Dr Dylan Harris Dr Mel Jefferson Heart Failure and Palliative Care: An audit of a hospital palliative care teams’ involvement with end stage heart failure patients Dr Dylan Harris Dr Mel Jefferson Hospital Palliative Care Team Department of Palliative Medicine University Hospital of Wales

Heart Failure: facts and figures ◆ Definition -“Inability of the heart to keep up with the demands on it”

Heart Failure: facts and figures ◆ Definition -“Inability of the heart to keep up with the demands on it” ♦ Incidence/Prevalence - Population prevalence 1 to 3%, 10% in very elderly. - Incidence & prevalence increase dramatically over the age 75 years - Number of patients with CHF will increase rapidly because: (a) increase in survival after acute myocardial infarction (b) ageing of the population (c) advances in medical device treatments

Heart Failure: facts and figures ◆ Definition -“Inability of the heart to keep up with the demands on it” ♦ Incidence/Prevalence - Population prevalence 1 to 3%, 10% in very elderly. - Incidence & prevalence increase dramatically over the age 75 years - Number of patients with CHF will increase rapidly because: (a) increase in survival after acute myocardial infarction (b) ageing of the population (c) advances in medical device treatments ◆ Prognosis - After first admission for heart failure 5-yr mortality= 75% - 40% die within 1 year of diagnosis - 50% die suddenly

NYHA Classification of Heart Failure Class I: asymptomatic No limitation in physical activity despite presence of heart disease. Class II: mild Slight limitation in physical activity. More strenuous activity causes shortness of breath - for example, walking on steep inclines and several flights of steps. Patients in this group can continue to have an almost normal lifestyle and employment Class III: moderate More marked limitation of activity which interferes with work. Walking on the flat produces symptoms Class IV: severe Unable to carry out any physical activity without symptoms. Patients are breathless at rest and mostly housebound

NYHA Classification of Heart Failure Class I: asymptomatic No limitation in physical activity despite presence of heart disease. MORTALITY 20% at 5 years Class II: mild Slight limitation in physical activity. More strenuous activity causes shortness of breath - for example, walking on steep inclines and several flights of steps. Patients in this group can continue to have an almost normal lifestyle and employment 3-25% / year Class III: moderate More marked limitation of activity which interferes with work. Walking on the flat produces symptoms 10-45% / year Class IV: severe Unable to carry out any physical activity without symptoms. Patients are breathless at rest and mostly housebound 40-50% / year

mid-1990's, England and Wales One-year survival rates, heart failure and major cancers compared, mid-1990's, England and Wales ONS (2001); Cowie MR et al (2000) Heart 83: 505-510 www.heartstats.org

Heart Failure: disease trajectory

Heart Failure: Palliative Care Needs Murray SA, Boyd K, Kendall M et al. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ 2002;325:929-

Heart Failure: Palliative Care Needs

Audit Standard

Audit Standard “practices and hospitals should audit …. (1) The number and percentage of people with heart failure for whom specialist palliative care advice has been sought ….. (2) The access to palliative care support ….. (3) When the aim of treatment is to control symptoms a palliative approach … good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”

Audit Type Audit Period Patient Identification Retrospective Case Note Audit (Medical notes and palliative care notes) Audit Period April 2005-April 2007 Patient Identification Patients from ISCO Database with diagnosis “heart failure”

Audit Criteria (1) The number and percentage of people with heart failure for whom specialist palliative care advice has been sought …..

Patients identified from ISCO = 21 The number and percentage of people with heart failure for whom specialist palliative care advice has been sought ….. Patients identified from ISCO = 21 (April 2005-April 2007) Patients audited = 18 (2 not heart failure, 1 no notes) % of patients ?? ? % admissions ? % heart failure deaths ? % admissions with stage III/IV heart failure

Audit: Patient characteristics Age: 53-95 years mean 76.1 years Sex: 10 (56%) male 8 (44%) female NYHA: Class III: 4 (22%) Class IV: 14 (78%)

Audit Criteria (2) “The access to palliative care support ….” -Are heart failure referrals accepted (and what are they referred for) ? -How long does to take for patients to be seen by the palliative care team ?

“The access to palliative care support ….” Heart failure referrals accepted: yes Time to generate referral unclear: 7 patients (39%) same day: 7 patients (39%) 1 day: 3 patients (16%) 3 days: 1 patient (6%) Time from referral to assessment 0 (same day): 15 patients (83%) 1 day: 2 patient (11%) 2 day: 1 patient (6%)

“The access to palliative care support ….” Reason for referral Symptom management 13 patients (72%) Support 4 (24%) Discharge 3 (17%) Unclear 3 (17%)

Audit Criteria (3) “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..” - What symptoms do patients have and how many ? - What interventions do we suggest ? - Is there any evidence they help ?

“good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..” SYMPTOM % PATIENTS Breathlessness 89% Pain 44% Anxiety 72% Nausea/vomiting 28% Chest secretions 17% Constipation 11% Oedema Fatigue 6% Anorexia Mouth Family anxiety/support 56%

“good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..”

1 symptom 0 patients 2 symptoms 7 patients (39%) “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..” 1 symptom 0 patients 2 symptoms 7 patients (39%) 3 symptoms 6 patients (33%) 4 or more 5 patients (28%)

Support for patient and their family/carer Breathlessness “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..” Interventions Support for patient and their family/carer Breathlessness Opiate po or sc (75% patients) Benzodiazpeines if anxiety factor (100%) Nausea/vomiting: anti-emetic depending on mechanism Constipation: laxative Anxiety: benzodiazepines, haloperidol, levomepromazine Chest secretions: hyosine

Benefit for our suggested interventions How to measure ? “still breathless but not troubled by it so much” “does not feel as anxious as he did yesterday” “no pain” “appears comfortable, no longer grimacing” Little variation in other variables/intervention

% PATIENTS BENEFIT FROM INTERVENTION* “good symptom control, psychological support and open communication about disease outcome should be offered to all patients…..” SYMPTOM % PATIENTS BENEFIT FROM INTERVENTION* Breathlessness 56% Pain 75% Anxiety 54% Nausea/vomiting 80% Chest secretions 33% Constipation 0% Oedema Fatigue Anorexia Mouth *absence of evidence rather than evidence of absence

Length of interaction: 1-30 days (mean 5.7 days) Outcomes RIP: 13 patients (72%) Home: 3 patients (17%) Other: 2 patients (11%) Length of interaction: 1-30 days (mean 5.7 days) Patients referred for discharge and got home= 2/3 (1 RIP)

Conclusions 83% referrals seen the same day Given the prevalence of symptomatic heart failure inpatients referral rate seems low Polysymptomatic patients: >60% have 3 or more symptoms Large need for family support Palliative care interventions seem to help Difficult to measure objectively. More accurate documentation of symptom response would be useful e.g. ESTAS

Conclusions Which patients should be seen? Palliative Medicine 2006;20:211-214 Palliative Medicine 2007;21:385-390

Future directions - Collaborative working between palliative care and heart failure services - Various approaches, dependent on (1) local expertise of the HF team (2) and their interest/enthusiasm to engage with palliative care Locally: -open referral policy -easy access for advice -collaborative working with interested and palliative care “friendly” cardiologist and geriatrician -heart failure MDT attended by a member of the palliative care team