Tuesday, February 16, 2016

Palliative Care and Cardiology

by Staci Mandrola

As a palliative care doctor with a cardiologist husband, we have some interesting conversations after work. Recently John and I have been working on talks to engage cardiologists, cardiac APRNS, PAs, RNs and social workers in end of life issues particular to people living with heart failure. We both recognize from our work that management of distressing symptoms, discussion of goals of care and psychosocial/spiritual support for people living with heart failure and their families can do much more good if employed over years rather than days or weeks. Yet so often, palliative care is mistakenly viewed as only for dying people and that hospice care is only for dying people ready to admit they are dying and give up.

So my talk focuses on correcting misinformation: “When to say when: What is the difference between palliative care and hospice.” Ultimately, this is a challenge to change the perception that palliative care and hospice are about “when to say when.” I’m interested in hearing from others about strategies can we employ as palliative care teams and as cardiac teams to involve palliative care early in the life of a person dealing with heart failure, ideally from their first hospitalization.

Included in the talk is a case for discussion with two variables. A 62yo man with end stage heart failure is dependent on inotropes and not a candidate for heart transplant due to multiple comorbidities. His primary cardiologist had recommended a VAD (ventricular assist device). In question 1, this man is awaiting the arrival of his first grandchild; his heart’s desire is to meet her. In question 2, the man has completed his life’s work; he had confided in the hospital chaplain that “he is ready to go.”

I showed my idea to John and his comment was “no cardiologist is going to ask about that stuff!” It gave me pause to reflect - Do they? Should they? Should all persons who give healthcare to people with serious diseases elicit goals of care? How do we help foster this practice?

John’s talk is “ICDs: When we should…and when we shouldn’t.” ICDs (implantable cardioverter defibrillator). are life saving devices with proven value in selected people. Yet, the trials demonstrating benefit of ICDs enrolled mostly younger men without other serious diseases. We see people with heart failure over time are increasingly burdened with comorbidity. So how do we frame an ICD’s benefits and risks in older, debilitated people who have multiple comorbidities and a shorter expected lifespan? Maybe one helpful factor to elicit is returning to the issue of aligning therapy with a person’s goals.

Would there be value in having a palliative care consult before ICD implantation or generator change in this group of people?

I hope you join John and I as we host #hpm chat Wednesday night to talk about these issues in palliative care and cardiology.

Dr. Staci Mandrola is a wife, mom, grandma and palliative care doc working as part of a kick ass team at the Robley Rex VAMC.

T1 How do we encourage early palliative care consultation for people dealing with heart failure and dispel the myth that palliative care is only for actively dying people?

T2 Should cardiac teams routinely ask about goals of care?

T3 Should all people with heart failure have a palliative care consult before ICD implantation?

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 2/17/2015 - 9p ET/ 6p PT
Host: Dr. Staci Mandrola  and John Mandrola 

 and go to www.hpmchat.org for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org

For more on past tweetchats, see our archive here.

Photo credit: "Searching For the Answer" by Erica Frechman and Carolinas Palliative Care and Hospice Group - Used with permission under CC BY SA 2.0
Image Credit: #hpm chat Feb 17, 2016 by Christian Sinclair for Pallimed CC BY SA 2.0

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