9/30/2016 Disclosure Palliative Care as a member of the Heart Transplant Team Dr. Giovanni Elia has no relevant financial relationships to disclose Giovanni Elia, MD Associate Director Palliative Care Services Division of Hospital Medicine Palliative Care Program Division of Hospital Medicine Palliative Care Program Objectives Case overview 1. Define and identify key domains of palliative � 43 year old man with multiple pre-existing care chronic illnesses: diabetes, hypertension, 2. Describe the palliative care needs of coronary artery disease, chronic kidney patients evaluated for heart transplant disease 3. Describe communication strategies with � Transferred from a community hospital in patients with serious illnesses and their cardiogenic shock. families � ECMO followed by LVAD (BTT) 4. Discuss models for optimizing palliative care for patients evaluated for heart transplant 1
9/30/2016 Case psychosocial details Timeline Oct 15 Oct 21 Nov 4 Nov – Jan Jan 7 � Post-op course: Admission ECMO LVAD • Multiple OR washouts Died (BTT) • Cardiac arrest (Nov 16) � Multiple complications • Hypoxic brain injury • Multi-system organ � hypoxic brain injury 1 month after admission. failure � Remained in ICU without neurologic recovery for almost 2 more months � Died after withdrawal of life support in setting of Oct 27 Nov 18 Dec 2 Jan 7 • Initial Consult • Meeting with • PCS Meeting • CT surgery multi-system organ failure • LVAD Wife & Sister with Wife & team meeting � Significant distress among clinicians over ICU Preparedness Sister w/ family – poor “has a strong Planning • Bad news prognosis temperament” course related to treatments patient was • No AD from • PCS support to “time with neurology family “fight” receiving, likely outcome. children” “he did not afterward “positive attitude” “continue contemplate • Withdrawal of “aggressive treatments” negative life support, intervention” outcomes” death What can we learn? WHO Palliative Care….... � Palliative Care is an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness…...... � provides relief from pain and other distressing symptoms � intends neither to hasten or postpone death 8 9 2
9/30/2016 Definition of PC according to CT …..WHO Palliative Care Surgery � uses a team approach to address the needs of patients and their families “Palliative care is not synonymous with hospice � is applicable early in the course of illness, in but rather functions alongside invasive and conjunction with other therapies that are curative treatments. Palliative care specialists intended to prolong life….....and includes assist patients with defining values and goals those investigations needed to better that inform decision-making.” understand and manage distressing clinical Kirkpatrick, Wieselthaler et al. complications BMJ 2015 Division of Hospital Medicine 1 Palliative Care Program 0 Optimal Timing of Palliative Care Palliative Care Hospice 3
9/30/2016 Domains involved in the experience of human suffering Palliative Care is a Team Sport • Patient, family & Physical Physical • Symptom staff education management and support • Goals of care Psychosocia Psychosocia Emotiona l Emotiona l Patient Patient Doctors Nurses l l and and family family Social Chaplains Workers Practical Practical Spiritual Spiritual • Meaning of • Coping & adapting illness to illness • Psychological & • Advance care Division of Hospital Medicine emotional planning support Palliative Care Program Primary & Specialized Palliative Care � Primary Palliative Care � Provided by the patient’s primary / main clinicians & the other members of the Transplant team The evidence � Specialized Palliative Care � Provided by an interdisciplinary team with training and experience in palliative care � Supports patient & family � Key role is also to support primary providers (i.e.Transplant team members) Division of Hospital Medicine Palliative Care Program 4
9/30/2016 Statistics CHF Mortality and Prevalence � CHF burden � 50% 5 years after diagnosis � 5 million patients – Roger VL et al, JAMA 2004 � 550,000 new cases/year � 36% in 1 year after admission for HF � $30 billion � Most symptomatic – Curtis LH et al, Arch Intern Med 2008 � 10-15% of the CHF population � Prevalence projected to increase by � Account for 60% cost 25% 2010-2030 � Majority of 57,000 deaths/year – Roger VL et al, Circulation 2012 Thom et al. Circulation 2006 Miller and Lietz J Heart Transplant 2006 Division of Hospital Medicine Palliative Care Program Palliative Care Needs: Heart Failure Benefits of Palliative Care � Breathlessness, fatigue, pain, drowsiness, dry � Inpatient, prospectively randomized HF mouth (50%+ of patients) patients: 116/116 � 1 and 3 months follow-up � Depression, psychological distress (40%+) � Significant improvement of symptom burden � Patient & CG psychosocial & spiritual support (8.39/4.7 p<0.001) , QOL (12.92/8 p <0.001) and ACP completion (HR 2.87 p<0.03) � Advance care planning � No change in 30-day readmission rate, hospice referral and 6 month mortality Sidebottom et al, J Pall Med 2015 Bekelman et al J Card Fail 2007 Division of Hospital Medicine Division of Hospital Medicine Rutledge et al J Am Coll Cardiol 2006 Palliative Care Program Palliative Care Program 5
9/30/2016 CMS Requirements LVAD/Transplant Candidate Pool � 250,000-500,000 ESHF pts in terminal phase Beneficiaries receiving VADs for DT of disease � Mean survival 3.4 months � must be managed by an explicitly identified � Inotrope dependent = up to 94% 1 yr mortality cohesive, multidisciplinary team of medical � 80k-150k pts/yr could benefit from transplant professionals … � 2200 heart transplants done per year � LVAD as DT may be an alternative � Team must include “palliative care specialist” Lietz et al. J Card Surg 2010 Division of Hospital Medicine Lietz et al; J Card Surg 2010;25:462-471 Palliative Care Program Benefits of Palliative Care � “Proactive palliative medicine consultation for patients being considered for or being treated with DT improves advance care planning and The “What If” Question thus contributes to better overall care of these patients.” � “Our experience highlights focused advance care planning, thorough exploration of goals of care, and expert symptom management and end-of-life care when appropriate.” Swetz et al.Mayo Clin Proc. 2011 Division of Hospital Medicine Division of Hospital Medicine Palliative Care Program Palliative Care Program 6
9/30/2016 Attitude Unrealistic Expectations Talking with patients and families Gratitude Division of Hospital Medicine Division of Hospital Medicine Palliative Care Program Palliative Care Program Talking with Patients and Families…. ….Talking with Patients and Families � Elicit understanding � “ I was wondering if you could tell me what � Summarize the patient’s condition you (your father) ” � Begin from where the family is you understand about what is going on with � Avoid jargon (mechanical ventilation, pressors, CRRT) � “What have the other doctors told you?” � Check for understanding � “What did your cardiologist say about how he’s (you’re) doing?” Curtis and White Chest 2008;134:835-43 Curtis and White Chest 2008;134:835-43 7
9/30/2016 Expressing Worry Make a Recommendation � “ Based on what I know about your mother and the medical situation… I recommend ” � “I’m worried that your mother is getting worse despite our best efforts and best treatments.” � Don’t force the family to decide � “I worry that even if we attempt surgery, your brother will not be able to leave the � Check for agreement and leave room for hospital or even the ICU.” disagreement � Shares your concern � Shares uncertainty Use your expertise to help family with the � Shares emotion/empathy decision making process � Softer way to share bad news Communication in Cultural Diversity Better Words to Say � “ There is nothing more we can do ” “ I wish there was something we could � Non-English speaking � � Different Culture get better. ” � “ Would you like us to do everything possible? ” do to make your heart/lungs/kidneys � Use interpreter, never the family or friends “ How were you hoping we could help? ” for GOC discussions � � Patients’ relations specialists Pantilat JAMA 2009;301:1279-81 3 2 8
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