End Stage Disease Progression and Complications – Cardiac Disorders (Learning Hospice)

Regardless of etiology, many chronic cardiac diseases have a common end-point of right, left, or biventricular heart failure (HF). According to the Center for Disease Prevention and Control (CDC) data, in 2010, 57,757 deaths were caused by HF in the United States, making cardiac disease or heart failure (HF) was listed as the most common cause of death in the United States.

Death is often sudden. Some people with the advanced coronary disease die quickly and without warning from arrhythmias. However, many live for prolonged periods of time with HF managed by medical and surgical interventions. Yet, reversal of HF is rare, unless surgical intervention is available. It is therefore difficult to predict the end of life.

The disease course can be one of chronic illness with a long period of general decline in function, interspersed with exacerbation and partial recovery. The degree of HF is not clearly correlated with life expectancy or symptoms; because of those with very poor ventricular function can live with only minimal symptoms, whereas others with similar ventricular function can be very symptomatic.

The patient who is dying of advanced heart failure is those who are no longer respond to drug therapy, not a candidate for further invasive procedures, and present with significant symptoms due to the underlying pathophysiology.

End-stage disease progression of cardiac disorders often includes:

• dyspnea: opioids often help to relieve dyspnea. Other interventions include positioning the patient with head of the bed elevated, using a fan aimed toward the patient’s face, administering oxygen, and avoiding NSAIDs (which may reduce the effects of diuretics and other drugs). If dyspnea is related to pulmonary edema, diuretics and vasodilators may provide relief.
• pain: this may be cardiac or edema-related, affecting the chest or the entire body. Opioids are generally the drugs of choice to relieve pain related to end-stage disease.
• fatigue/ depression: relieving other symptoms and providing both physical and emotional support may help to reduce fatigue and depression.
• fluid retention: Elevating the legs to improve circulation and administration of diuretics and vasodilators (as for dyspnea) may provide some relief.
• general weakness: Patients will become bed bound as the condition progresses and unable to attend to ADLs without assistance.

Signs/ symptoms of HF falls into 2 categories:

• Fluid accumulation: dyspnea, orthopedic, and edema
• reduced cardiac output: fatigue, weakness, especially with exertion

Common symptoms experienced by patients with heart failure and common interventions:

• Pain (affected 78%) — interventions: identify etiology, if possible; consider opioids for angina
• Dyspnea (affected 61%) — Optimize medication; treat reversible causes such as effusions, dysrhythmias, COPD
• Depression (affected 59%) — Screen for hypoactive delirium, screen for chemical owing, CAGE; consider SSRI, use psychostimulants with caution
• Insomnia (affected 45%) — Screen for delirium; screen for depression; treat reversible causes such as pain or dyspnea
• Anorexia (affected 43%) — Screen for treatable causes such as depression, delirium, constipation
• Anxiety (affected 30%) — Screen for delirium, depression, spiritual, or emotional suffering
• Constipation (affected 37%) — Monitor fluid balance
• Nausea/ Vomiting (affected 32%) — Appropriate bowel program when using opioids; optimize anti-emetic regimen; NG tube for decompression

Factors to support Hospice referral: (both 1 and 2 should be present. Factors from 3 will add supporting documentation)

1. at the time of initial certification or recertification, the patient is or has been optimally treated for heart disease, or is not a candidate for surgical procedures, or refuses those procedures.
   • Optimally treated means that patients who are not on vasodilators have a medical reason for refusing those drugs, such as hypotension or renal disease.
2. Patient with CHF or angina should meet the criteria for the New York Heart Association Class IV.
   • This means he/she is unable to carry on any physical activity without discomfort, and symptoms are present even at rest. If any physical activity is undertaken, physical discomfort increases.
   • CHF may be documented with an ejection fraction of less or equal to 20% if this data is available.
3. Use these factors to add supporting documentation:
   • treatment-resistant symptomatic supraventricular or ventricular arrhythmias
   • history of cardiac arrest or resuscitation
   • history of unexplained syncope
   • brain embolism of cardiac origin
   • concomitant HIV disease

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A 54-year-old patient with end-stage renal failure dies of sudden cardiac arrest 6 days after withdrawal of dialysis. This patient’s death was most likely caused by hyperkalemia (elevated serum potassium level)

• a common complication of end-stage renal failure as a result of the diminished ability of the failing kidney to excrete potassium
• life-threatening hyperkalemia is often asymptomatic until sudden cardiac arrest occurs

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References:

Corridor (2006). Hospice Quickflips: A Guide for Hospice Clinicians

Yennurajalingam, S., & Bruera, E. (2016). Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care (2nd. Ed.)