Vol 65: JULY | JUILLET 2019 |Canadian Family Physician | Le Médecin de famille canadien
479 É D I T O R I A L G E R I A T R I C G E M S
Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.
End-of-life discussions in advanced heart failure
Frank Molnar MScMD CM FRCPC Chris Frank MD CCFP(COE) FCFP
Clinical question
When and how should I start end-of-life (EOL) discussions with older patients with advanced heart failure (HF)?
Bottom line
Guidelines recommend discussing goals of care (GOC) and EOL issues with patients with advanced HF1; and, as specialists do not consistently do this, primary care pro- viders are often left with this critical role.
Evidence
The defining features of HF in older persons are complexity and comorbidities. Patients with HF older than age 75 have on average more than 5 concurrent chronic conditions, including a 2-fold increased risk of dementia.2,3 Therefore, HF been referred to as a cardiogeriatric syndrome.4
A Canadian study of older patients discharged from hospital found mortality rates of 17% and 27% at 6 and 12 months, respectively.5 Using criteria for advanced HF, mortality can be as high as 75% at 1 year.6 There is a clear need for advance care planning and GOC and EOL discus- sions, as well as a palliative care approach.
Approach
First we need to recognize when patients have developed advanced or end-stage HF; its presentation can be non- specific and includes fatigue, anorexia, and delirium.7 It is characterized by severe and nonreversible HF symptoms despite optimal therapy. An excellent review of advanced (or stage D) HF is available,6 and Box 1 lists markers of the disease6 but presents only a partial picture focused on 1 system. To learn how to factor in other comorbidities, read
“An approach to management of advanced heart failure in the older person.”8 Another useful resource for prognosti- cation is ePrognosis (https://eprognosis.ucsf.edu/).
Ideally, the cardiologist provides prognosis based on car- diac factors and device-based therapy, while the primary care provider, knowing the patient and family best, discusses prognosis in the broader context of the whole patient.
Implementation
Once advanced HF is recognized, the Serious Illness Communication Guide (www.ariadnelabs.org/areas-of- work/serious-illness-care) can assist with productive dis- cussions. Four questions can help structure a discussion:
Does the patient know his or her prognosis? What does the
patient want to achieve in the time that is left? What is his or her biggest fear for what lies ahead? What is the patient willing to sacrifice for the possibility of more time? Another useful resource for GOC discussions is the Speak Up web- site (www.advancecareplanning.ca). To learn more about the nuances of advance care planning in different prov- inces and territories, read “Facilitating effective end-of-life communication—helping people decide.”9
Dr Molnar is a specialist in geriatric medicine practising in Ottawa, Ont. Dr Frank is a family physician practising in Kingston, Ont.
Competing interests None declared References
1. Howlett JG, Chan M, Ezekowitz JA, Harkness K, Heckman GA, Kouz S, et al. The Canadian Cardio- vascular Society Heart Failure companion: bridging guidelines to your practice. Can J Cardiol 2016;32(3):296-310. Epub 2015 Jun 25.
2. Murad K, Goff DC Jr, Morgan TM, Burke GL, Bartz TM, Kizer JR, et al. Burden of comorbidities and functional and cognitive impairments in elderly patients at the initial diagnosis of heart failure and their impact on total mortality: the Cardiovascular Health Study. JACC Heart Fail 2015;3:542-50.
3. Dodson JA, Truong TTN, Towle VR, Kerins G, Chaudhry SI. Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes. Am J Med 2013;126(2):120-6.
4. Rich MW. Heart failure in the 21st century: a cardiogeriatric syndrome. J Gerontol A Biol Sci Med Sci 2001;56(2):M88-96.
5. Alter DA, Ko DT, Tu JV, Stukel TA, Lee DS, Laupacis A, et al. The average lifespan of patients discharged from hospital with heart failure. J Gen Intern Med 2012;27(9):1171-9.
6. Fang JC, Ewald GA, Allen LA, Butler J, Westlake Canary CA, Colvin-Adams M, et al. Advanced (stage D) heart failure: a statement from the Heart Failure Society of American Guidelines Committee.
J Card Fail 2015;21(6):519-34.
7. Azad N, Lemay G. Management of chronic heart failure in the older population. J Geriatr Cardiol 2014;11(4):329-37.
8. Azad N, Srivaratharajah K, Khoury L. An approach to management of advanced heart failure in the older person. Can Geriatr Soc J CME 2016;6(2):1-13.
9. Frank C, Puxty J. Facilitating effective end-of-life communication—helping people decide.
Can Geriatr Soc J CME 2016;6(2):1-9.
Box 1. Indicators of advanced HF
• Repeat (≥ 2) hospitalizations or ED visits for HF in past year
• Progressive deterioration in renal function (eg, rise in blood urea nitrogen and creatinine levels)
• Weight loss without other cause (eg, cardiac cachexia)
• Intolerance of ACEI due to hypotension or worsening renal function
• Intolerance of β-blockers because of worsening HF or hypotension
• Frequent SBP of < 90 mm Hg
• Persistent dyspnea with activities (eg, dressing, bathing) requiring rest
• Inability to walk 1 block on level ground owing to dyspnea or fatigue
• Need to escalate diuretics to maintain volume status—
often reaching daily furosemide equivalent dose of
> 160 mg or use of supplemental metolazone therapy
• Progressive decline in serum sodium, usually < 133 mEq/L
• Frequent implantable cardioverter defibrillator shocks ACEI—angiotensin-converting enzyme inhibitor, ED—emergency department, HF—heart failure, SBP—systolic blood pressure.
Data from Fang et al.6
