Palliative Care in Heart Failure: General Principles & Local Resources

1. Palliative Care in Heart Failure:General Principles & Local Resources Anne Kinderman, MD Chris Strayhorn, MD

2. What we hope you will learn • Identify opportunities to support patients with heart failure at distinct points: • Early • Progression to serious illness • Last 1-2 years of life • Describe resources to meet palliative care needs of your patients • Apply principles to your patient panel Zuckerberg San Francisco General Hospital and Trauma Center

3. Road Map • Palliative care overview • Care of a typical HF patient through illness course, identifying at each stage: • Needs • Interventions & Resources • Opportunity for reflection/discussion in small groups • Questions/discussion Zuckerberg San Francisco General Hospital and Trauma Center

4. Palliative Care Overview Zuckerberg San Francisco General Hospital and Trauma Center

5. Experiences with Palliative Care? Harry Bliss, 2008

6. What is Palliative Care?

7. What is Palliative Care? • “Palliative care is the medical subspecialty focused on preventing, treating and relieving the pain and other debilitating effects of serious and chronic illness.” • “Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.” Center to Advance Palliative Care

8. Palliative Care Domains

9. Time Integrated Model for Serious Illness Care “Best care possible” 100 bereavement Curative care % focus Hospice Care Palliative Care 0 death Terminal phase Adapted from S Pantilat, PCLC 2005

10. Benefits of Palliative Care(heart failure) • Improved Quality of Life • Improved symptom management • Decreased caregiver stress • Improved patient, family satisfaction • Decreased use of hospital, ED Wong F, 2016 Heart Adler E, 2009 Circulation Zuckerberg San Francisco General Hospital and Trauma Center

11. Palliative Care Specialists for Everyone? Outpatient Pal Care Team at ZSFG: 1 physician, 0.4 NP, 1 SW, 0.4 chaplain 4 half-days/week clinic ~1000 SFHN patients die each year from chronic illness This Photo by Unknown Author is licensed under CC BY Zuckerberg San Francisco General Hospital and Trauma Center

12. Developing Continuum of SFHN Palliative Care Services Intensity of services, Intensity of need

13. Integrating Palliative Care into Serious Illness Care

14. Disease Trajectories

15. Integrating Palliative care into heart failure mgmt Zuckerberg San Francisco General Hospital and Trauma Center

16. Mr. Jackson • 55 y.o. M with HTN, HL, CAD, stage I CKD • Recently c/o fatigue, harder to work • TTE showed mild reduced LVEF • No DPOA or Adv Directive on file Zuckerberg San Francisco General Hospital and Trauma Center

17. Integrating Palliative Care into Serious Illness Care

18. Primary Palliative Care Primary treating clinicians screen for and address palliative care needs • Generalist (PCP, case mgr, cardiologist) delivers care • Specialist acts as support • Palliative care education, training • QI support • Patient-specific questions Zuckerberg San Francisco General Hospital and Trauma Center

19. Early Palliative Care Needs • Diuretics, ß blocker • Depression screening • What to expect, look out for • Purpose of treatment • Implications on work, relationships, housing, etc. • Important components of QOL, priorities • Identify surrogate • Adv Directive • Identify sources of strength and support

20. Making it do-able • Brief interventions • Education • 1 exploring question • Take “on ramps” when patients present them • Leverage others • Case manager • BHT • Consider group visits for Adv Care Planning Zuckerberg San Francisco General Hospital and Trauma Center

21. Primary Palliative Care Resources • Palliative Care Fast Facts • Online education • CSU Institute for Palliative Care • Training & shadowing • Half-day skills training • Intensive training • UCSF Interprofessional Continuing Education in Palliative Care Zuckerberg San Francisco General Hospital and Trauma Center

22. Mr. Jackson – 3 years later • Admitted for episode of chest pain, SOB • Discovered to have progressive CAD, gets stent to LAD • TTE showed LVEF 40% • Seems reluctant to engage in advance care planning despite attempts Zuckerberg San Francisco General Hospital and Trauma Center

23. Integrating Palliative Care into Serious Illness Care

24. Clinician-supportedPalliative Care Primary providers continue to deliver care with added support from palliative care specialist(s) • Routine case review with high-risk patient providers • As needed case conferences to assist frontline providers when feeling stuck • Email Chris Strayhorn or eConsult • Inpatient consults if patient is hospitalized Zuckerberg San Francisco General Hospital and Trauma Center

25. Mr. Jackson – 1 year later • Admitted with progressive LE edema, SOB with limited exertion • Wife now doing majority of his IADLs • TTE showed LVEF 30% • You’re worried prognosis may be limited Zuckerberg San Francisco General Hospital and Trauma Center

26. Integrating Palliative Care into Serious Illness Care

27. SB 1004: Groundbreaking Legislation for Medi-Cal Patients • Signed into law Sept 2014 • Mandates • Access to palliative care services • State must provide • Guidance for patient eligibility • Standards for palliative care • Technical assistance • Budget neutral • Implementation: January 2018

28. SB 1004: Who qualifies? • General Eligibility • Late stage of illness, expected to decline • Appropriate disease-modifying treatment has been implemented or offered • Patient/family willing to engage in advance care planning and with the palliative care team (first) • Disease Specific Eligibility—Advanced Disease • CHF • ESLD • COPD • Cancer 52% of deaths

29. SB 1004 Eligibility, Cont • Disease-Specific Eligibility— Advanced Disease as evidenced by: • CHF– BOTH: NYHA III or IV and EF< 30% (or serious co-morbidities) • COPD– EITHER: FEV1<35% and 02<3L or 02 >3L • ESLD– EITHER: MELD >19 or Liver damage (alb<3 and INR>1.3) and SBE, hepatic encephalopathy, hepatorenal syndrome, or recurrent esoph varices • Cancer– BOTH: Stage III or IV and Karnofsky Performance Scale < 70% or failed two therapies Zuckerberg San Francisco General Hospital and Trauma Center

30. Serious Illness Needs • Opioids for dyspnea • Methylphenidate for fatigue • Somatic complaints • Depression and Anxiety • Transportation • Cost of Care • Ability to work • Family dynamics • Months to years-Range? • Prognostic Uncertainty • What’s next phase like? • Reinforce Strengths • Address Existential Distress • LVAD? • Transplant? • Length of life vs QOL (Blurred in CHF)

31. Serious Illness Resources • Palliative Care • Plus Clinic • By the Bay Health • Other Resources • Shanti- Navigators for HIV and gynecological CA • SFHN Cancer Navigator Program • CCM • ED Case Management Zuckerberg San Francisco General Hospital and Trauma Center

32. Mr. Jackson – 6 months later • Comes in for monthly follow up • Sometimes even dyspneic at rest • Wife sounds overwhelmed with managing care • Pt voices difficulty with med side effects, feeling tired all the time Zuckerberg San Francisco General Hospital and Trauma Center

33. Integrating Palliative Care into Serious Illness Care

34. Serious Illness Needs • Intensify symptom management • Frailty • Pain • Anorexia • Cost • Location of care • Caregiver support • In-home services • Transportation • if needed • Weeks to months • Uncertainty remains • Hospice Options • Symptom management vs clarity • Some therapy no longer tolerated • Blurred line Palliative vs Curative • Home vs Facility • Existential distress persists • Support strengths • Local clergy or religious community • Funeral plans?

35. End of Life Care Resources • Hospice agencies • Hospice by the Bay • Vitas • Pathways • Asian Pacific Home Care and Hospice • Multiple other hospice agencies • Support groups through various agencies Zuckerberg San Francisco General Hospital and Trauma Center

36. Small group discussion Zuckerberg San Francisco General Hospital and Trauma Center

37. Discussion: 5 min • What are the biggest challenges you face in caring for patients with progressive heart failure? • What resources would be helpful to better manage your HF patients through their illness? • REPORT OUT Zuckerberg San Francisco General Hospital and Trauma Center

38. Patient List Review • The SFHN is working to provide you with a list of your patients who potentially meet SB 1004 criteria – CAVEATS: • Only pts who have TTE/TEE in our system • Only SFHP patients with minimum utilization • Your role will be to review your patients to make a final determination and refer if needed • eConsult – specify if you think home-based services would be especially beneficial • The Plus Team is available to discuss with you in cases that are unclear Zuckerberg San Francisco General Hospital and Trauma Center

39. Next steps and take-home points Zuckerberg San Francisco General Hospital and Trauma Center

40. Next Steps • Think about what level of support you might need for different patients • Consider additional training in palliative care • Contact us if you’re interested in QI in palliative care in your setting Zuckerberg San Francisco General Hospital and Trauma Center

41. Take Home Points • Palliative Care is delivered across a continuum—from diagnosis to advanced disease and end of life • Palliative Care is a team sport–use the resources at your disposal to address the multiple domains of serious illness • The Palliative Care teams at ZSFG are available to support you and your patients anywhere along the journey Zuckerberg San Francisco General Hospital and Trauma Center

42. More information • Nice Review Articles • Gelfman L, 2017 Heart Fail Review – defines primary vs. specialty pal care interventions in HF • Adler E, 2009 Circulation – review of palliative care interventions in advanced HF • Palliative care training • Sign up if you’re interested in half-day session and/or shadowing • (Primary Palliative Care Resources, slide 21) Zuckerberg San Francisco General Hospital and Trauma Center

43. Zuckerberg San Francisco General Hospital and Trauma Center