Disclosures Advanced Heart Failure I have nothing to disclose - - PDF document

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Palliative Care Program

Palliative Care in Advanced Heart Failure

Steven Pantilat, MD

Professor of Medicine Kates-Burnard and Hellman Distinguished Professor in Palliative Care Director, Palliative Care Program and Palliative Care Quality Network University of California, San Francisco Twitter: @stevepantilat

Disclosures

• I have nothing to disclose

Palliative Care Program

Life Expectancy: Good News, Bad News

30,000 BCE 2009 1,000 BCE 15,000 BCE

Life expectancy (years)

Death Rate: 100%

Palliative Care Program

Heart Failure

• 5 million US adults have CHF

– 1 in 5 adults will develop heart failure – Affects 10% of adults 75 years and older

• Most frequent cause of hospitalization in

elders

• Treatments increase quality and length of

life

• AHA. 2006 Heart and Stroke Statistical Update

Redfield et al. JAMA 2003;289:194–202

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Palliative Care Program

Stewart et al. Eur J Heart Fail 2001; 3:315-22 Stevenson and Stevenson J Cardio Electrophys 2001;12:112-4 Tribouilloy et al. Eur Heart J 2008;29:339-47 Roger et al. JAMA 2004;292:344-50

250,000 5 years 1/3 to 1/2

Palliative Care Program

Why Palliative Care for Patients with Heart Failure?

• High mortality
• Significant symptom burden
• Repeated hospitalizations
• Palliative care improves symptoms, quality
• f life, satisfaction, and family outcomes
• Required by Medicare for destination LVAD

Rogers et al. JACC 2017;70:531-41 Pantilat, Steimle, and Davidson: Advanced Heart Disease in Cherny et al. eds, Oxford Textbook of Pall Med, 2015. Oxford, UK. Pantilat et al. JHM 2012;7:567-72

Palliative Care Program

Symptoms in Patients with Chronic Disease

Symptom Inpt CA Outpt CA HF Pain 43-81% 50% 41-78% Fatigue 81% 18% 69-82% Dyspnea 19-61% 71% 60-88% Depression 37% 59% 9-56% Mean # 14 +/- 5 10 +/- 6

Pantilat et al. J Card Failure 2010;16:S88 Weiss et al. Lancet 2001;357:1311-5 Ng and von Gunten J Pain Sympt Man 1998;16:307-16 Levenson et al. JAGS 2000;48:S101-9 Solano et al. J Pain Sympt Man 2006;31:58-69

Palliative Care is medical care focused

• n improving quality of

life for people with serious illness

✓ ✓

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Palliative Care Program

Concurrent Palliative Care

“Live as well as possible for as long as possible”

% focus

• f care

100 Time Death Terminal phase Bereavement

Palliative care Curative care Hospice

Palliative Care Program

Advance care planning

time

Intensity

• f patient

needs

+ Primary Palliative Care + Hospice Home PC + Consultative PC

Integrating Palliative and Heart Failure Care

Palliative Care Program

Talking about what is really going on will destroy hope Talking about hope encourages it

• Hope is durable

– Hopelessness is a sign of depression – Depression, even in serious illness and near the end of life, is not normal and responds to treatment

• Discussing prognosis will not take away hope
• For healing where there is no cure
• For comfort in the face of suffering
• For all that can still be despite all that cannot be

– ICU wedding – Donuts

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The Golden Questions

• “When you think about the future, what do

you hope for?”

• “When you think about what lies ahead,

what worries you the most?”

Most Important Issues at End of Life

Making sure family not burdened financially by my care: 67% Being comfortable and without pain: 66% Being at peace spiritually: 61% Making sure my family is not burdened by tough decisions about my care: 60% Living as long as possible: 36%

California HealthCare Foundation 2011

Palliative Care Program

Advance Care Planning in Heart Failure

• Early

– Identify and document a surrogate – Routine practice – Websites, videos, groups

• Later

– Preferences for ER and hospitalization

El-Jawahri et al. Circ 2016;134:52-60 Prepareforyourcare.org theconversationproject.org

Palliative Care Program

“There is nothing more we can do”

Simply not true Feels like abandonment

x

Better Words to Say

“I wish there was something we could do to make your heart stronger.”

Pantilat JAMA 2009;301:1279-81

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Better Words to Say

“Would you like us to do everything possible?” “How were you hoping we could help?”

x

Pantilat JAMA 2009;301:1279-81

The goal is not to have a good death The goal is to live a good life

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Palliative Care Program

• Address distressing symptoms in

people with heart failure

• Discuss advance care planning early

and revisit

• Integrate palliative care and advanced

heart failure care

• Talk about hope to encourage it
• The goal is to live a good life

Palliative Care in Heart Failure

Palliative Care Program