Palliative care from a

cardiologist’s

perspective

Tim Sutton, Cardiologist

Counties Manukau DHB

1

Common cardiac conditions

Symptoms and their management

Focus on failing heart

Early and late treatments

Disease trajectory

End stages

Management of symptoms / medications

ICDs and what to do with them

Challenges

2

Common chronic cardiac diseases:

Ischaemic heart disease

Stable

Symptoms

Angina, breathlessness

Medications

Aspirin, statin, antianginals

Treatments

Medical therapy

Stenting

Bypass surgery

Unstable

– acute coronary syndromes

Symptoms

Chest discomfort, acute heart failure

Medications

Dual antiplatelet therapy, statin,

ACE inhibitors, beta blockers

Treatments

Medical therapy

Stenting

Bypass surgery3

Common chronic cardiac diseases:

Heart failure

Reduced EF (HFReF)

Symptoms

Breathlessness, swelling, fatigue, anorexia, angina

Medications

Preserved EF (HFPeF)

Drug Symptoms Survival Symptoms

Diuretic Yes Yes

ACE inhibitor Yes Yes

Beta blocker Yes Yes

ARA Yes Yes Maybe

Digoxin Maybe

Nitrates Yes 4

Advanced heart failure treatments

Cardiac resynchronisation (CRT) : P vs D

Implantable cardioverter defibrillator

Cardiac transplantation

Common chronic cardiac diseases:

Heart failure

5

Symptoms

None, palpitations, breathlessness, fatigue

Medications

To control symptoms

To prevent strokes

Interventions

Pulmonary vein isolation

Pacemaker and AV node ablation

Common chronic cardiac diseases:

Abnormal heart rhythms : Atrial fibrillation

Congestive heart failure 1

Hypertension 1

Age 1 or 2

Diabetes 1

Stroke 2

Vascular disease 1

Sex category F : 1

CHA2DS2VASc Score Annual Stroke risk (%)

0 <1

1 1.3

2 2.2

3 3.2

4 4

5 6.7

6 9.8

7 9.6

8 6.7

6.7 15.2

6

Too slow

Pacemaker

Too fast

Medication

Ablation

ICD

Common chronic cardiac diseases:

Abnormal heart rhythms : Too fast or slow

7

Mortality from Cardiac Disease in

New Zealand

0

20

40

60

80

100

120

140

160

180

1948 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Other forms of heart diseaseMortality rates, 1948–2013

TotalRate (per

Note: Rates are age standardised to the World Health Organization (WHO) standard world

0

50

100

150

200

250

300

350

400

1948 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Ischaemic heart diseaseMortality rates, 1948–2013

TotalRate (per

Note: Rates are age standardised to the World Health Organization (WHO) standard

0

1000

2000

3000

4000

5000

6000

7000

8000

1948 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Ischaemic heart diseaseNumber of deaths, 1948–2013

Total

0

500

1000

1500

2000

2500

1948 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Other forms of heart diseaseNumber of deaths, 1948–2013

Total

8

How do we die?

With a normal heart but other terminal disease

With cardiac disease, but not from a cardiac cause

With cardiac disease

Sudden cardiac death

Pump failure

9

Illness trajectories

and palliative care

BMJ. 330(7498):1007-1011

Valve disease or acute / subacute cardiomyopathy

Chronic heart failure or Atrial fibrillation

Multiple comorbidities

10

Appropriate care during then near the end of life

BMJ. 330 (7498):1007-1011

1997 Palliative care model

2017 Palliative

care model

11

Characteristics of the stages of

progressive heart failureD

isease

modif

yin

g o

r pote

nti

ally c

ura

tive

Supportive and palliative care

Stage I : Chronic disease management phase : NYHA I-III

Effective therapy to prolong survival and improve

Symptoms

Patient and carer education and supported

self management

Regular monitoring and

appropriate review

European Journal of Heart Failure (2009) 11, 433–443

12

Heart failure Treatment Timeline

Pre 1980s 1980s

Bed rest

Inactivity

Fluid

restriction

Diuretics

Digoxin

Heart

transplant

13

Heart failure Treatment Timeline

Pre 1980s 1980s

Bed rest

Inactivity

Fluid

restriction

Diuretics

Digoxin

Heart

transplant

Diuretics

Digoxin

Vasodilators

Inotropes

Heart

transplant

(in NZ)

14

Heart failure Treatment Timeline

Pre 1980s 1980s 1990

Bed rest

Inactivity

Fluid

restriction

Diuretics

Digoxin

Heart

transplant

Diuretics

Digoxin

Vasodilators

Inotropes

Heart

transplant

(in NZ)

Diuretics

ACE inhibitors /

ARBs

Betablockers

Aldosterone

receptor

antagonists

15

Mode of Death in Heart Failure with

Preserved and Reduced EF

J Am Coll Cardiol.2017; 69 (5) 556-69

16

Heart failure Treatment Timeline

Pre 1980s 1980s 1990 2000-20

Bed rest

Inactivity

Fluid

restriction

Diuretics

Digoxin

Heart

transplant

ICDs

Cardiac

resynchronisation

LVAD

ARNIs

Diuretics

Digoxin

Vasodilators

Inotropes

Heart

transplant

(in NZ)

Diuretics

ACE inhibitors /

ARBs

Betablockers

Aldosterone

receptor

antagonists

17

Heart failure Treatment Timeline

Pre 1980s 1980s 1990 2000-202020 and beyond

18

Heart failure Treatment Timeline

Pre 1980s 1980s 1990 2000-202020 and beyond

Bed rest

Inactivity

Fluid

restriction

Diuretics

Digoxin

Heart

transplant

ICDs

Cardiac

resynchronisation

LVAD

1st Palliative care

statement (2009)

ARNIs

Diuretics

Digoxin

Vasodilators

Inotropes

Heart

transplant

(in NZ)

Diuretics

ACE inhibitors /

ARBs

Betablockers

Aldosterone

receptor

antagonists

Gene therapy

Cell genesis

Artifical heart

19

Timeline of Palliative Care in Cardiology

20

Characteristics of the stages of

progressive heart failureD

isease

modif

yin

g o

r pote

nti

ally c

ura

tive

Supportive and palliative care

Stage I : Chronic disease management phase : NYHA I-III

Effective therapy to prolong survival and improve

Symptoms

Patient and carer education and supported

self management

Regular monitoring and

appropriate review

European Journal of Heart Failure (2009) 11, 433–44321

Characteristics of the stage of progressive heart

failureD

isease

modif

yin

g o

r pote

nti

ally c

ura

tive

Supportive and palliative care

Stage I : Chronic disease management phase : NYHA I-III

Effective therapy to prolong survival and improve symptoms

Patient and carer education and supported self management

Regular monitoring and appropriate review

European Journal of Heart Failure (2009) 11, 433–443

Stage II : Supportive and palliative care phase NYHA III-IV

Increased admissions to hospital

Goal of care shifts to maintaining optimal symptom control and

quality of life

Holistic, multidisciplinary involvement with patient and their carers

Start discussions re disease trajectory and advanced care plan22

Markers of

advancing disease Age

Recurrent hospitalision for

decompensated heart failure

and / or a related diagnosis

NYHA IV symptoms

Worsening renal function

Cardiac cachexia

Hyponatraemia

Refractory hypotension

necessitating withdrawal of

medical therapy

NYHA Class Symptoms

I Nil

II Mild

III Moderate

IV Severe or at rest

23

Jo 68 year Maori male

Rheumatic fever as a child – residual moderate AR

MI aged 55 - CABG and mechanical AVR performed

Post op EF 40% with inferior scar from MI

Community cardiac arrest – 57 : bystander CPR - good

recovery : secondary ICD implanted

Onset of permanent AF aged 60 – rate controlled

Gradually worsening LV function with evolution of

worsening MR and TR with pulmonary hypertension

24

Examination• PR 70 BP 90/60 – no postural drop

• Looks cachectic

• JVP above earlobes: Chest clear : Metal heart sounds and murmurs : pulsatile liver with ascites: Oedema to sacrum

Investigations• Hb 85 with ferritin 45

• Creatinine 230 eGFR 22ml/min/1.73m2

• Albumin 27

25

Medications

• Warfarin

• Aspirin

• Metoprolol CR 95mg

• Digoxin 125mcg

• Losartan 50mg

• Bumetanide 3mg bd

• Atorvastatin 80mg

• Spironolactone 50mg od

• Allopurinol 300mg

• Metformin 1g bd

• Vitamin D 50 000

monthly

• Multivitamins

• Omeprazole 40mg o

26

Over last year:

• 4 admissions with heart failure :

• Sept 16 : 6 days

• Jan 17 : 4 days

• Apr 17 : 10 days

• Jun 17 : 17 days

• Struggling with ADLs : sleeps on 3 pillows or in a chair

• Weight 120kg in Sept 16 and now 105kg – but still oedematous

• Appetite not so good

27

Discussion with Joe

“How do you feel things are going with your health?”

Discussion about where things are heading

“If your were to pass away peacefully would you be comfortable

with this? And would you family?”

“Would you like to look at stopping some of your pills?”

28

Deprescription

• Statins

• Anticoagulants• Antiplatelets agents

• Anticoagulants

• Aldosterone receptor antagonists

• ACE inhibitors

• Beta blockers

• Diuretics

29

• What does function does an ICD have?

• Treating bradycardias through back up pacing

• Treating tachycardias through

o Overdrive pacing

o Defibrillating

NZMJ (2010): 123: 1309

ICD Deactivation

30

ICDs prolong life by preventing sudden death

ICDs do not modify the underlying disease

process

Patients with ICDs still die

Death may be

o Due to the underlying cardiac disease

o Due to an underlying non cardiac

pathology

o ICD failure

ICD Deactivation

31

When to discuss?

• Around the time of implantation

• When the patient’s quality of life is declining to the point

where they have reached a point where an ICD discharge

would delay the dying process without adding quality of life /

not be wanted by them

Who should discuss?

• Ideally done in the ambulatory setting

• Clinician who knows the patient and is familiar with their

disease, its management plan and the disease trajectory

• Can involve patient’s primary cardiologist if non cardiac

pathology

ICD Deactivation

32

ICD Deactivation

NZMJ (2010): 123: 1309

• Is not painful

• Will not cause sudden death when the ICD is deactivated

• Will help prevent what can be an unpleasant death

• Who deactivates the ICD?• ICD or Pacing technologist

• Pacing clinic / hospital / hospice

• Need documentation that this has been discussed with the patient and the family

Auckland /Northland DHB: 021 808 605 Counties Manukau DHB: 021 240 7535

Waitemata DHB: 021 806 98533

http://www.advancecareplanning.org.nz/healthcare/

Why am I making an advanced care plan?

When I am dying…

After my death….

34

Advance Directives

Among Hospitalised

Patients with Heart

Failure

JACC Heart Failure 2015 3 (2) 112-21

35

Characteristics of the stage of progressive heart

failureD

isease

modif

yin

g o

r pote

nti

ally c

ura

tive

Supportive and palliative care Bereavement care

Stage I : Chronic disease management phase : NYHA I-III

• Effective therapy to prolong survival and improve symptoms

• Patient and carer education and supported self

management

• Regular monitoring and appropriate review

Poor prognostic markers

Focus on patient / family

end of life cares and wishes

Emotional support

Stage III

Terminal care phase

36

Palliation of symptoms in

chronic heart failure

➢ Dyspnoea

➢ Diuretics for hypovolaemia

➢ Opiates

➢ Benzodiazepines

➢ Pain

➢ Antianginals

➢ Non NSAID based analgesia

➢ Annorexia / cachexia

➢ Treat the reversible

➢ Small regular meals / nutritional supplementation

➢ Fatigue

➢ Correct the reversible

➢ Exercise

➢ Psychological support

➢ Depression

➢ Psychological support

➢ SSRIs

37

Pericardial disease in palliative care

(effusions)

Approximately 30% of effusions treated at MMH

are malignant

1 year survival < 10%

Treatment is for symptomatic relief

Pericardiocentesis

Pericardial window

Heart, lung and Circulation2014 Volume 23, Supplement 1, Page e38

38

Palliative care…through a team approach

Is applicable early in the course of illness in

conjunction with other therapies that are intended

to prolong life

Offers family a support system to help the family

cope during the patient’s illness and in their own

bereavement

Enhance quality of life and may positively

influence the course of illness

Offers a support system to help patients life as

actively as possible until death

Affirms life and regards dying as a normal process

Provides relief from distressing symptoms

Intends neither to hasten or postpone death

Taha Hinengaro

Taha TinanaTaha WhanauTaha Wairua39

General

Medical

team

Health

psychologist

Spiritual /

religious

leaders

Cardiology

team

Physiotherapist

Palliative

care team

Primary care

Cultural

supportLawyers

Occupational

therapist

Nursing

staff

Alternative

therapist

40

Heart failure (HF) patients experience high rates of hospitalisation and mortality:

20% at 6 months, 30% at 12 months : a prognosis worse than some cancers

Studies show that between 80 – 87% of HF patients with a predicted survival of less than 1

and 2 years were unaware HF was a terminal illness

National and international HF guidelines recommend the introduction of palliative care

at the start of the illness trajectory

30-day readmission rates used as a benchmarking measure between hospitals in

NZ and worldwide for cost analysis of HF admissions and quality of care

HF Audit, Hutt 2015 – 62% of HF patients readmitted within 30 days were dead

within 6 months

Only 12% of these patients received palliative care41

JACC : Jul 17: 70 (3): 331-41

Medication Usual and Palliative care Usual Care

ACE inhibitor 17 (22.7) 16 (21.3)

ARB 4 (5.3) 7 (9.3)

Aldosterone antagonist 30 (40.0) 22 (29.3)

Aspirin 54 (72.0) 46 (61.3)

Beta-blocker 51 (68.0) 48 (64.0)

Diuretics

Bumetanide 1 (1.3) 1 (1.3)

Furosemide 39 (52.0) 49 (65.3)

Torsemide 27 (36.0) 14 (18.7)

Statin 43 (57.3) 41 (54.7)

42

Challenges to palliative care in Cardiology

Disease trajectories are not well defined

Cardiology practice and training focused on life

prolonging intervention

Patient expectations

Lack of access to resource – in and outpatients

Pressure of time

Palliative care discussions can be time consuming and

emotionally intense

43

I can’t help

Isn’t this

someone else

job… The

palliative care

team are involved

I’m too busy….

I’ll see

him tomorrow

Maybe

he’ll

die before I

see him…

I can’t

change his

situation

I won’t know

what to say

What if

I upset him

more?

I should have

done the

‘death and dying’ paper

at university

Courtesy of Miriam Wood, Health Psychologist, CMDHB

44

Physicians and death : who cares for the carers?

Current Oncology2017 24(4) e277-284

45

BurnoutMeasures That May Help Prevent BurnoutMindful meditationReflective writingAdequate supervision and mentoringSustainable workloadPromotion of feelings of choice and controlAppropriate recognition and rewardSupportive work communityPromotion of fairness and justice in the workplaceTraining in communication skillsDevelopment of self-awareness skillsPractice of self-care activitiesContinuing educational activitiesParticipation in researchMindfulness-based stress reduction for teamMeaning-centered intervention for team

IndividualOverwhelming physical and emotional exhaustionFeelings of cynicism and detachment from the jobA sense of ineffectiveness and lack of accomplishmentOveridentification or overinvolvementIrritability and hypervigilanceSleep problems, including nightmaresSocial withdrawalProfessional and personal boundary violationsPoor judgmentPerfectionism and rigidityQuestioning the meaning of lifeQuestioning prior religious beliefsInterpersonal conflictsAvoidance of emotionally difficult clinical situationsAddictive behaviorsNumbness and detachmentDifficulty in concentratingFrequent illnessStaff conflicts

TeamLow moraleHigh job turnoverImpaired job performance (decreased empathy, Increased absenteeism)

JAMA, March 18, 2009—Vol 301, No. 11

46

Palliative care in

Aortic Stenosis

“Palliative care has not traditionally been considered central in cardiac care, and cardiac patients receive proportionately less palliative care….. The integration of best palliative care practices in TAVI programs will establish a new gold standard of program development as new valve interventions evolve”

Curr Opinion Support Palliat Care 2016:10 : 18-23

30 days I year 2 years 5 years

TAVR SAVR TAVR SAVR TAVR SAVR TAVR SAVR

Partner 1 A 3.4 6.5 24.2 26.8 67.8 62.4

0.2 3.5 9.9 13.8 23.5 21.3

Partner 2 3.9 4.1 12.3 12.9 16.7 18.0

0.6 0.9 5.6 5.2 7.4 7.4

TAVR Med TAVR Med TAVR Med

Partner 1 B 5 2.8 30.7 49.7 57.5 85.9

0.5 1.1 11.1 7.8 34 17

JACC 2017: 70 (6); 689-70047

“Life is pleasant. Death is peaceful. It’s the transition that is troublesome”

Isaac Asimov

48