|
|
Palliative care and chronic heart failure |
Part 2
Patients with end stage cancer have always been the ‘core business’ for specialist palliative care services. However, more recently, patients with end stage chronic heart failure (CHF) are being referred to palliative care services. On the surface this appears to be reasonable given that CHF should be considered a ‘terminal disease’ given that the only cure for the majority is by heart transplantation. Survival after diagnosis of heart failure at one year is 85% and at five years is 50%. Patients with New York Heart Association Class III disease (dyspnoea on mild exertion) have a one-year survival of 80-90%; patients with Class IV (dyspnoea at rest) have a one-year survival of 50-70%.
CHF is not only an incurable disease but also the suffering involved can be considerable, particularly in the last years/months of life. A study by Murray et al (BMJ 2002) comparing dying with lung cancer or cardiac failure showed that patients with CHF had:
- Less information about their illness;
- A poorer understanding of illness and prognosis;
- Less involvement in important decision making including initiation of CPR, ventilation and tube feeding;
- Frustration with progressive losses, social isolation and the stress of monitoring a complex medication regimen;
- Fewer health services, social services and financial benefits;
- Less involvement with palliative care services;
- Poorly co-ordinated services.
CHF patients also have well-documented symptom control issues throughout the duration of their illness comparable to patients with cancer. The most commonly reported distressing symptoms are:
- Dyspnoea,
- Pain (often pain all over – non specified cause),
- Overwhelming tiredness,
- Functional impairment (difficulty walking),
- Depression,
- Anxiety.
Opioids are often overlooked in the management of left ventricular failure (Ward, Heart 2002, 87). Initially a dose of 2.5mg morphine every four hours can have enormous benefit. The dose can be titrated upwards and converted to a slow release preparation. The daily dose is usually less than that used for pain control. Laxatives are mandatory. Several beneficial effects of opioids are known:
- Depression of sympathetic vascular reflexes and histamine release cause arteriolar and venodilatation with resultant reduction in pre- and after-load.
- Reduced responsiveness of the dominant respiratory control centre, which is the carbon dioxide sensitive medullary reflex; as a result, the increase in respiratory rate in response to afferent stimuli from the lungs is decreased.
- A central opioid action reduces the usually associated mental distress.
There are differences, however, with end stage CHF compared with end stage cancer namely:
1. Treatment of the underlying condition
With cancer, palliation is often just that, the alleviation of symptoms without being able to control the underlying cancer, especially in end stage disease. However, with CHF, active management of improving cardiac function is the mainstay of treatment throughout the illness, even in the very end stage.
2. Disease trajectories
As highlighted in the previous article, there is a difference in the disease trajectories of end stage cancer and non-cancer diseases. There is a high degree of uncertainty regarding prognosis and predictability of death, hence a terminal phase of illness with non-cancer patients compared to cancer patients.
3. Acknowledging terminal illness
Finally, one of the greatest differences is the lack of acknowledgement that CHF is mostly a terminal disease, by patients, their carers and health care professionals. That being the case, this leads to poor communication and the loss of treatment choices for the patient, as they are not able to make informed decisions about the care they receive.
Given the above difficulties, it can be very difficult to identify patients who would benefit from referral to palliative care, or the timeliness of the referral. The below suggested protocol should help guide decision making.
SUGGESTED PROTOCOL FOR THE PALLIATION OF CHF
1. Optimal medical management (MJA 2001 [www.mja.com.au])
- ACE inhibitors
- Diuretics
- Beta blockers
- Spironolactone
- Angiotensin II receptor antagonists
- Digoxin
- Involvement of cardiologist
- Low dose opioids for dyspnoea
- Avoid tricyclic antidepressants, antihistamines, anti arrhythmics, NSAIDs, Calcium Channel blockers.
2. Non-pharmacological management
- Involvement of the Priority Health Care Program cardiac liaison officer (contact local Community Health).
- Regular physical activity.
- Patient support by doctor and community nurse is crucial (non compliance accounts for majority of readmissions to hospital).
- CPAP for obstructive sleep apnoea patients.
- Reduced sodium intake.
- Reduced fluid intake (1.5 litres per day).
- Avoid alcohol and smoking if possible.
- Daily weights if possible/necessary.
- Vaccination against influenza and pneumococcal disease.
3. GP involvement
GP involvement in health assessments, care planning, case conferencing and discharge planning (EPC item numbers).
4. Referral to the palliative care service
For patients with
- Difficult symptom control,
- Request to cease treatment,
- Patients who wish to pursue non aggressive/non invasive management of end stage disease,
- Support for terminal care.
Palliative care services cannot offer
1. Inpatient respite care,
2. Medical management of acute exacerbations of CHF,
3. Routine ‘out of hours’ nursing care.
If you require further information/references please contact Dr Joanne Doran, PC director for the NRAHS based at St Vincent’s Hospital on jdoran@svh.org.au.
See also Part 1 of this article
|
|
|
|
