Palliative Care Approach to Chronic Diseases: End Stages of Heart Failure, Chronic Obstructive Pulmonary Disease, Liver Failure, and Renal Failure

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Key points

  • Palliative and hospice services are underutilized by end-stage noncancer patients.

  • Patients with chronic end-stage disease have unique symptom management needs, and their management is a necessary skill for primary care physicians.

  • Uncertainty makes advance care planning difficult, but prognostic tools are available. Discussions should focus on defining and preserving a minimum quality of life.

  • Early hospice referral could benefit patients with symptomatic chronic end-stage conditions.

End-stage heart failure

Heart failure (HF) is a syndrome of reduced cardiac output resulting in fluid overload, edema, breathlessness, and fatigue.1, 2 HF is caused by structural or functional defects, commonly ischemic heart disease, toxins, infectious endocarditis, valve disease, systemic or pulmonary hypertension, arrhythmias, or chronic volume overload as seen in renal failure.1 Often the cause is multifactorial or idiopathic. More than 6.5 million American adults are living with HF, a number expected to increase

End-stage chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) encompasses the illnesses emphysema and chronic bronchitis, both progressive respiratory conditions characterized by incompletely reversible airflow obstructions from inflammation and parenchymal destruction.29 The most common cause by far is smoking; other causes include other toxic exposures, severe recurrent infections, and inherited conditions, such as alpha-1 antitrypsin deficiency (A1AD).29, 30 COPD affects 12 to 15 million American adults with

End-stage renal disease

Progression of patients to end-stage renal disease (ESRD) from chronic kidney disease (CKD) is difficult to predict. Many patients with the disease will remain in CKD I–V, whereas some may progress to ESRD. CKD is considered to be present in patients with glomerular filtration rate (GFR) less than 60 mL/min, whereas ESRD can be recognized in patients with GFR less than 15 mL/min. Quite often, patients with CKD are at higher risk of mortality associated with cardiovascular disease because the

End-stage liver disease

End-stage liver disease (ESLD) is typically seen in patients with liver failure or decompensated cirrhosis. Patients with decompensated cirrhosis display signs and symptoms of liver failure, including variceal bleeds, ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS).87 ESLD is considered the 12th leading cause of death in the United States, accounting for 40,326 deaths in 2015.88 Cirrhosis can also have several causes, including hepatitis B (15%), hepatitis C

Hospice for chronic conditions

Uncertainty over when to refer patients to hospice is often cited as one of the barriers to earlier hospice referral.103 The authors recommend partnering with local hospice medical directors or palliative care teams where available to assist in a consultative role to identify patients who may benefit from early hospice referral. Published hospice criteria for end-stage conditions are only a guideline for when to consider referral; however, not meeting these criteria is not a contraindication to

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    Disclosures: The authors have nothing to disclose.

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