About the Author: Dr Divya Sai Vanumu is a first year DNB (Palliative Medicine) resident at the Indo American Cancer Hospital, who is being trained under the guidance of Dr Praneeth Suvvari.
Dr Divya is a meticulous, patient and a committed young professional who has converted her passion into her profession.
Globally, the World Heart day is celebrated on 29th September. The day is celebrated to spread awareness about cardiovascular diseases which causes nearly half of all the non-communicable diseases in the world. The World Heart Federation has themed this years celebration around ‘Use Heart for every heart’ to urge people to use one’s heart to think differently, to make the right decisions and to act with courage to help others / another heart. When I read this, this resonated a lot with me as I have just begun my foray into palliative care. The below article, is my attempt to highlight the role of palliative care in cardiac patents.
Fatigue, breathing difficulties, disturbed sleep, chest discomfort /pain, weakness, dizziness are a few of the symptoms commonly seen in Cardiovascular diseases. These symptoms manifest in a variety of clinical profiles and remain to be a leading cause of death globally despite decades of advances in medical, surgical and device therapy. Just as any other chronic disease such as cancer, chronic respiratory diseases, HIV AIDS, or diabetes, a significant portion of adults (38.5%) with cardiovascular diseases are seen to be in need of palliative care services.
With the aging population on the rise, patients with serious cardiovascular disease increasingly suffer from noncardiac, multimorbid conditions and become eligible for interventions that palliate symptoms but also prolong life. Prolonging life with a constant disease burden leaves several of these patients to ask us, “When will I die?” or “What happens if I suddenly become short of breath?” or “What if I suddenly die during my sleep?”.
In several instances, patients with heart failure, in particular, tend to experience periods of stability interrupted by episodes of severe symptoms that can progress suddenly to the end stage. In these scenarios, we as palliative care professionals, can play a critical role in helping patients and their families, in formulating their advanced care plans and by helping them to be prepared for potential health emergencies that may unfurl over time. We can also assist the family in the decision-making process related to treatment options that will be available, well in advance rather than during a crisis.
There are however, several factors concerning modern death with cardiovascular disease, which complicates the end of life decision-making for patients with cardiac illnesses. The same is illustrated with the following case. A 49 year old male patient, with Ca Buccal mucosa, presented with decreased responsiveness and uncontrolled pain over the right side of his face. He also presented with decreased acceptance of feeds and a communicating wound on the right cheek. He had a history of Coronary Artery Bypass Grafting (CABG), a mitral valve replacement and was on tablet Nicoumalone (an anti coagulant). Further investigations revealed that his PT INR values were deranged with his overall disease condition showing poor prognosis. No further disease treatment was recommended and his symptom control therefore primarily relied on nursing issues, psychotherapeutic consultation along with managing his existing cardiac morbidity. His palliative care needs were assessed on the basis of the symptom burden of the treatment and his cardiac needs.
Management of cardiac patients, from the lens of a palliative care professional:
(1) The management of a patient with palliative care should be prognosis independent. This is especially critical in this the CVS disease patient population since the disease course is much more unpredictable in comparison to a disease such as cancer. The Palliative care team should ideally get involved early on in the disease course for adequate symptom management and to prepare for a smooth and timely transition to a hospice or for a dignified end.
(2) Each hospital admission is to be treated as a potential opportunity to discuss the palliative care needs of the patient and their caregivers. Palliative care professionals can help their cardiac patients and their caregivers navigate difficult treatment decisions such as whether to resuscitate the patient if his/her heart stops, or if a tube needs to be placed in the route to help the patient breathe better etc. Other distressing symptoms commonly associated with heart failure such as pain, breathlessness, fear ,insomnia etc. can also be addressed through medication and counselling support. All of these actions result in achieving the desired and improved outcomes not only during the disease course but also during the episodes of hospitalizations.
(3) It is important to educate the patient and the caregivers on when to seek help and to also improve medication adherence. Typically, these patients are expected to have a 6-month to 1-year mortality, in addition to constantly navigating a host of symptoms which include fatigue, difficulty in sleeping, shortness of breath, generalized weakness, nausea, sexual dysfunction, and bodily swelling. The fact that these patients are also usually on multiple lines of medications, deters them for complying to medication adherence. Despite showing temporary improvements due to optimization of medical management, there is a constant potential for a high recurrence rate of worsening symptoms and increased rates of hospital readmissions especially as the disease advances. Providing constant reassurance, helping them prepare an advance care plan and educating the patient and their caregivers regarding the disease course helps in reducing the caregivers anxiety, which is seen to be the biggest issue among caregivers of patients with heart diseases.
In conclusion, it is important for palliative care professionals to educate the patients and their caregivers about options for formulating and implementing advanced directives, and the role of palliative and hospice care services, before the condition of a patient with serious cardiac illness deteriorates to an extent where they cannot actively participate in decision making. One has to also be mindful of constantly re-evaluating these directives over changing clinical status and over time. It is also essential that we work alongside the patient and the caregiver to help them recognise the time point at which to transition from ‘improving survival’ to ‘improving quality of life’ so that a peaceful and dignified death can be ensured.