Article

El paciente con insuficiencia cardiaca terminal: dificultad en la identificación y en la toma de decisiones

Revista multidisciplinar de gerontología, ISSN 1139-0921, Vol. 14, Nº. 2, 2004, pags. 90-96
Source: OAI

ABSTRACT La insuficiencia cardiaca (IC) es una enfermedad cardiovascular con una pravalencia, incidencia y mortalidad en continuo aumento. Las pautas actuales óptimas de tratamiento consiguen sólo retardar su evolución pero no detener su progresión. La IC es una enfermedad con una alta mortalidad, incluso ya en momentos cercanos al debut. Aproximadamente al 40% de las muertes por IC serán debidos a progresión de la enfermedad a fase terminal, no obstante al curso evolutivo da la IC es difícil da predecir, por lo que identificar a los pacientes que están en fase terminal de la enfermedad en muchas ocasiones no se consigue. Frecuentemente no existe la sensación de padecer una enfermedad terminal ni en el paciente ni en la familia, ni muchas veces tampoco en el personal sanitario, que no reconoce la proximidad da la muerte, con lo que al paciente acaba falleciendo con tratamiento activo para la IC y que muchas veces será fácil. Las guías da las diversas sociedades médicas sobre el manejo da la IC daban incluir en sus capítulos información sobra los pacientes con IC terminal e intentar definir unos criterios pronósticos de la IC terminal. Es necesario realizar un esfuerzo por parte de todos los profesionales de la salud para mejorar la identificación y manejo de los pacientes con IC terminal.

0 Bookmarks
 · 
126 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Congestive heart failure is a major cause of mortality and morbidity in the elderly but the disease impact on the oldest and sickest population has not been defined. To review the mortality and hospital readmission rate of institutionalized elderly persons with congestive heart failure and to examine the relation of baseline characteristics to subsequent clinical outcomes. This was a retrospective analysis based on chart review of 231 residents of the Philadelphia (Pa) Geriatric Center (63 congregate housing tenants and 168 nursing home residents) 80 years and older, hospitalized with congestive heart failure from 1989 to 1995. Patients' demographic data and clinical, electrocardiographic, and echocardiographic findings were obtained from their initial (index) hospitalization records. Subsequent outcomes were obtained from their outpatient (nursing home or office) records. Thirteen percent died during the index hospitalization but the total mortality during the follow-up period was 87%. One hundred forty-six patients (63%) died in the first year with a mean +/- SD survival of 4+/-4 months and a readmission rate of 3.9 per patient-year. Eighty-five patients survived the first year with a readmission rate of 1.2 per patient-year and 54 patients subsequently died, with a mean +/- SD survival of 28+/-12 months. The first-year decedents and survivors were comparable in sex, age, medical history, and electrocardiographic findings. However, patients who died in the first year, compared with survivors, were more likely to be nursing home residents (81% vs 59%), have New York Heart Association class IV heart failure (54% vs 32%), have impaired left ventricular function by echocardiogram (53% vs 32%), and have renal insufficiency (32% vs 11%). Very elderly persons with congestive heart failure had a guarded long-term prognosis. Nursing home residency, class IV heart failure, impaired left ventricular function, and renal insufficiency were associated with higher risk for early death and repetitive hospitalizations.
    Archives of Internal Medicine 01/1998; 158(22):2464-8. · 11.46 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Many developed countries have seen declining mortality rates for heart disease, together with an alleged decline in incidence and a seemingly paradoxical increase in health care demands. This paper presents a model for forecasting the plausible evolution of heart disease morbidity. The simulation model combines data from different sources. It generates acute coronary event and mortality rates from published data on incidences, recurrences, and lethalities of different heart disease conditions and interventions. Forecasts are based on plausible scenarios for declining incidence and increasing survival. Mortality is postponed more than incidence. Prevalence rates of morbidity will decrease among the young and middle-aged but increase among the elderly. As the milder disease states act as risk factors for the more severe states, effects will culminate in the most severe disease states with a disproportionate increase in older people. Increasing health care needs in the face of declining mortality rates are no contradiction, but reflect a tradeoff of mortality for morbidity. The aging of the population will accentuate this morbidity increase.
    American Journal of Public Health 02/1994; 84(1):20-8. · 3.93 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Context Many individuals involved with care of the dying advocate expanding access to hospice care for persons with advanced lung, heart, or liver disease. However, to be eligible, these patients generally must have a prognosis for survival of less than 6 months.Objective To test the ability of currently available criteria to identify a population with a survival prognosis of 6 months or less among seriously ill hospitalized patients with 1 of 3 commonly fatal chronic diseases.Design Validation study using data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) phase 1 (June 1989-June 1991) and phase 2 (January 1992-January 1994), with a 6-month follow-up.Setting and Patients Consecutive sample of 2607 seriously ill patients from 5 US medical centers who were hospitalized with chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, and who survived to hospital discharge.Main Outcome Measures Descriptive and operating characteristics of 5 general and 2 disease-specific clinical criteria for identifying patients with a survival prognosis of 6 months or less, and 3 sets of combination criteria (broad, intermediate, and narrow inclusion) aimed at providing low, medium, and high thresholds for hospice eligibility based on National Hospice Organization guidelines.Results Seventy-five percent of the sample survived more than 6 months after hospital discharge; 44% expressed a preference for palliative care. Broad inclusion criteria identified 923 patients eligible for hospice care, of whom 70% survived longer than 6 months. Intermediate inclusion criteria identified 300 patients, of whom 65% survived longer than 6 months. Narrow inclusion criteria identified 19 patients, of whom 53% survived longer than 6 months. Sensitivities and specificities of the combination criteria were 41.7% and 66.7% (broad inclusion), 16.2% and 90.1% (intermediate inclusion), and 1.4% and 99.5% (narrow inclusion), respectively.Conclusions These data indicate that for seriously ill hospitalized patients with advanced chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, recommended clinical prediction criteria are not effective in identifying a population with a survival prognosis of 6 months or less. Figures in this Article Technological advances in medicine and improvements in public health have enabled Americans to live longer and to survive potentially life-threatening events such as childbirth, infectious disease, and injury. A result of these advances has been the emergence of serious chronic diseases as a major pathway toward death. Among the most common chronic diseases are chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and end-stage liver disease (ESLD). Together, these 3 diseases account for almost 2 million hospitalizations and more than 175,000 deaths annually.1- 2 In contrast to incurable metastatic cancer, in which there is often a marked decline in weight and function near the end of life,3 diseases involving chronic organ failure tend to have a more erratic course and to produce death at a time that is difficult to predict.4- 6 As a result, many patients with COPD, CHF, or ESLD never experience a time during which they are clearly dying of their disease. This observation has important implications for the treatment of patients with such diseases, especially with regard to their eligibility for hospice care. Hospice programs in the United States provide specialized medical and support services for the management of terminal illness, mostly in patients' homes. The Medicare hospice benefit covers comprehensive services, including home care, short-term inpatient care, and medication costs, and is paid at a daily capitation rate of approximately $100.7 Hospice care is also a covered benefit under most private insurance plans, managed care organizations, and state Medicaid programs.8 Hospice care has received widespread approval9- 10 and is increasing in popularity; in the last 5 years, annual growth in the number of patients receiving hospice care nationwide has averaged 16%.8 The few studies comparing hospice with other care at the end of life suggest that (1) patients11 and families are satisfied with hospice care, (2) patients have fewer regrets than nonhospice patients, and (3) patients receiving hospice care are more likely to die in a way that is consistent with their wishes.12- 13 Despite its advantages, however, hospice care serves a small portion of the dying population for only a short period of time. About 20% of patients who die in the United States receive hospice care.7 Most patients enrolled in hospice are dying of cancer, although the proportion of hospice admissions for other diseases has increased steadily in recent years.8 Under Medicare regulations, a beneficiary is eligible for hospice care coverage only if both the patient's attending physician and the medical director of the hospice certify that "the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course."14 Surprisingly, the precise meaning of this definition has never been explicated and remains unclear.15- 16 For example, the phrase "a life expectancy of 6 months or less if the terminal illness runs its normal course" could be interpreted to mean that among patients with similar prognosis, more than half would be dead within 6 months. Alternatively, the phrase could be interpreted to require a much higher degree of prognostic accuracy (eg, 80% or 90% of patients would be dead within 6 months). Aggregate Medicare survival data suggest that actual practice tends to reflect the latter, narrower interpretation.6 Only 15% of patients receiving Medicare hospice benefits survive longer than 6 months. The median survival of Medicare patients enrolled in hospice is under 40 days.17 Government regulators, too, may expect a high level of accuracy in predicting 6-month survival—not only in terms of aggregate patient data, but also at the level of individual patients. Fraud and abuse auditors acting for the Department of Health and Human Services Office of the Inspector General have begun investigating hospices and requiring repayment to Medicare for some patients who survived for more than 6 months.18 The Institute of Medicine's Committee on Care at the End of Life voiced its concern that regulators "may not understand the uncertainty inherent in projecting survival,"19 and that the Medicare prognosis provision "implies a degree of precision that does not exist."20 As the National Hospice Organization (NHO) has pointed out, "the Office of the Inspector General's intense scrutiny has had a chilling effect on appropriate referrals of terminally ill beneficiaries."21 The effect has been especially pronounced in patients dying of chronic conditions whose courses are difficult to predict.20 The comparatively predictable final course of cancer—with its 1- to 2-month phase of progressive decline at the end of life—is well suited to the hospice model of care.3 But for individuals dying of diseases other than cancer, access has been limited, in part because they rarely manifest a discrete phase of inexorable decline at the end of life.5 Nonetheless, many have suggested that hospice care be expanded to manage the care of persons dying of chronic diseases such as COPD, CHF, amyotrophic lateral sclerosis, and Alzheimer disease.22- 26 In an effort to clarify eligibility for hospice care among patients with CHF, COPD, and other serious illnesses, the NHO has drafted guidelines for determining prognosis in selected noncancer diseases.23 The guidelines were created by an expert panel after an extensive review of the medical literature concerning short-term mortality in noncancer diseases. They were intended as a starting point for determining patient eligibility under the Medicare hospice benefit, with the caveat that their accuracy would need to be validated by future research. Despite this, they have already been widely accepted and used. In fact, the Health Care Financing Administration has distributed NHO's guidelines to its fiscal intermediaries as a tool to assist in the claims process.27 These offices have, in turn, used the guidelines in developing the conditions under which Medicare coverage for hospice care is approved or denied.27 In this study, we applied a variety of potential criteria for determining prognosis, including those based on NHO guidelines, to an existing database28 to evaluate their accuracy in predicting death within 6 months among seriously ill patients with advanced chronic disease.
    JAMA The Journal of the American Medical Association 01/1999; 282(17):1638-1645. · 29.98 Impact Factor

Full-text (2 Sources)

View
50 Downloads
Available from
Jun 2, 2014