Approaches to Managing the Palliative Care Needs of Patients with Heart FailureDr.Caroline McGuinty MD FRCPCRodolfo Pike RN MN NP

Approaches to Managing the Palliative Care Needs of Patients with Heart FailureDr.Caroline McGuinty MD FRCPCRodolfo Pike RN MN NP Conflict of Interest Disclosures•Grants/research support: None.•Consulting fees: Astra Zeneca, Pfizer, Novartis, Servier•Speaker fees: Novartis, Servier•Other: None.•I willdiscussoff-label uses for palliative care medications. OBJECTIVES 1.Describe current state of palliative care in heart failure2.Describe an approach to changing needs for patients with advanced heart failure3.Understand how to access enhanced supports for patients with difficult symptom control needs at end of life. OBJECTIVES 1.Describe current state of palliative care in heart failure2.Describe an approach to changing needs for patients with advanced heart failure3.Understand how to access enhanced supports for patients with difficult symptom control needs at end of life. Palliative CareThe World Health Organization“An approach that improves quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.” Allen, L. et al. BMJ2016;353:i1010 Scope of the problem•Once heart failure becomes “advanced”, 1 year survival is 60-80%•1 year mortality after 1stHF admission ranges between 20-30%•70% will be readmitted or die in the 12 months after HF admission.•Up to 75% of community-dwelling adults with heart failure die in hospital.ESC Heart Fail. 2018 Apr;5(2):271-278Heart and Stroke 2013 adapted from Ross 2006Quinn, K. et al. J Am Heart Assoc 2020; 9 (5 Symptom burden in Heart Failure •Similar or worse symptom burden and quality of life than cancer.DyspneaFatigueDepressionAnxietyInsomniaDecreased functionPainPoor cognitive function•Increasingly complex medical decision making. The Journal of heart and lung transplantation. 1992;11(2 Pt 1):273-9.Lancet. 2003;362(9378):147-58.Archives of internal medicine. 2004;164(21):2321-4.Journal of cardiac failure. 2012;18(10):776-83Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2012;7(7):567-72Journal of general internal medicine. 2009;24(5):592-8. More Malignant than Cancer. Stewart et al, European Journal of Heart Failure, Volume: 3, Issue: 3, Pages: 315-322 Distribution of adults in need of palliative care at the end of life by disease groups. World Health Organization 2014 Palliative care in heart failure in Canada Canadian studies suggest: •Proportion of adults dying with HF who receive PC is half of that for those dying with cancer.1•Palliative care most commonly initiated <30 days before death2.•Median time from inpatient PC consultation to death 6 days3. •Less than a quarter of patients access palliative care during terminal hospitalization3.•Palliative care led by non specialist physicians2. •Less likely to be admitted to palliative care unit. 1.Seow, H. et al. BMJ Open 2018; 8:e0211472.Quinn, K. et al. J Am Heart Assoc 2020; 9 (5)3.Nazim, A. et al. CJC 34 (2018): 1215-1218 The Evidence for Palliative Care in HF•Decreased symptom burden.•Improved NYHA class.•Improved quality of life.•Decreased hospitalization rates.•Reduced healthcare costs.•More likely to die at homeJ Card Failure. 2012 Dec; 18 (12): 894-899European Journal of Heart Failure (2014) 16, 1142–1151Journal of PalliatveMedicine 2015. 18 (2).Heart 2016;102:1100–1108 J Am CollCardiology2017 Jul18;70(3):331-341Journal of PalliativeMedicine 2017. 20 (1)Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.AnnuRev Public Health 2014. 35: 459-75 OBJECTIVES 1.Describe current state of palliative care in heart failure2.Describe an approach to changing needs for patients with advanced heart failure3.Understand how to access enhanced supports for patients with difficult symptom control needs at end of life. DEATH BEREAVEMENT EOL PALLIATIVE CARE LIFE PROLONGING CARE LIFE PROLONGING CARE EOL PC FOCUS OF CAREFOCUS OF CARETIME → TIME → DEATH Palliative Care Adler et al. JAMA.1999;281: 163–168 Palliative Care Model in HF Advance Care Planning Goals ofCare Code Status McIlvennan, C. Allen, L. BMJ 2016;352:i1010 Establishing Goals and Values Circulation. 2012 April 17; 125(15): 1928–1952 Nova Scotia Health Authority, 2019 Improving Communication•Patient decision aid•Improved patient knowledge•Reduced decisional conflict•Increased patient decision making Circulation. 2012 April 17; 125(15): 1928–1952 Colorado Program for Patient Centered Decisions 2018Cochrane Database SystRev. 2009; (3) CD001431. Advance Care Planning www.myspeakupplan.ca Dyspnea•Optimize guideline-directed therapy•Non pharmacological: handheld fan, rehab•Diuretics•Inotropes•Opioids: •Literature suggests safe in patients with HF•Mixed results in patients with HF•Remains first line recommendation for refractory symptoms EurHeart J 2012; 33: 1787–1847. N EnglJ Med,341(1999), pp.709-717Pain Med 2018 Mar 1;19(3):485-490 Am J HospPalliativeCare2019 Feb 25:1049909119832816EurJ Heart Fail. 2011 Sep;13(9):1006-12 J Pain Symptom Manage 2010; 39: 831–838EurJ Heart Fail 2011; 13: 1006–1012.EurJ Heart Fail. 2002; 4: 753–756 J PalliatMed2013: 16: 250–255. 2017 CCS HF GuidelinesUpdate. Pain •Common in HF but underdiagnosed.•Mild pain: acetaminophen.•Moderate to severe pain: Opioids as first-line therapy, oral route, regular dosing,titrate dose according to pain intensity on ESAS scale until adequate relief•Avoid NSAIDs and Codeine.•Consider complementary medicine optionsPain Symptom Management 38:698–707PalliativeMedicine27(9) 822–828Canadian Family PhysicianSeptember 2017,63(9)674-680;Clinical Practice Guideline, Canadian Family Physician 2018, Volume 64. Nausea•Prokinetics: •Metoclopramide 5-20 mg po/iv/scq6h PRN•Antiemetic drug of choice •Dopamine Antagonists•Haldol 0.5-1 mg po/iv/scq4h prn•Olanzapine 2.5-5 mg po/scqhs+/-q4h prn•Methotrimeprazine (Nozinan) 2.5-5 mg poor 6.25-12.5 mg po/sc/iv q4h prnJ Support Oncol6(3):119–1242017 CCS HF Guideline UpdateCFP 2018. 64(2) 111-120. Be aware QT prolongation! Depression •Use low-dose SSRIs as first-line therapy•Sertraline and venlafaxine safe in HF. •Avoid tricyclic antidepressants.•Cognitive-behaviouraltherapy, spiritual support, mindfulness-based training, and dignity therapyJournal of the American College of Cardiology. 2010;56(9):692-9.The Journal of clinical psychiatry. 2014;75(6):e552-8Canadian Family PhysicianSeptember 2017,63(9)674-680; Fatigue•Optimize guideline-directed therapy•Rehabilitation•Rule out sleep disordered breathing, iron deficiency, depression•Inotropic support 2017 CCS HF Guideline UpdateDiamant,Met al. CurrOpinCardiology2020, 35:156-161 OBJECTIVES 1.Describe current state of palliative care in heart failure2.Describe an approach to changing needs for patients with advanced heart failure3.Understand how to access enhanced supports for patients with difficult symptom control needs at end of life. Chuzi, S et al. Current Heart Failure Reports 2019; 16:220-228 Specialist Palliative Care •Need for shared decision-making despite prognostic uncertainty•Integration of palliative care into the HF team•Co-locate within HF clinic •Impact of outpatient PC programs in HF needs further study•Specialized palliative care clinic or inpatient consult service •Community access can be limited depending on region•Home inotrope program COVID-19 Palliative Resources https://www.pallium.ca/pallium-canadas-covid-19-response-resources/ www.pallium.ca Thank you! PAL-HF J Am CollCardiology2017 Jul18;70(3):331-341 •Improved QoL and satisfaction•Meta-analysis-decreased rehospitalizations•Decrease in resource utilization Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46. Palliative Care: Improved Survival Prospective study of outpatient PC consultation in recently hospitalized patients with HF. Improvement in symptoms at 3 months.Improved physical health per the Minnesota Living with Heart Failure score. J Card Failure. 2012 Dec; 18 (12): 894-899 Palliative homecare program for patients with Heart Failure European Journal of Heart Failure (2014) 16, 1142–1151 Improved quality of life, symptom burden, NYHA class.Decreased hospitalization rates compared with usual care. •Inpatient PC consult•Improved PHQ-9 scores and Minnesota Living with Heart Failure score at 1 and 3 months. •No difference in readmission at 30 days, hospice use or death within 6 months. Heart 2016;102:1100–1108 Goals of Integrating Palliative Care •Better communication•Better quality of life•Better transitions of care•Better outcomes