8347BrokenHeart FMGrand Rounds

7/27/2019 8347BrokenHeart FMGrand Rounds

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Palliative Care of the Broken HeartPalliative Care of the Broken Heart

Allan Ramsay, MDAllan Ramsay, MD

Medical DirectorMedical Director

Fletcher Allen Health CareFletcher Allen Health CarePalliative Care ServicePalliative Care Service

Family Medicine Grand RoundsFamily Medicine Grand Rounds

September, 2010September, 2010


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Palliative Care at Fletcher AllenPalliative Care at Fletcher Allen

Barb Segal, RN,MSBarb Segal, RN,MS

Maura McClure, RN, MSNMaura McClure, RN, MSN

Ursula McVeigh, MDUrsula McVeigh, MD

Director of Palliative CareDirector of Palliative Care

Education and HospiceEducation and Hospice

Ann Laramee, APRN,MSAnn Laramee, APRN,MS

Cardiology Clinical NurseCardiology Clinical Nurse

SpecialistSpecialist

Bob Macauley, MDBob Macauley, MD

Pediatric Advanced CarePediatric Advanced Care

TeamTeam


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ObjectivesObjectives

To review the principles ofTo review the principles ofprimaryprimary palliative carepalliative carefor patients with late stage congestive heart failure.for patients with late stage congestive heart failure.

To know when the palliative care consultation canTo know when the palliative care consultation can

improve the care of heart failure.improve the care of heart failure. Case reports will be used to describe the benefitsCase reports will be used to describe the benefits

and risks of the newer technical interventionsand risks of the newer technical interventions

(bridge therapies) for late stage CHF.(bridge therapies) for late stage CHF.


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Ninety Million Americans Now Have ChronicNinety Million Americans Now Have Chronic

LifeLife--Limiting DiseaseLimiting Disease

1. Long period of goodfunction with a fewweeks of rapid

decline (cancer, 20%,~ 65-75 and older).


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To examine the effect of early palliativeTo examine the effect of early palliative

care integrated with standard oncologiccare integrated with standard oncologic

care on;care on; PatientPatient--reported outcomesreported outcomes

The use of health servicesThe use of health services

The quality of EOL care among NSCLC ptsThe quality of EOL care among NSCLC pts


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Palliative Care Extends Life, Study Finds

Study: Advanced Cancer Patients

Receiving Early Palliative Care Live Longer

Palliative Care Can Help Cancer Patients Live Longer

Cancer strategy: Easing the burden

Study shows patients who start palliative care early livelonger

Palliative care, which helps the gravely i ll make the most of

the time they have left, provided a surprising bonus for

terminal lung cancer patients: More time left to enjoy.
http://www.google.com/imgres?imgurl=http://www.heymarci.com/wp-content/uploads/2008/08/bostonglobe_logo.gif&imgrefurl=http://heymarci.com/media/&usg=__o-WMxCfTpRNQobX5CY-MLhc-qj0=&h=81&w=452&sz=7&hl=en&start=3&zoom=1&tbnid=3YplBmC7abiwjM:&tbnh=23&tbnw=127&prev=/images%3Fq%3Dboston%2Bglobe%2Blogo%26hl%3Den%26safe%3Dactive%26gbv%3D2%26tbs%3Disch:1&itbs=1http://www.google.com/imgres?imgurl=http://www.blogkindle.com/wp-content/uploads/2009/07/USA-Today-Logo.bmp&imgrefurl=http://blogkindle.com/category/kindle-sales/&usg=__3rV7auxk7H1daaZs9rGYOa5BSRk=&h=296&w=472&sz=410&hl=en&start=1&zoom=1&tbnid=AyXNAh__T16fhM:&tbnh=81&tbnw=129&prev=/images%3Fq%3Dusa%2Btoday%26hl%3Den%26safe%3Dactive%26gbv%3D2%26tbs%3Disch:1&itbs=1http://www.google.com/imgres?imgurl=http://www.mediabistro.com/fishbowlny/original/nytimes-logo.jpg&imgrefurl=http://www.mediabistro.com/fishbowlny/newspapers/the_new_york_times_whats_not_to_love_89483.asp&usg=__ZpsHQJI6bJVcUrHvnBXrRmTWIlg=&h=160&w=205&sz=14&hl=en&start=13&zoom=1&tbnid=jt_EOjOCpq3eyM:&tbnh=82&tbnw=105&prev=/images%3Fq%3Dthe%2Bnew%2Byork%2Btimes%2Blogo%26hl%3Den%26safe%3Dactive%26sa%3DN%26gbv%3D2%26tbs%3Disch:1&itbs=1http://www.google.com/imgres?imgurl=http://chiroeco.com/chiro-blog/files/2010/01/wall-street-journal-logo.jpg&imgrefurl=http://chiroeco.com/chiro-blog/blog/2010/01/&usg=__DmLo69vi4d__VPn023Nr04eVFlw=&h=424&w=600&sz=205&hl=en&start=1&zoom=1&tbnid=uroquK4-G9kk5M:&tbnh=95&tbnw=135&prev=/images%3Fq%3Dwall%2Bstreet%2Bjournal%2Blogo%26hl%3Den%26safe%3Dactive%26gbv%3D2%26tbs%3Disch:1&itbs=1


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Ninety Million Americans Now Have ChronicNinety Million Americans Now Have Chronic

LifeLife--Limiting DiseaseLimiting Disease(Butler, K: NYT June 20, 2010)(Butler, K: NYT June 20, 2010)

1. Long period of goodfunction with a few weeks ofrapid decline (cancer, 20%,~ 65-75 and older).

2. Slow decline in physicalcapabilities with seriousexacerbations, death cancome suddenly (CHF, 25%,~ 70-80).

3. Long term decline, needingyears of personal care(dementia, 40%, 80-90).


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What do you think when you are consideringWhat do you think when you are considering

end of life care for CHF?end of life care for CHF?

1.1. Palliative care means it is time toPalliative care means it is time tostop cardiac medications and allstop cardiac medications and allmonitoring.monitoring.

True or falseTrue or false

2.2. Patients with heart disease arePatients with heart disease are

rightfully optimistic about therightfully optimistic about thebenefits of CPR since thisbenefits of CPR since thisprocedure has dramaticallyprocedure has dramaticallyimproved in the past 13 years.improved in the past 13 years.

True or falseTrue or false

3. It is so difficult to determineprognosis in patients with CHFthat a hospice referral is rarelyappropriate for end of life care.

True or false


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Prevalence of Cardiovascular Disease inPrevalence of Cardiovascular Disease in

AmericansAmericans

Source: American Heart Association 2004


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Cardiovascular Disease Mortality TrendsCardiovascular Disease Mortality Trends

for Males and Femalesfor Males and Females

Source: American Heart Association 2004


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Why should Palliative Care focus on CHF?Why should Palliative Care focus on CHF?

There are 500,000 new cases of CHF in the US each yearThere are 500,000 new cases of CHF in the US each year

(5m total) and one million hospital admissions.(5m total) and one million hospital admissions. Yearly costs are over 30 billion dollarsYearly costs are over 30 billion dollars

At Fletcher Allen:At Fletcher Allen: 3030--50% of CHF admissions exceed the Medicare DRG50% of CHF admissions exceed the Medicare DRG

An average of 30 patients are admitted to FAHC eachAn average of 30 patients are admitted to FAHC eachmonth with CHF (predicted 30 day mortality rate ofmonth with CHF (predicted 30 day mortality rate of

13.7%)13.7%) This data has the attention of all who believe in chronicThis data has the attention of all who believe in chronic

care management and the PCMHcare management and the PCMH


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THE CABOT POLLTHE CABOT POLL

Where would you want to spendWhere would you want to spend

the last days of your life?the last days of your life?N.H.N.H. VT.VT.

HomeHome 71.0 80.871.0 80.8

Inpatient hospiceInpatient hospice 15.2 0.515.2 0.5 Home of friend/familyHome of friend/family 6.7 3.86.7 3.8

Assisted livingAssisted living 4.2 2.84.2 2.8

HospitalHospital 0.4 0.50.4 0.5 Nursing homeNursing home 0.0 0.30.0 0.3


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Zero percent would choose to spend the lastZero percent would choose to spend the last

days of their life like thisdays of their life like this--


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Ramsay Rule #1Ramsay Rule #1

All patients with endAll patients with endstage CHF need astage CHF need a

primary careprimary care

physician (andphysician (and

rarely a palliativerarely a palliative

care consult).care consult).


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Case Report #1Case Report #1

H.S. is an 87 year old woman with pulmonaryH.S. is an 87 year old woman with pulmonary

hypertension, ASCVD, AF, and severe aortic stenosis.hypertension, ASCVD, AF, and severe aortic stenosis.She is admitted with worsening edema, anasarca, andShe is admitted with worsening edema, anasarca, anddyspnea. H.S. is weak but has been able to managedyspnea. H.S. is weak but has been able to manageher ownher own ADLsADLs with family and social support. Shewith family and social support. She

has been on maximal doses of diuretics, metoprolol,has been on maximal doses of diuretics, metoprolol,lisinopril, and LTOT. After her last hospitalizationlisinopril, and LTOT. After her last hospitalizationshe was transferred to SAR at a local nursing homeshe was transferred to SAR at a local nursing homeand only stayed two weeks. At the time of thisand only stayed two weeks. At the time of this

admission her BUN is 75 and creatinine 2.8. On theadmission her BUN is 75 and creatinine 2.8. On thethird hospital day the Palliative Care Service isthird hospital day the Palliative Care Service isconsulted to assist in symptom management andconsulted to assist in symptom management anddeveloping a plan of care.developing a plan of care.


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NYHA Functional ClassificationNYHA Functional Classification

I.I. No limitation of physicalNo limitation of physical

activity (mild)activity (mild)II.II. Slight limitationSlight limitation-- ordinaryordinaryphysical activity results inphysical activity results infatigue or dyspneafatigue or dyspnea

III.III. Marked limitation ofMarked limitation of

physical activity. Less thanphysical activity. Less thanordinary activityordinary activitycausescausesdyspnea, palpitations, ordyspnea, palpitations, orfatigue (moderate)fatigue (moderate)

IV.IV. Unable to carry out anyUnable to carry out anyphysical activity withoutphysical activity withoutdiscomfort; symptoms atdiscomfort; symptoms atrest. Any physical activityrest. Any physical activityincreases symptomsincreases symptoms(severe)(severe)


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Palliative Care Issues in CHF

PainPain------------------CHF is not usually a painful conditionCHF is not usually a painful condition

DyspneaDyspnea--------Optimize HF meds, diuretics, considerOptimize HF meds, diuretics, considernonnon--traditional therapiestraditional therapies

FatigueFatigue--------psychostimulantspsychostimulants,, SSRIsSSRIs

Advanced Care DecisionsAdvanced Care Decisions


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Do patients with CHF have pain?Do patients with CHF have pain?

(J Pain Symptom Manage 35;594)(J Pain Symptom Manage 35;594)((EurEurJJ CardiovasCardiovas NursNurs 2003;213)2003;213)

Multiple studies of symptom burden in patients withMultiple studies of symptom burden in patients with

late stage CHF have shown a pain prevalence oflate stage CHF have shown a pain prevalence of

3333--67%67%

Comparisons of pain reports between NSCLC andComparisons of pain reports between NSCLC and

CHF patients show a similar incidenceCHF patients show a similar incidence

Edema (anasarca), ascites, ischemic bowel,Edema (anasarca), ascites, ischemic bowel,

arthralgia, arthritis, pleuritic pain from effusions.arthralgia, arthritis, pleuritic pain from effusions.

These misconceptions lead to undertreatment andThese misconceptions lead to undertreatment and

significant EOL sufferingsignificant EOL suffering


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Dyspnea management in CHFDyspnea management in CHF(J Amer(J Amer CollColl Card 2007:49;1136)Card 2007:49;1136)

Diuretics, opiates, oxygen, and (nitrates) are the mainstays ofDiuretics, opiates, oxygen, and (nitrates) are the mainstays of

therapy.therapy. Diuretics vs. Ultrafiltration (200 pts)Diuretics vs. Ultrafiltration (200 pts)

At 48 hr inc fluid loss in UF groupAt 48 hr inc fluid loss in UF group

No diff in dyspnea scores or creatinineNo diff in dyspnea scores or creatinine

At 90d fewerAt 90d fewer rehosprehosp in UF groupin UF group

No diff in 90d mortalityNo diff in 90d mortality

HFSA categorizes UF as evidence Category C (expert opinionHFSA categorizes UF as evidence Category C (expert opinion

only)only)

BiPaP can be used as a bridge therapy in acute pulmonaryBiPaP can be used as a bridge therapy in acute pulmonaryedema to avoid intubation during diuretic induction (HFSAedema to avoid intubation during diuretic induction (HFSACategory B)Category B)


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Case #1: CHFCase #1: CHF

H.S.H.S.s medications were discontinued if not directly relateds medications were discontinued if not directly related

to her symptoms (statins, warfarin). Metoprolol wasto her symptoms (statins, warfarin). Metoprolol was

continued and diuretics were used on an as neededcontinued and diuretics were used on an as needed

basis. H.S. was begun on MSO4 5mg Q6H and herbasis. H.S. was begun on MSO4 5mg Q6H and her

dyspnea improved. She was discharged home ondyspnea improved. She was discharged home onHospice the day following her palliative careHospice the day following her palliative care

consultation, to the care of her family physician. Threeconsultation, to the care of her family physician. Three

weeks after arriving home she developed moreweeks after arriving home she developed moreweakness and dyspnea. H.S. was transferred toweakness and dyspnea. H.S. was transferred to

Vermont Respite House. Six months later she recertifiedVermont Respite House. Six months later she recertified

for hospice care at VRH.for hospice care at VRH.


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CongratulationsCongratulations-- You have outlived yourYou have outlived your

outlived your Hospice prophecy!outlived your Hospice prophecy!


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Prognosis in NonPrognosis in Non--Malignant ConditionsMalignant Conditions

(CHF, COPD, CVA, Dementia)(CHF, COPD, CVA, Dementia)

Doctors are poorDoctors are poor

prognosticators and tend to beprognosticators and tend to beoverly optimistic.overly optimistic.

Only 20% predictions (definedOnly 20% predictions (definedas within 33% of actualas within 33% of actualsurvival) were accurate in onesurvival) were accurate in onestudy.study.

As the duration of theAs the duration of thephysicianphysician--patient relationshippatient relationshipincreases, prognostic accuracyincreases, prognostic accuracy

decreases.decreases.

(BMJ 2000;320:469)(BMJ 2000;320:469)

How undue optimism hurts ourHow undue optimism hurts our

patients:patients:1)1) Impedes good careImpedes good care

2)2) Delays advanced planningDelays advanced planningdecisions and DNR ordersdecisions and DNR orders

3)3) Leads to an abruptLeads to an abrupt

transition from curative totransition from curative topalliative care goalspalliative care goals

Ask yourself:Ask yourself:Would I beWould I besurprised if this patientsurprised if this patientdied in the next year?died in the next year?

(Support. JAMA(Support. JAMA1995;274:1591)1995;274:1591)


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Prognosis in CHFPrognosis in CHF

LimitedLimitedprognosisprognosis

variables:variables: HospitalizationHospitalization

Elevated BUN/Elevated BUN/CreatCreat

SBP100SBP100

Dec LV EF


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Seattle Heart Failure Model and CHFSeattle Heart Failure Model and CHF

(Seattle Heart Failure Model: http://(Seattle Heart Failure Model: http://depts.washington.edu/shfmdepts.washington.edu/shfm/)/)


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Prognosis in CHF is not a SciencePrognosis in CHF is not a Science

There are seven modelsfor predicting short andlong term mortality.

CHF follows an

unpredictable diseasetrajectory.

The meticulous use of

CHF meds and devicetherapies continues tochange CHF prognosis.


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Prognostic Uncertainty in CHFPrognostic Uncertainty in CHF(Circulation 2009;120:2597(Circulation 2009;120:2597--2606)2606)

Accurate prognostication is difficult in CHF

This uncertainty can provide a basis for initiating end-of-

life discussions:

Advance care planning

Educating patients and families about the

unpredictable, but usually terminal nature of CHF

(danger of sudden death)

Ascertaining specific goals of care

People are almost never upset when they have planned

ahead and outlived our predictions!


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Physicians shouldPhysicians shouldnever rely solely onnever rely solely on

bridgebridge therapiestherapies

and technology toand technology toprovide hope forprovide hope for

their patients withtheir patients with

end stage CHF.end stage CHF.


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Case # 2Case # 2

J K is a 74 year old man with late stage CHF, COPD,J K is a 74 year old man with late stage CHF, COPD,

and osteoarthritis. He has been on home O2 andand osteoarthritis. He has been on home O2 andmaximal medical therapy for CHF over the past twomaximal medical therapy for CHF over the past twoyears. His last measured EF was 25%. An ICD wasyears. His last measured EF was 25%. An ICD wasplaced 18 months ago. J K is transferred from anplaced 18 months ago. J K is transferred from an

OSH for management of a hip fracture. Decision toOSH for management of a hip fracture. Decision totransfer was prompted by chest pain and risingtransfer was prompted by chest pain and risingtroponin c/w a NSTEMI. During the first three daystroponin c/w a NSTEMI. During the first three daysof his hospital stay he develops worsening CHFof his hospital stay he develops worsening CHF

requiring a brief period of BiPAP therapy. Diureticrequiring a brief period of BiPAP therapy. Diuretictherapy leads to renal failure and hypotension.therapy leads to renal failure and hypotension.Dobutamine infusion improves his creatinine andDobutamine infusion improves his creatinine andstabilizes his blood pressure. Repair of the hipstabilizes his blood pressure. Repair of the hip

fracture is postponed.fracture is postponed.


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How long Do I have Doc and can you atHow long Do I have Doc and can you at

least get me home?least get me home?

BiPAPBiPAP

FurosemideFurosemide

infusionsinfusions DobutamineDobutamine

AICD/CRTAICD/CRT

CPRCPR

MICUMICU


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Inotropic Therapy for CHFInotropic Therapy for CHF(J Card Failure 2010;16(6):475)(J Card Failure 2010;16(6):475)

Milrinone (phosphodiesterase inhibitor) andMilrinone (phosphodiesterase inhibitor) and

dobutamine (beta receptor agonist) have been useddobutamine (beta receptor agonist) have been usedfor relief of symptoms in late stage CHFfor relief of symptoms in late stage CHF

Some home care infusion companies will provideSome home care infusion companies will providedobutamine without proof of benefit with invasivedobutamine without proof of benefit with invasive

cardiac testingcardiac testing Mortality is high in patients on chronic inotropicMortality is high in patients on chronic inotropic

therapy (> 50% at six months and increased overtherapy (> 50% at six months and increased overplacebo for milrinone)placebo for milrinone)

Cost is high, even with reduction in hospital daysCost is high, even with reduction in hospital days Patients being considered for chronic inotropicPatients being considered for chronic inotropic

therapy should have a palliative care consulttherapy should have a palliative care consult


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Implantable Devices and CHFImplantable Devices and CHF(Circ 2009:120;2597)(Circ 2009:120;2597)

Cardiac Resynchronization Therapy (CRT)Cardiac Resynchronization Therapy (CRT)

EF120msec,symptomaticEF120msec,symptomatic Reduced symptoms, reduced hosp, slight reduction in allReduced symptoms, reduced hosp, slight reduction in all

cause mortalitycause mortality

Often combined with ICDOften combined with ICD

ICD/PMICD/PM Qualitative studies show that patients do not fullyQualitative studies show that patients do not fully

understand how the devices work and develop a complexunderstand how the devices work and develop a complexpsychological relationship with thempsychological relationship with them

Most devices remain active until death (1/3 turned off)Most devices remain active until death (1/3 turned off) High likelihood the ICD will discharge prior to deathHigh likelihood the ICD will discharge prior to death

One small study showed no diff in the time betweenOne small study showed no diff in the time betweendeactivation and deathdeactivation and death


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CPR and CHFCPR and CHF(NEJ M 2009;361:22)(NEJ M 2009;361:22)

CPR studied from 1992 to 2005 in a nationalCPR studied from 1992 to 2005 in a national

Medicare data base (433,985 pts)Medicare data base (433,985 pts) 18 % pts survived to d/c18 % pts survived to d/c-- no diff over timeno diff over time

Fewer surviving pts were discharged homeFewer surviving pts were discharged home

A gradual increase occurred in the # of pts whoA gradual increase occurred in the # of pts whohad CPR prior to dying in the hosphad CPR prior to dying in the hosp

Informed AssentInformed Assent ((ItIts not really your choices not really your choice))

All providers agree that CPR would not lead toAll providers agree that CPR would not lead torestoration of meaningful liferestoration of meaningful life-- is not indicatedis not indicated

Patient/family have the right to disagreePatient/family have the right to disagree


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Case #2Case #2

J KJ Ks pain was controlled with morphine 5s pain was controlled with morphine 5--10mg po10mg po

q2h prn. Cardiology and palliative care met toq2h prn. Cardiology and palliative care met todiscuss the option of home dobutamine therapy.discuss the option of home dobutamine therapy.This would require additional invasive testing whichThis would require additional invasive testing whichwould risk worsening his renal failure. Orthopedicswould risk worsening his renal failure. Orthopedics

was willing to repair his hip fracture whenever hiswas willing to repair his hip fracture whenever hispreoperative medical clearance was completed.preoperative medical clearance was completed.J KJ Ks was despondent over the delay in decisionss was despondent over the delay in decisionsabout surgery and began to state that his primaryabout surgery and began to state that his primary

goal was to be at home. A meeting was held togoal was to be at home. A meeting was held todiscuss his current treatment plan.discuss his current treatment plan.


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Critical Care Family Conferences:Critical Care Family Conferences:

The EvidenceThe Evidence (Crit Care Med 2006;34:364)(Crit Care Med 2006;34:364)

SUPPORTSUPPORT--Strong proactive measures may be needed toStrong proactive measures may be needed to

improve endimprove end--ofof--life carelife care(1995)(1995) Eight studies (1994Eight studies (1994--2005) report outcomes from family2005) report outcomes from family

members of patients who died in the ICUmembers of patients who died in the ICU

All eight indicated physicians must improve skills inAll eight indicated physicians must improve skills in

communicating with families of dying patientscommunicating with families of dying patients Thirteen trials (1995Thirteen trials (1995--2004) of interventions designed to2004) of interventions designed to

improve communication with family members of patientsimprove communication with family members of patientsdying in the ICU:dying in the ICU:

Earlier use of palliative care reduced ICU LOSEarlier use of palliative care reduced ICU LOS Collectively the results suggest that the major determinantCollectively the results suggest that the major determinant

of improving the care of families of dying patients in theof improving the care of families of dying patients in theICU is early and intensive communicationICU is early and intensive communication


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Summary of Key Steps for an Effective Patient andSummary of Key Steps for an Effective Patient and

Family MeetingFamily Meeting

1.1. PrePre--meeting planningmeeting planning2.2. Introductions/BuildIntroductions/Build

relationshiprelationship

3.3. What does theWhat does thepatient/family know?patient/family know?

4.4. Medical reviewMedical review--

including prognosisincluding prognosis5.5. Discuss patient valuesDiscuss patient values

6.6. Silence, respond toSilence, respond toemotions (conflict)emotions (conflict)

7. Present options

8.8. EmpathyEmpathy9.9. Transform goals into aTransform goals into a

medical planmedical plan

10.10. Summarize and documentSummarize and document


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Being Heard at LifeBeing Heard at Lifes Ends End

((through the valley of the shadow of death)through the valley of the shadow of death)

Patients and families wantPatients and families wanttwo things: the prognosistwo things: the prognosisforfor meaningfulmeaningful recovery andrecovery andourour recommendationsrecommendationsbased on that prognosis.based on that prognosis.

You will not know what isYou will not know what ismeaningful withoutmeaningful withoutspending the time to explorespending the time to explorethe personthe persons life and valuess life and values

Stopping burdensomeStopping burdensome

therapies can be just as ortherapies can be just as oreven more hopeful thaneven more hopeful thanstarting themstarting them


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Case #2Case #2

After a careful discussion of each of his treatmentAfter a careful discussion of each of his treatment

options J K agreed that he would not want CPR,options J K agreed that he would not want CPR,defibrillation, or BiPAP if these interventions woulddefibrillation, or BiPAP if these interventions wouldlesson his chance of returning home. J Klesson his chance of returning home. J Ks homes homehospice agency was contacted and his family werehospice agency was contacted and his family wereable to set up a 24/7 schedule to assist his wife. Hisable to set up a 24/7 schedule to assist his wife. Hisdischarge medications included morphine, oxygen,discharge medications included morphine, oxygen,furosemide, aspirin, and prn lorazepam. J Kfurosemide, aspirin, and prn lorazepam. J K

remained bedridden due to his hip fracture and diedremained bedridden due to his hip fracture and diedpeacefully at home 3 weeks after discharge.peacefully at home 3 weeks after discharge.


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2010 Palliative Care/Heart Failure Data2010 Palliative Care/Heart Failure Data(Nationally 1.6% of CHF admissions are referred for hospice care(Nationally 1.6% of CHF admissions are referred for hospice care))

DiagnosisDiagnosis TotalTotal PercentPercent

CardiomyopathyCardiomyopathy 1515 1919

CHFCHF 5050 6363

EndEnd--stage HFstage HF 99 1111

Heart FailureHeart Failure 55 66

TotalTotal 7979

D/C aliveD/C alive 4949 6262

Family meetingsFamily meetings 6969 8787

HospiceHospice 1111 2222


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Fletcher AllenFletcher Allens Quality Improvement Projects Quality Improvement Project

for CHF Patientsfor CHF Patients

1.1. Educational programs focused on both diseaseEducational programs focused on both disease

management and palliative care.management and palliative care.2.2. Define primary and tertiary palliative care for patientsDefine primary and tertiary palliative care for patients

with CHF.with CHF.

3.3. Develop criteria that will assist with identification ofDevelop criteria that will assist with identification ofinpatients who could benefit from palliative care.inpatients who could benefit from palliative care.

4.4. Create protocols for CHF care management that canCreate protocols for CHF care management that canbecome a statewidebecome a statewide blueprintblueprint..


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CHF and Palliative CareCHF and Palliative Care

The specific aim is toThe specific aim is toimprove the process andimprove the process and

quality of palliative carequality of palliative care

for the patients and theirfor the patients and their

families who are livingfamilies who are living

with CHF.with CHF.


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If skydiving is on yourIf skydiving is on yourbucket list, do itbucket list, do it

beforebefore your EF is:your EF is:

30% (possibly)30% (possibly)

20% (probably)20% (probably)

10% (definitely)10% (definitely)


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QuestionsQuestions

In an attempt to display competency or undying love, we loseIn an attempt to display competency or undying love, we losesight of the doublesight of the double--edged nature of our cuttingedged nature of our cutting--edge wizardry.edge wizardry.We battle away until the last precious hours of life, believingWe battle away until the last precious hours of life, believingthat cure is the only goal. We inflict misguided treatments onthat cure is the only goal. We inflict misguided treatments on

not just others but ourselves. During these final, torturednot just others but ourselves. During these final, torturedmoments it is as if the promise of the nineteenth century hasmoments it is as if the promise of the nineteenth century hasbecome the curse of the twentybecome the curse of the twenty--first.first.

from:from:Final Exam: A SurgeonFinal Exam: A Surgeons Reflections on Moralitys Reflections on Morality

Pauline Chen, MDPauline Chen, MD


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Internet ResourcesInternet Resources

www.eperc.mcw.edu/www.eperc.mcw.edu/ (Fast Facts about(Fast Facts about

palliative care)palliative care)

www.capc.orgwww.capc.org (Center to Advance Palliative(Center to Advance Palliative

Care)Care) www.aahpm.orgwww.aahpm.org (Amer Acad of Hospice and(Amer Acad of Hospice and

Palliative Medicine)Palliative Medicine)
http://www.eperc.mcw.edu/http://www.eperc.mcw.edu/http://www.capc.org/http://www.capc.org/http://www.aahpm.org/http://www.aahpm.org/http://www.aahpm.org/http://www.capc.org/http://www.eperc.mcw.edu/

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