The Palliation of End-Stage Heart Disease. Dr. Jana Pilkey MD, FRCP(C) Internal Medicine, Palliative Medicine March 14 th , 2007. “It is easier to die of Cancer than Heart or Renal failure” John Hinton (Medical Attending Physician) 1963. Objectives.
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Dr. Jana Pilkey MD, FRCP(C)
Internal Medicine, Palliative Medicine
March 14th, 2007
“It is easier to die of Cancer than Heart or Renal failure” John Hinton (Medical Attending Physician) 1963
Similarities to Cancer failure”
Anxiety & depression
Insomnia & confusion
Fear of the futureClinical Features
O’Brien et al. BMJ 1998
Differences From Cancer
(J Pain and Symp Manage, 2006)
Lung Cancer failure”
Clearer trajectory – able to plan for death
Initially feel well but told you are ill
Good understanding of diagnosis and prognosis
Swinging between hope and despair
Gradual decline, acute deterioration, sudden death
Feel ill but told you are well
Little understanding of diagnosis and prognosis
Relatives isolated and exhausted
Daily grind of hopelessnessExperience of Patients
Lung Cancer failure”
Cancer takes over life
Treatment dominates life
Feel worse on treatment
Financial benefits accessible
Services available in the community
Care prioritized as “cancer” or “terminal”
Shrinking social world
Feel better on treatment
Less access to financial benefits
Services less available in the community
Less priority as “chronic illness”Experience of Patients
(Hauptman 2005, Taylor 2003, Ward 2002)
CHF Risk Model failure”
(Canadian Cardiovascualr Outcomes Research Team, JAMA 2003)
Respiratory Rate (breaths/min)(minimal 20;maximal 45)
Systolic blood pressure (mmHg)
Blood Urea Nitrogen ( mmol/L)
Sodium Concentration <136 mEq/L
Hemoglobin <100 g/L(not required for 30-day Score)
One-Year Score failure”
One-Year Mortality Rate (%)
30-Day Mortality Rate (%)
CHF Risk Model
Our patient has a score of 127
Clinical Assessment failure”
Ineligible or Declines
Zambroski, Cheryl. Patients With Heart Failure Who Die in Hospice.
AM Heart J 2005; 149:558-64.
Pantilat, Steven. Palliative Care for Patients with Heart Failure. JAMA, 2004; 291: 2476-82.
Hanratty, Barbara. Doctors’ Perceptions of Palliative Care for Heart Failure: Focus Group Study. BMJ 2002:325: 581-585.
Nanas John. Long-term Intermittent Dobutamine Infusion, Combined with Oral Amiodarone for End-Stage Heart Failure. Chest 2004; 125: 1198-1204.
Lopez-Candales, Angel. Need for Hospice and Palliative Care Services in Patients with End-Stage Hearat Failure Treated with Intermittent Infusion of Inotropes. Clin. Cardio. 2004, 27, 23-28.
Goldstein, NF.Management of implantable cardioverter defibrillators in end-of-life care.Ann Intern Med. 2004 Dec 7;141(11):835-8.