Chapter 44: Palliative Care in Heart Failure

PATIENT CASE

Bob Hart is a 56-year-old divorced man with a history of acute on chronic systolic heart failure (HF) secondary to nonischemic cardiomyopathy, type 2 diabetes, and obesity. He was admitted to the cardiac service with multiple HF-related symptoms including shortness of breath, cough, weight gain, lightheadedness, generalized weakness, and fatigue. His HF was first diagnosed 9 years ago and a recent echo revealed a left ventricular ejection fraction (EF) of <20%. Bob underwent right heart catheterization and was found to have a low cardiac index. During the admission his condition worsened, which prompted the team to start a dobutamine infusion and begin workup for possible advanced HF therapies. In addition to HF symptoms, Bob suffers from bilateral leg pain secondary to diabetic neuropathy. Psychosocially, he is currently undergoing a divorce and lives alone, but he has an adult daughter who is very involved in his care.

Bob was evaluated by a multidisciplinary team that included a cardiologist, cardiothoracic surgeon, social worker, and palliative care team. His treatment options included a left ventricular assist device (LVAD) implant as destination therapy or continuation of inotropes with focus on comfort care. He was not a transplant candidate due to morbid obesity and complications related to diabetes. After extensive discussion with the interdisciplinary team, Bob assessed his risks and benefits and determined that home-based management without surgery was congruent with his goals of care. While in the hospital his medical therapy was optimized and he was started on low-dose oxycodone to help manage refractory dyspnea and neuropathic pain not controlled with gabapentin.

Bob was discharged home with an inotrope infusion and initiation of home hospice. The hospice team provided frequent palliative domain-focused support to Bob and his daughter. He died at home 2 months following this hospitalization, surrounded by his family with minimal symptom burden. Bereavement services were provided by hospice to the family following the patient’s death.

INTRODUCTION

Heart disease is the number one cause of death in the United States, accounting for almost a quarter of all deaths in 2013.¹ HF is a chronic, terminal illness mentioned in over 11% of all death certificates in the United States.² Palliative care is an integral component of chronic HF care that can assist with treatment of refractory symptoms, clarify goals of care in the face of prognostic uncertainty, help with determining the appropriate location of care, and provide psychosocial support for the patient and family. This care is provided with close collaboration between a palliative care consultant and the primary cardiology team. Palliative care should be introduced early in the disease process with increasing focus as HF progresses (Figure 44-1). Early integration of palliative medicine and institutional funding for palliative care is now a recommendation by the American Heart Association.³