Palliative Care in heart failure

Elaine Lee, Specialist Heart Failure Nurse and

Sally Lawton, Senior Lecturer in Palliative Care (Nursing) NHS G

Aims of presentation

To show how the palliative approach fits with the heart failure serviceTo discuss the stages of the palliative approach within ‘Living and Dying well’:

IdentificationAssessmentReview and monitoringEnd of life phase

Palliative care

Gold Standards Framework

Case Study - Uncertainty

84 year old male with asbestosis and advanced HFWould have preferred to stay at homeDN team arranged for hospital bed etc for his houseElderly wife not able to look after him when he could no longer weight bareAdmitted to Woodend Hospital

Facts on Heart Failure

40% of people diagnosed with Heart Failure will die within a year (BHF, 2008).

40% of patients admitted to hospital will be readmitted within 6 months (BHF,2008).

Heart Failure has a worse prognosis than many cancers.

Heart Failure versesCancer Mortality

0 20 40 60 80 100

Melanoma

Breast

Uterus

Bladder

Prostate

NHL

Colon

Heart failure

Ovarian

Kidney

Leukaemia

Stomach

Oesophagus

Lung

Pancreas

One year survival rate (%)

The one-year survival rate for heart failure is worse than that for cancer of the breast, uterus, prostate & bladder

Coronary heart disease statistics: heart failure supplement., BHF 2002, http://www.heartstats.org, accessed 25.02.04. Based on Quinn M et al. ONS 2001 & Cowie MR et al. Heart 2000; 83: 505-510.

Average Length of Hospital Admission HF vs Other Conditions

0 5 10 15 20 25 30

All

Circulatory

CHD

Angina

Acute M I

Chronic CHD

Heart failure

Stroke

Diabetes

Cancer

Colorectal cancer

Lung cancer

Breast cancer

Bladder cancer

Nervous sytem

Respiratory

Digestive

GU

Injury & po isoning

Ma

in d

iag

no

sis

Number of inpatient days

Coronary heart disease statistics: heart failure supplement., BHF 2002, http://www.heartstats.org, accessed 25.02.04. Based on Hospital Episode Statistics DOH 2001 at http://www.dh.gov.uk/publicationsandstatistics/statistics/hospitalepisodestatistics/fs/en accessed 10.03.04

Identification

Old Model

diagnosis death

New Model

diagnosis death

Background - Worsening HF

Symptoms despite optimal therapy3 or more hospital admissions with HF in 3 monthsDependent for more than three activities of daily living Reduced performance score Cardiac Cachexia (weight loss >10% in 6 months)Resistant hyponatraemiaSerum Albumin <25g/lMultiple shocks from device

Functional assessment

Review and monitoring

Advance care planningPalliative registerE-PCSDNA CPRDS1500Patient preferences

Referral criteriaInclusion Criteria

A new diagnosis of left ventricular systolic dysfunction (LVSD)New York Heart Association (NYHA) stage III/IV Existing LVSD who have an admission due to decompensation.Residing in Grampian regionWilling to be followed up at home

Exclusion Criteria

Unwilling to receive the heart failure specialist nurse serviceGood left ventricle systolic functionOther life threatening illness requiring palliative care

Case Study – the ‘ideal’ patient!

Review and monitoring – heart failure

Education and SupportAlleviate SymptomsImprove Quality of LifeDelay Disease ProgressionProlong Patient SurvivalReduce Sudden Cardiac DeathReduce Hospital Admissions (and cost)

Case Study – comfort care

END OF LIFE?

Last few daysLast few weeksLast few monthsLast year (or longer)

Case study –‘active’ and ‘palliative’ care

End of life phase - challenges

Preferred place of care?Deactivation of implantable device?Anticipatory prescribing?Being at home to die?

Case Study - end of life

81 year old male with advanced HFPalliative markers presentOP clinic CRT discussedAdmitted for investigations for aboveNot suitableIV inotropes 48 hoursDeteriorated and died in CCU