Patricia M. Fogelman DNP

Janine Gerringer CRNP

Geisinger Health System

Danville, PA

PCNP November 2015

The Heart Of The

Matter

Cardiac Biotechnology: Withdrawal and Management Of

End Stage Heart Failure.

NO DISCLOSURES

BACKGROUND

• The role of the APRN is to advocate, offer treatment for relief of distressing symptoms before withdrawing vasopressors and other forms of life support.

• The APRN should anticipate the need to provide palliative management of terminal heart failure symptoms.

• APRNs should discuss changes patients may move through in the dying process and assure that the patient/family understand these changes and the mutual goal of a peaceful death.

• APRNs should always refer to any institutional policies regarding withdrawal of vasopressors, and heart failure APRNs can be critical players in developing these protocols.

DISCONTINUATION OF VASOPRESSORS

• Vasopressors are medications delivered intravenously to support blood pressure during periods of hemodynamic instability in the acute care setting, most notably in the treatment of shock.

• Examples of vasopressors are epinephrine, norepinephrine, phenylephrine, and vasopressin.

DISCONTINUATION OF VASOPRESSORS

• Vasopressors are generally withdrawn when other forms of life support, ( ventilator, dialysis) are withdrawn

• Medications are withdrawn either at the same time or before or after ventilator support, without the need for medication weaning.

DISCONTINUATION OF INOTROPES

• Intravenous inotropic agents are used in acutely ill, hospitalized heart failure patients with a severely reduced ejection fraction.

• In acute settings, inotropes are used to establish hemodynamic stability by increasing systemic perfusion and preserving end-organ function.

• Use focuses on clinical improvement or as a bridge to a more permanent treatment such as surgery, cardiac transplant, or left ventricular assist device (LVAD) placement.

DISCONTINUATION OF INOTROPES

• Inotropes may be used as long-term palliative treatment in patients whose advanced heart failure is refractory to other guideline-directed oral medications and who are not candidates for a VAD or cardiac transplant.

• Goal: symptom relief Inotrope treatment is initiated based on hemodynamics demonstrating clinical benefit and on the patient’s wishes.

• Goals of care and possible end-of-life scenarios should be discussed before starting continuous inotrope therapy.

INOTROPES

• The most common inotropes used in the home setting are milrinone, dobutamine, and dopamine.

• Monitor patients for the risks of continuous inotropic therapy, such as central line infection, hypotension. and arrhythmias.

• To minimize the risk of adverse effects such as arrhythmias, the lowest dose needed for symptom relief should be used.

• If the patient is no longer benefiting from inotrope therapy, the APRN should revisit the goals of care.

VENTRICULAR ASSIST DEVICES: VAD

VENTRICULAR ASSIST DEVICES: VAD

• Mechanical circulatory support is a becoming a widely accepted treatment for patients with advanced (stage D) heart failure with a reduced ejection fraction refractory to guideline-directed oral medications and cardiac device intervention.

• VADs are designed to assist the patient’s failing native ventricle by improving cardiac output.

• Long-term LVADs are surgically implanted pumps that connect from the left ventricle to the ascending aorta to assist with systemic circulation:

• Blood exits the left ventricle through the inflow cannula, enters the pump, and is then directed through an outflow cannula to the aorta.

• An external driveline and power source is connected to the body to power the pump.

VAD: TEAM DYNAMICS

• In October 2014, the Joint Commission mandated that certified destination therapy VAD programs have a palliative care representative who has experience with the VAD population on the institution’s interdisciplinary team.

• Palliative care services should be used from the beginning while the patient is undergoing evaluation prior to implantation: palliative care team promotes goals-of-care discussions and should be available to support patients who have decided to undergo LVAD implantation as well aspatients who have been deemed ineligible for an LVAD or decline implantation in favor of optimal medical management alone.

VAD: TEAM DYNAMICS

• APRN provides ongoing assessment of quality of life, goals of care, and health status.

• Major changes in health status due to device-related complications or other comorbidities not related to the device may lead to revisiting end-of-life discussions.

• Potential complications that may lead to death include stroke, infection, and multiple-organ failure.

VAD: ETHICS

• Petrucci and colleagues devised a 10-point model for addressing ethical concerns in the treatment of VAD patients:

• Advance directives are important in VAD patients because most patients and families are not aware of the issues that may arise while the patient is supported with a VAD.

• For example, the VAD can continue to mechanically support the blood pressure in an otherwise fatal situation.

• Discussion should be based on the type of support the VAD will offer, either as destination therapy or a bridge to transplant

• Discussion should occur before an advance directive is formulated regarding complications: bleeding, neurological events, and infection.

• This is the time when any major conflicts between the patient and designated decision makers should be addressed.

Petrucci R, Benish LA, Carrow BL, et al. Ethical considerations for ventricular assist device support: A 10-point model. ASAIO J. 2011; 57: 268–73.

VAD: DISCONTINUATION

• First refer to any institutional protocols regarding VAD deactivation. In the absence of a formal institutional protocol, Wiegand and colleagues outlined key points for LVAD withdrawal:

• Be familiar with the system’s alarms and how to turn them off so as not to cause any additional distress to the patient and the patient’s family members.

• Order and monitor the efficacy of medications directed toward patient comfort prior to LVAD device deactivation, as the cardiovascular circulation may significantly decrease when the LVAD ceases function.

Wiegand DL, Kalowes PG. Withdrawal of cardiac medications and devices. AACN Adv CritCare. 2007; 18(4): 415.

VAD DISCONTINUATION

• Removal of the power sources and the driveline from the controller will cease the function of the LVAD. As with ventilator removal, the APRN should be prepared to act quickly to prevent and treat signs and symptoms of discomfort.

VAD: DISCONTINUATION

• Deactivation can occur in the hospital or at home, depending on the patient’s medical condition/wishes and whether the event is acute or chronic.

• In the hospital, the APRN can oversee the process and be available to support the patient and the staff, incl writing orders for discontinuation and administering medications for comfort.

• If deactivation is to occur at home, the APRN may be responsible for teaching the patient’s family or hospice staff how to deactivate the device and how to administer medication for the patient’s comfort to ensure a peaceful death.

PACEMAKERS & AUTOMATIC IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS (AICD)

• Pacemakers are commonly used to treat patients with symptomatic bradycardia and sinus node dysfunction.

• ICDs are devices that increase survival by terminating life-threatening arrhythmias. ICDs do not treat heart failure by improving cardiac function or decreasing symptom burden, but they decrease the risk of sudden cardiac death.

• Institution that implant cardiac devices should have protocols in place that clearly outline the process to deactivate when withdrawal of such care is appropriate.

IMPLANTABLE DEVICES: DISCUSSIONS

• Palliative care professionals can facilitate discussions regarding deactivation, including the patient’s and family’s wishes as well as expected symptom management.

• The final decision as to whether an ICD is burdensome should be made by the patient or a surrogate decision maker.

• In a study by Buchhalter and colleagues, of the patients who underwent cardiac device deactivation, more than half of the requests for device deactivation came from surrogate decision makers.

Buchhalter LC, Ottenberg AL, Webster TL, Swetz KM, Hayes DL, Mueller PS. Features and outcomes of patients who underwent cardiac device deactivation. JAMA Intern Med. 2014; 174(1): 80–5.

PACER/ICD: DISCONTINUATION

• Deactivation should be performed by healthcare professionals with electrophysiology experience when possible: device-trained nurses, technologists, physicians.

• In the absence of a device-trained specialist, deactivation can be performed by a healthcare professional under the guidance of an industry representative.

PACER/ICD DISCONTINUATION

• The defibrillator function of an ICD is separate from the pacing function. Pacing does not need to be disabled when the ICD is reprogrammed. Pacing may treat bradyarrhythmias and cardiac resynchronization at the end of life for symptomatic relief in patients without causing discomfort.

• When a patient is at home with hospice or home health, a pacemaker magnet can be used to deactivate an ICD generator if a programmer is unavailable.

PACER/ICD: DISCONTINUATION

• These general steps can be followed in any setting in which deactivation occurs, including acute care hospitals, patient care facilities, or the patient’s home:

• Pacemakers: change the programming mode or lower the rate and adjust output so that the device is no longer functional.

• ICD: change the programming or, for certain pulse generators, constant application of a magnet over the device.

• Placement of a magnet over a pulse generator of most ICDs will temporarily cease the anti-tachycardia therapies while not affecting the pacemaker function.

• To spare a patient from multiple painful shocks, a doughnut magnet and instructions for use should be provided to patients with a terminal diagnosis.

• Reassure patient: deactivation of the ICD through reprogramming is not painful.

The Heart Of The Matter

• Withdrawal of device support is an issue rife with ethical and moral conflict, further emphasizing the need for early involvement of Palliative Care in partnership with cardiology so that effective, comprehensive care can be delivered to patients with advanced heart failure.

BARRIERS

• Difficult prognostication in population with exacerbations & high risk for sudden death.

• Deficits in provider knowledge.

• Medical providers, often perceiving death as a “failure,” tend to avoid these discussions.

Connors AF Jr, Dawson NV, Desbiens NA, et al. A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA. 1995; 274(20): 1591–8.

BARRIERS

HOWEVER…

• Patients with advanced failure have demonstrated preferences to cease therapies or procedures they deem to be ineffective/burdensome AND often ask about deactivating devices that had been placed earlier in their disease course, when there was more benefit gained.

• As disease trajectory evolves, patients demonstrate a desire and willingness to discuss end-of-life planning.

• Patients want to redefine the goals of care and establish a plan for pain and symptom management when their disease can no longer be controlled or managed by their present medical regimen.

OVERCOMING BARRIERS

• Continued promotion of palliative care education and awareness.

• APRNs can facilitate the delivery of palliative care to heart failure patients by promoting their educational activities on their units:

• End-of-Life Nursing Education Consortium (ELNEC): This national education initiative strives to enhance the delivery of palliative care by providing education and development tools for nursing staff.

ELNEC: WWW.AACN.NCHE.EDU/ELNEC

• End-of-Life Nursing Education Consortium (ELNEC).

• National education initiative to improve palliative care.

• Provides undergraduate and graduate nursing faculty, CE providers, staff development educators, specialty nurses in pediatrics, oncology, critical care and geriatrics, and other nurses with training in palliative care so they can teach this essential information to nursing students and practicing nurses.

• The project began in February 2000, initially funded by a major grant from The Robert Wood Johnson Foundation (RWJF).

• Additional funding from: National Cancer (NCI) and Open Society Institutes, the Aetna, Archstone, Oncology Nursing, California HealthCare, Milbank, and Cambia Health Foundations, and the Department of Veteran Affairs (VA).

American Association of Colleges of Nursing. End-of-Life Nursing Education Consortium (ELNEC). Available at http://www.aacn.nche.edu/elnec. Accessed August 26, 2015.

ELNEC• The ELNEC project is administered by the American Association of

Colleges of Nursing (AACN), Washington, DC and the City of Hope, Los Angeles, CA.

• The esteemed faculty includes a national cadre of nursing leaders in palliative care.

• To date, over 30,100 nurses and other healthcare professionals, representing all 50 US states + 86 international countries have received ELNEC training.

• ELNEC Trainers host professional development seminars for practicing nurses, incorporate ELNEC content into nursing curriculum, host regional training sessions to expand ELNEC’s reach into rural and underserved communities, present ELNEC at national and international conferences, coordinating community partnerships, and improve the quality of nursing care in other innovative ways.

• It is estimated that since its inception, ELNEC trainers have returned to their institutions and communities and have trained over 600,000 nurses and other healthcare providers.

MANAGING THE SYMPTOMS OF

END STAGE HEART FAILURE

HEART FAILURE: SYMPTOMS

• Predominant symptoms:

• Pain, Anxiety, and Dyspnea.

• Nausea, hallucinations

• LVADs: highest mortality risk factor is traumatic brain bleed, leading to death.

• For these patients, control of neurotrauma-related symptoms is of utmost importance, as they can often be most distressing to the family. Symptoms can include increased secretions, agitation, and myoclonic or seizure-like activity.

SYMPTOM PREVALENCE

Symptom prevalence:

• Pain (78%)

• Dyspnea (61%)

• Depression (59%)

• Insomnia (45%)

• Anorexia (43%)

• Anxiety (30%)

• Constipation (37%)

• Nausea/vomiting (32%)

• Fatigue, Difficulty ambulating, and Edema

APRN Facilitates Discussions To Determine The Goals Of Care By:

• Direct communication with the patient/family

• Arranging a family meeting with palliative care and medical teams

• If early in the disease trajectory, simply initiate the referral to palliative care.

PAIN & DYSPNEA

Best relieved using a multimodal approach:

• Relief of pain and dyspnea with opioid therapy

• Control of air hunger with supplemental addition of air movement through a ceiling or oscillating fan.

• Air movement across one’s face often reduces the sensation of breathlessness, leading to a decreased sense of air hunger/dyspnea and anxiety.

• A cooler temperature can also be helpful, as will reducing humidity, which can also lead to feeling short of breath.

Terminal cardiac patients struggle with symptoms that may be physical, psychological,

and spiritual.

Not all suffering is physical.

However, the physical symptoms may often cause the most initial distress to the patient and

will be what the family members remember after death.

LORAZEPAM (ATIVAN)

• Used to treat nausea and anxiety due to advancing disease, uncontrolled dyspnea, or fear of dying.

• Cardiac patients become more dyspneic with disease progression, leading to increasing levels of anxiety.

• They may have nausea from the effects of hypoperfusion and hypotension.

• Dosing varies based on the patient’s history and needs.

• Begin at 0.5 mg intravenously or orally every 4 hours as needed and rapidly titrate up to an effective dose.

• Intensol liquid elixir can be given under the tongue/buccal mucosa.

• Doses may be needed every hour for some patients.

FUROSEMIDE (LASIX)

• Heart failure patients at the end of life are often fluid-overloaded

• Fluid status should be assessed prior to device removal: if overload is noted, additional Lasix can be provided prior to withdrawal.

• Doses will vary: heart failure patients through the course of their illness tend to tolerate relatively high doses of diuretics. Therefore, there is no “correct” dose but instead there is a “right dose for the patient.”

• Place urinary catheter for comfort: frequent urination could create more distress than relief.

• Stop therapies that do not provide or contribute to comfort: IV fluids, continuous infusions, etc.

• Opioids, when given as an infusion, can be concentrated to limit unnecessary fluids: the pharmacy can assist with this higher concentration.

HYOSCYAMINE (LEVSIN)

• As their level of consciousness decreases, dying patients lose their ability to swallow and clear oral secretions.

• As air moves over the secretions, the resulting turbulence produces noisy ventilation with each breath, described as “gurgling” or “death rattle. “

• The rattle is a good predictor of approaching death; one study indicated that the median time from onset of the death rattle to death was 16 hours.

• Given as IV or SQ injection for the management of oral secretions, preferred over suctioning

• Dosing generally begins at 0.125 mg given intravenously every 4 hours.

SCOPOLAMINE (TRANS-DERM SCOP)

• Scopolamine patches provide decreased secretions over a longer period of time.

• While scopolamine should not be used for acute symptoms, it does have the benefit of a steady state of symptom management.

• The usual starting dose for scopolamine is a 1.5-mg patch placed on the hairless area of skin just behind one ear.

• The patch needs to be replaced every 72 hours.

• Dose can be increased to 2-3 patches in severe cases, though it is best to use prn hyoscyamine with 1 patch to determine accurate need.

HALOPERIDOL (HALDOL)

• Can be given as a liquid, subcutaneous or intravenous injection for management of agitation, restlessness, nausea, or terminal delirium.

• Terminal delirium: acute change in the level of arousal with altered sleep/wake cycle, mumbling speech, disturbance of memory/attention and perceptual disturbances with delusions/hallucinations.

• Haloperidol is administered in a dose-escalation process similar to that used to treat pain: the starting dose is 0.5 to 2 mg given orally or intravenously.

• The frequency can be every hour as needed.

• Helpful with refractory nausea.

CARE TO PROMOTE HUMAN DIGNITY

• If patient is feeling warm or uncomfortable: cool mouth swabs, cool compress to forehead

• For mild dyspnea: oscillating fan, air movement across the face

• For increased oral secretions (or those not yet controlled by medications such as hyoscyamine): position the patient on his or her side or in a semi-prone position to facilitate postural drainage.

• For mild discomfort: gentle massage, soft music, comforting stimuli (e.g., reading favorite poems or stories, religious music, aromatherapy)

• Ask the patient and their family/caregivers:

• What helps you relax? What would help you feel more comfortable?

• Try to meet their requests whenever possible

FINAL THOUGHTS

• Management of heart failure begins with a TEAM approach to advance care planning.

• Early intervention represents a collaboration between cardiology and palliative care to optimize patient care and well-being.

• Early and ongoing discussions with patients and families are key.

• APRN is an advocate for heart failure patients/families to ensure they receive excellent care throughout the illness and at the end of life: Keen assessment skills, partnership with palliative care, and close follow-up will ensure optimal symptom management.

• End-of-life care, like many aspects of medicine, is not a perfect science:

“When the elephants fight, it is the grass that suffers.”

THANK YOU!