD, COPD, DM • Recently hospitalized for pneumonia, now at her PCP’s office for flu • Reports increased fatigue, SOB throughout the day, unable to go up and down stairs, decreased appetite • Needs help at home, feels overwhelmed w/ medication changes
- 45. Conclusion • Advanced cardiacdisease significantly impacts the quality of life of patients & their families • VITAS offers comprehensive care to people with advanced cardiac disease & their families by providing – Aggressive symptom management – Helpful in-home services – Education about disease process – Psychosocial & spiritual support – Higher levels of care when clinically indicated to prevent re-hospitalization