Palliative therapy for heart failure

Question: 

When does a CHF patient move from stage III to pallative/hospice care? My 80 year old father has biventricular failure, afib controlled by ICD (pacemaker/defib) but is having recurrent ER episodes from pitted edema, plural effusion, high risk of atelecatsis, ejection fraction of 35%, and is getting dizzy to the point of agonal breathing during the last episode (I thought he went into cardiac arrest). I don't know what I can do to help him or watch out for. He lives totally alone (mom passed away April 2012) and is on every med possible for his condition. They've been playing with his rampril and lasix dosage trying to control the dizziness but cant' find the right dose. I'm very worried about him failing fast and don't know what to expect.
 

Your father's condition appears no longer managible at home. My advice: You need to meet with his doctors and confirm that his present therapy has indeed maxed out. One concern in this repect: his heart function = 35% is usually easily managed by doctors exeprienced in heart failure. Likewise, not all pleural effusions are caused by heart failure. Even then, sometimes simple drainage may be enough to tip the scale back to easier treatment overall. If the effusion proves to be caused by a malignancy that would also change any further treatment plans.

It may therfore be worth a 2nd opinion to confirm this. However, if the final conclusion is that there is no other practical option available (and if possible your father should participate in these discussions), comfort care and preferably, transfer to a hospice (or a facility like it) becomes the next step.

I passed your question and my answer to my daughter, an internist-geriatrician who has had a very different experience with patients than I encountered managing cardio-thoracic surgical patients. Please read her answer below!

Hello,

I am Dr. T's daughter, visiting for the holiday, also a physician and an internal medicine doctor with experience in palliative care, geriatrics, and congestive heart failure. When I read Dr. T's response I told him I thought a different perspective might be useful.

I want to express my sympathy for you and for dad. It is clear he has been struggling, and I'm sure it has been difficult for all of you. It sounds to me as if your father's disease has progressed (a good sign of that with heart failure is needing to go to the hospital more often within 6 months), and that a reassessment of his goals of care (such as focusing on comfort) could make sense. Certainly a second opinion from a cardiologist is never a bad idea per se (I would certainly make sure a cardiologist on board if not already there), but my guess  (with you, I suspect) is that a palliative care consult would be more useful.

Palliative care is a philosophy of care focusing on the care of symptoms of chronic disease, and ANY patient with serious chronic disease should be considered for a palliative care consult. They can help by helping focus on how your dad is FEELING, and treating the symptoms (the shortness of breath, the anxiety, etc), rather than the disease process, and helping you and your dad understand his disease, its prognosis and options for the future. Depending on your father's goals, these might include continuing the current plan of care (which sounds like frequent doctors' visits, lots of medications, and lots of hospitalizations) OR deciding to forgo hospitalizations or turning off the AICD, etc, and investigating options such as hospice.

A good palliative care team is an excellent complement to a medical team, and having palliative care on board is often thought to contribute very favorably to a patient's experience even when getting the most aggressive care (such as chemotherapy). You do not need to be hospice-eligible (that is, with an anticipated lifespan reasonably less than six months) or even to be a comfort-measures-only patient to benefit from palliative care.

Note that (outside of cancer patients) it can be difficult to access palliative care outside of the hospital. If I were you, I would talk about options for palliative care, choosing a less aggressive path of care, etc. with the patient's primary care doctor and/or the next time your father is the hospital, asking the admitting team to consider a palliative care consult.

I wish you and your father my best wishes in this difficult time,

Dr. L. T, MD

I hope you find these opinions useful, as they provide a different perspective based on our respective backgrounds. Even so, our recommendations were relatively similar!

Hope this helps,
Dr T

Comments

It's often really hard at this point. I hope it's comforting to know that you and your dad are not alone in this, and don't have to be. I think it's great you are reaching out (even to my wonderful Dad, Dr. T, on his website!) and plan to be there at his cardiologist appointment. Do more of this. Don't try to figure this out on your own. I hope you are one of the lucky ones who has an outpatient palliative care service available. If not, reach out to your dad's primary care doctor (we ARE trained to help with these issues, too!) Good luck, and I'd love to hear how things turn out with your father (keep Dad posted if you can-- I will ask him to let me know how things turn out!).

Thank you for your speedy response. Yes this is very hard for both of us. We've been through a lot. He's a very tough man (veteran, blue collar worker who always opted for 3 shifts for the extra money for the family) and seeing him like this is just sad. I am seeing his cardiologist and the CHF clinic this week to assess next steps which may include supplimental oxygen. It's the emotional side (i.e. when to be ok with pallative) that is tough for him to realize.  

Post new comment

The content of this field is kept private and will not be shown publicly.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Allowed HTML tags: <a> <em> <strong> <cite> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Lines and paragraphs break automatically.

More information about formatting options

Type the characters you see in this picture. (verify using audio)
Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.