Prognostication and End of Life Care COPD and CHF

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
ALOS
COPD
National
69
38
65
65
Local
19
9
37
35
(All
numbers
in days)
Early 1900s
Current
Medicine's Focus
Comfort
Cure
Cause of Death
Infectious Diseases/
Communicable Diseases
1720 per 100,000
(1900)
50
Chronic Illnesses
Home
Institutions
Caregiver
Family
Disease/Dying
Trajectory
Relatively Short
Strangers/
Health Care Providers
Prolonged
Death rate
Average Life
Expectancy
Site of Death
865 per 100, 000
(1997)
76
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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%
< 10 % (e.g. MI, accident)
Health Status
•
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?



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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

9/13/2013
Hypercapnia: pCO2 ≥ 50 mm HG
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
0-2
3-4
4-6
7-10
One year
mortality
Two year
mortality
52 month
mortality
2%
2%
2%
5%
6%
8%
14%
31%
19%
32%
40%
80%

If pCO2 > 50,




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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


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Opiates – best drug to alleviate symptom of dyspnea
Anxiolytics – do not help dyspnea, but will help
anxiety associated with dyspnea
Oxygen
Cough Suppressants
Steroids

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
Positioning – upright
Open window, bedside fan
Humidified Air
Pulmonary rehabilitation

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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%
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(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

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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.



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Chest x-ray
Cardiology consultation
IV diuretics for acute exacerbation
Remain on transplant list
YES

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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


Anxiety from CHF or Dyspnea


Opiates
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


LVAD



Improves Quality of Life, but shortens survival
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”