MDNews - Minnesota

Assisting with End-of-life Decisions DE SPITE A DVA NCE S BEING made in the early diagnosis and management of the condition, there is ultimately no cure for heart failure. The role of the physician in heart failure management is to allow the patient to live a long, happy life with the condition — a commitment that includes broaching topics that may be uncomfortable, such as palliative and hospice care choices. "End-of-life decisions can be difficult for patients with chronic, complex medical conditions," says Eric Ernst, MD, FACC, cardiologist with University of Minnesota Health Heart Care and Medical Director of the University of Minnesota Health C.O.R.E. Clinic. "Patients have to decide what their wishes are, and we certainly respect that. At the C.O.R.E. Clinic, we work with families to fill out advance directives that allow patients to start these conversations." In Minnesota, advance directives (also known as health care directives) combine the living will and durable power of attorney for health care into a single document that appoints an agent to make healthcare decisions for the patient, leaves healthcare instructions within reasonable and legal medical practice, and details personal beliefs and wishes. Patients may also choose to use a Physician Orders for Life-Sustaining Treatment form, a legal document that communicates end-of-life wishes to medical personnel during an emergency. When patients are ready to transition to palliative care but do not meet the requirements for hospice treatment, the outpatient palliative care program helps patients and families through what can be a difficult time. For patients who have been receiving interven- tional care for congestive heart failure, advanced heart failure may require re-evaluation of treatments and devices originally intended to improve longevity and quality of life. Implantable cardioverter defibrillators and mechanical heart pumps may no longer provide the same benefits, though the discomfort sometimes associated with these devices remains. Inpatient and home-based hospice programs allow families to receive necessary services when the time is right. Those are the types of topics families and patients can discuss in-depth with team members at the C.O.R.E. Clinic. All members understand the sensitive nature of advanced heart failure and strive to act as a united resource during these difficult times. MANAGING ARRHY THMIAS In addition to addressing heart failure directly, heart rhythm problems are part of standard evaluation and treatment at the C.O.R .E. Clinic. "Electrica l problems ca n of ten worsen congestive hea r t fa i lure by compromising pumping f unction a nd causing uncontrolled heart rate," says Dr. Ernst. "Knowing how and when to engage electrophysiolog y exper ts to help ma nage these conditions with medication or device therapy improves symptoms and morta lity for patients with heart failure." A rrhy thmia s such a s atria l fibrillation respond well to medications. More complex ventricula r a rrhy thmias may be life threatening, a nd drugs do not a lways help. In these cases, it is important to implant defibrillators or pacema kers to circumvent potentia lly catastrophic events. Recurrent ventricular arrhy thmias not stabilized by implanted devices may require treatment with ablation. LONG-TERM MANAGEMENT Once patients are stable and on optima l medica l and device therapy, routine follow-up o¦ce visits provide the necessary level of care for most patients. However, some stable patients may diverge from their treatment courses or develop worsening symptoms. When necessary, patients may be brought to the clinic for urgent outpatient management with intravenous medica l therapy. One of the key components of the C.O.R .E. Clinic is ensuring patients maintain a robust relationship with their primar y care provider throughout the treatment process. According to Dr. Ernst, ha lf of a ll patients admit ted to the hospita l due to congestive heart failure have at least five other major medica l diagnoses. W hen patients work with their primary care provider to address other medical issues, it becomes easier to properly manage congestive heart failure. Pursuing cooperative collaboration, preventive disease manage- ment and personalized relationships with patients allows C.O.R.E. Clinic providers to positively impact the lives of patients, even when they are faced with complex diagnoses. ■ 0 9 M D N E W S .C O M /// M D N E W S M I N N E S O TA ■ 2 017

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