Palliative and/or Hospice Care for Elderly Patients being Considered for Device Therapy

C. Richard Conti, MD, MACC

Palliative Care

Palliative care is the relief of symptoms without dealing with the underlying cause, e.g. use of analgesia, to relieve pain. The use of such an agent alleviates the symptoms without curing the underlying disease. This is the type of care for patients with serious illnesses. It focuses on improving quality of life, not just in your body, but also in your mind and spirit. There is a thin line between palliative care and hospice care.

Hospice Care

As I understand it, hospice care is for all patients with illnesses that have a prognosis of 6 months or less. However, I am at a loss to understand how anyone can prognosticate life span in an individual patient but must admit that experienced physicians can present the patient and the family with an educated guess.

Hospice care is about providing as much functional satisfying lifestyle as possible. The concept of hospice is involvement by not only the patient but the patient ’ s family including the desires of the patient and their family. Hospice care involves symptom management, (similar to palliative care),emotional support, spiritual support and psychosocial support. It is not about prolonging dying or shortening life. I guess comfort care is the best way to describe it so that patients can enjoy whatever it is they like to enjoy. The goal of hospice care is to improve the individual ’ s quality of remaining life.Curative treatment is no longer a consideration in patients in hospice. But it is not withdrawal of care.

Device Therapy

In 2018, I am most familiar with the following devices used in patients with “cardiac symptoms”.

1. rTanscatheter Aortic Valve Replacement (TAVR)for aortic stenosis patients at high risk for surgical aortic valve replacement.

2. Biventricular pacing and ICD (BV ICD) for systolic heart failure patients.

3. Ventricular Assist Devices in heart failure patients as a bridge to transplant or as destination therapy in patients not eligible for heart transplantation.

Obviously these procedures have their indications but as a cardiologist who has seen many patients that are being considered for these procedures, I am beginning to wonder who should be the patients that should not receive any of these devices.

Who Determines the Cause of“Cardiac Symptoms”

Frailty is a lar ge concern in the elderly patient despite the fact that there are many patients whose chronologic age is consistent with their physiologic age, i.e. they look young, feel young and act young.However, there are also many patients whose chronologic age is much greater than their physiologic age. In any elderly patients, it must be determined whether frailty is related to the disease for which a device is being considered, or frailty is simply related to age. For example an extremely old patient who is quite frail but frailness is not related to whatever disease is being evaluated, will not do as well with a ventricular assist device or TAVR or BV ICD compared to a patient whose frailty is related to the disease e.g. aortic stenosis in the patient being considered for a TAVR. Decisions about the complex patients usually are not made by a single physician but by a consensus of a group of persons, similar to what is done for cancer patients.

Identification of Patients Who Should not Receive Devices

This is not an easy task but one that should be unde-r taken by the physician in char ge of the patient, i.e.the physician who takes ownership of the patient.

The patient ’ s physician must determine if the patient is a candidate for palliative care or hospice.Once that is done, they should initiate discussions with the patient and the family, before calling on someone who is not the patient ’ s physician to discuss palliative or hospice care.

Team Approach to Management

In 2018, a team approach to patient management seems to be in vogue. I am not happy with this approach and I am concerned that a team approach to the management of these kinds of patients may confuse the patient and the patient ’ s family. In the past it used to be the patients primary care physician who was responsible for hospital and long term management of these patients. That is not the case in 2018 where multiple physicians see the patients for short periods of time and most do not manage the patient over a long period of time either in hospital or as an outpatient.

Decision Making in the Patient with“Cardiac Symptoms”

The patients physician must determine if the patient who is bed-ridden is unable to do anything productive. Because of the underling pathology of their disease makes them that way. If that is the case then perhaps the addition of a VAD or aortic valve replacement or BV ICD may improve their functionality. If that is not the case then these devices seem not warranted.

Another example comes to mind, i.e. a patient with multiple myocardial infarctions with chronic scarring in the left ventricular. Often these patients will not respond to left ventricular pacing, since pacemakers do not pace scar. Therefore these patients are not going to increase their cardiac output despite the use of the device. Of course in some instances one could argue that the only way one can know if that is true is to try it. Speckle tracking echo may be useful in this instance.

It is a bit of a trick trying to decide what is causing the poor functionality of the patient and probably should be the responsibility of the patient ’ s physician based on their consultants opinions. Remember a consultant is a consult to the patient ’ s physician,not to the patient and the family.

Conclusion

1. Among the many issues facing the patient ’ s physician, the real issues are chronologic and physiologic age and frailty of the patient and how the patient’ s physician decides on palliative care and hospice care for the patient.

2. Patients and families seem to be confused by“ teams” that visit these patients. I think it ’ s really important for the patient and the family to know who the attending physician is and relate specif cally to that individual about such important matters.