James F. Kravec, M.D., F.A.C.P Chairman, Department of Internal Medicine, St. Elizabeth Health Center Chair, General Internal Medicine, Northeast Ohio Medical University Associate Medical Director, Hospice of the Valley
When should I call in hospice on this CHF or COPD patient?
1. Learn the Medicare guidelines for hospice eligibility for patients with COPD 2. Understand when to ask for a hospice referral for a diagnosis of CHF 3. Know the methods for treating the end of life symptoms in patients with COPD and CHF
Low length of stay in local hospice agency Patient and family does not experience full scope of hospice services and full benefit Increase on cost in initial hospice care versus later routine care Many patients are never referred to hospice care Less comfort measures for patient No bereavement and counseling services for families
Average LOS Mean LOS ALOS CHF National 69 38 65 65 Local 19 9 37 35 ALOS COPD (All numbers in days)
Early 1900s Current Medicine's Focus Comfort Cure Cause of Death Infectious Diseases/ Communicable Diseases Death rate 1720 per 100,000 (1900) Average Life Expectancy Chronic Illnesses 865 per 100, 000 (1997) 50 76 Site of Death Home Institutions Caregiver Family Strangers/ Health Care Providers Disease/Dying Trajectory Relatively Short Prolonged
Cancer 41.3% Heart Disease 11.8% Debility 11.2% Dementia 10.1% Pulmonary Disease 7.9% Other 6.5% Stroke and Coma 3.8% Renal Disease 2.6% ALS/motor neuron 2.3% Liver Disease 2.0% HIV 0.6%
Health Status < 10 % (e.g. MI, accident) Time 8
Decline Time 9
Decline Crises Death Time 10
Signs of Impending Death: Respiratory secretions (death Rattle): Median time to death (MTD) 57 hours +/- 23 hours Respirations with mandibular movement MTD 7.6 hours +/- 2.5 hours Cyanosis/mottling: MTD 5.1 hours +/- 1.1 hour Lack of radial pulse: MTD 2.6 hours +/- 1 hour 12
82 year old female Admitted to hospital for COPD exacerbations 3 times in last 12 months SpO2 84% on RA, 91% on 4 L O2 via NC Limited in her daily activity due to dyspnea She declines further hospitalizations Now What?
Unpredictable disease trajectory Of 19 other common Hospice diagnoses, only end stage dementia has a less certain 6-month prognosis Many physicians and caregivers do not recognize that COPD is life-threatening disease
Primary Factors: Disabling dyspnea at rest Progressive pulmonary disease (eg, increasing emergency department visits or hospitalizations for pulmonary infections and/or respiratory failure) Hypoxemia at rest on supplemental O2 po2 55 mm Hg on supplemental O2 O2 sat 88% on supplemental O2 or Hypercapnia: pco2 50 mm HG 9/13/2013 15
Secondary Factors: FEV1 after bronchodilator < 30% of predicted Decreased FEV1 on serial testing > 40 ml per year Unintentional weight loss > 10% of body weight in 6 months Resting tachycardia > 100/min in patient with severe chronic COPD Documented cor pulmonale or right heart failure due to advanced pulmonary disease 9/13/2013 16
If there are symptoms of dyspnea despite maximal COPD management. If there is a desire not to return frequently to the hospital. If there is worsening functional status.
Chest x-ray Oxygen IV steroids for acute exacerbation IV antibiotics YES
B = Body Mass Index O = Airflow Obstruction D = Dyspnea E = Exercise Capacity
Variable Points on BODE Index 0 1 2 3 FEV1 (% predicted) 65 50-64 36-49 35 Distance walked in 6 min (meters) >350 250-349 150-249 149 MMRC dyspnea scale* 0-1 2 3 4 Body-mass index (BMI) >21 21
BODE Index Score One year mortality Two year mortality 52 month mortality 0-2 2% 6% 19% 3-4 2% 8% 32% 4-6 2% 14% 40% 7-10 5% 31% 80%
If pco2 > 50, 10% of patients will die during the hospitalization 33% of patients will die within 6 months of the hospitalization 43% of patients will die within 12 months of the hospitalization If mechanical ventilation is needed, there is a 25% chance of death during the hospitalization If mechanical ventilation is needed for >72 hours, there is a 50% 12-month survival
Opiates best drug to alleviate symptom of dyspnea Anxiolytics do not help dyspnea, but will help anxiety associated with dyspnea Oxygen Cough Suppressants Steroids
Positioning upright Open window, bedside fan Humidified Air Pulmonary rehabilitation
A 65 year old male has EF of 15% He is seen by PCP and cardiology and patient is on maximum medical therapy. He has been hospitalized 4 times in the last 12 months for volume overload At baseline, he has minimal completion independently of his ADLs He has dyspnea at rest.
Systolic Heart Failure has a worse prognosis than Diastolic Heart Failure NYHA used for prognostication
NYHA I Symptoms only with more than ordinary activity NYHA II Symptoms with ordinary activity = 1 year mortality is 7% NYHA III Symptoms with minimal activity = 1 year mortality is 13% NYHA IV Symptoms with rest = 1 year mortality is 20-52%
(Computer Program Website) = http://depts.washington.edu/shfm More severe NYHA classification Ischemic etiology Low EF Low Sodium Low Systolic BP
Primary Factors: Symptoms of recurrent heart failure or angina at rest, Discomfort with any activity (NYHA Class IV) Patient already optimally treated with diuretics and vasodilators (ie, ACE inhibitors) 9/13/2013 29
Secondary Factors: Ejection fraction 20% Symptomatic arrhythmias History of cardiac arrest and CPR Unexplained syncope Embolic CVA of cardiac origin HIV disease 9/13/2013 30
If the NYHA Class is III or IV (high 1 year mortality rate) If there focus on quality of life and not aggressive therapy such as LVAD or cardiac transplantation If there is a desire not to return frequently to the hospital.
Chest x-ray Cardiology consultation IV diuretics for acute exacerbation Remain on transplant list YES
Patients have low EF and poor renal perfusion and low cerebral perfusion Low cerebral perfusion may cause confusion Low renal perfusion may cause delayed excretion of drugs Palliative medications may cause confusion = low doses are used initially
Dyspnea Opiates Anxiety from CHF or Dyspnea Benzodiazepine Depression 50% of CHF patients have depression and anxiety
ICD Deactivation Electrophysiologist or ICD company representative to deactivate Magnet taped over ICD Optimal Medical Management used to control symptoms, so in most instances, these medications are continued
IV Ionotropes Improves Quality of Life, but shortens survival LVAD either a bridge to transplantation or a destination therapy If LVAD is a destination therapy, patients survived an average of 2 years Cardiac Transplant 90% of patients are alive at year 1 50% of patients are alive at year 10
Terminal Diagnosis 6 month or less Prognosis 2 Physicians
How people die remains in the memories of those who live on