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Flashcards in CHF review Deck (61)
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1
Q

Heart failure in women stats?

A
  • HF contributes to 35% of total female CVD deaths
  • women have more comordities - more HTN, valvular disease and thyroid dysfxn, less obstructive CAD, DM strong risk for CAD and HF in women, LVH increase RF for death in women
  • BNP over 500 more predictive of death in women
  • women w/ acute HF have more preserved EF (2x men), clinical course more benign
  • benefit more from CRT, donate 46% of tx heart and receive 36%, more complications w/ VAD implantation
2
Q

Definition of HF?

A
  • complex, heterogenous, and progressive syndrome characterized by structural and/or fxnl abnormalities in cardiac contraction, consequent adverse neuro-hormonal adaptations and remodeling and co-morbidities that collectively alter myocardial fxn, fluid regulation, respiration, and perfusion and overall hemodynamic stability
3
Q

Etiologies of HF w/ reduced EF?

A
  • non-myocardial: Valvular disease - AS, AR, MR, MS
  • high output: anemia, AV fistula
  • myocardial: HTN, CAD, DM, dilated cardiomyopathy, infiltrative myopathy
4
Q

Etiologies of of HF w/ preserved EF?

A
  • non-myocardial: valvular disease, postcardial constraint - constriction, tamponade
  • high output: anemia, AV fistula
  • myocardial:
    HTN, CAD, diabetes, cardiomyopathy, ionfiltrative myopathy
5
Q

What are unusual causes of cardiomyopathy?

A
  • hypertrophic obstructive cardiomyopathy (HCM) - LV myocyte hypertrophy - genetic
  • AL amyloid cardiomyopathy - LVH w/o other causes - very poor prognosis
  • myocarditis - inflammatory disease from infectious or noninfectious process
  • Tachycardia induced cardiomyopathy - systolic or diastolic dysfxn due to rapid and/or irregular arrhythmia
  • Takotsubo cardiomyopathy: broken heart syndrome - transient apical ballooning syndrome post severe stress
  • peripartum cardiomyopathy - low EF heart failure in last month of preg to 5 months post delivery
6
Q

Co-morbid conditions assoc w/ HF?

A

up to 40% of HF pts have 5 or more chronic conditions -

  • anemia
  • gout
  • HTN
  • renal dysfxn
  • lung disease - sleep -disordered breathing
  • rapid or irregular dysrhythmias
  • diabetes
  • thyroid disorders
7
Q

Neuro-hormonal mechanisms and compensatory mechanisms in HF?

A
  • poor ventricular fxn/myocardial damage (post MI, dilated cardiomyopathy) -
  • leads to HF - this leads to decreased stroke volume and CO - this leads to neurohormonal response - this leads to activation of sympathetic sytem and RAAS - vasoconstriction, and sodium and fluid retention - increased vasopressin and aldosterone - this leads to further stress on ventricular wall and dilation (remodeling) - leads to worsening of ventricular fn - further HF
8
Q

2 diff types of remodeling inf HF?

A
  • hypertrophy (preserved EF heart failure) - LVEF over 50%

- dilation (reduced EF HF) - - LVEF less than 40%

9
Q

What is HFpEF?

A
  • increasing prevalence
  • HF sxs in those w/ LVEF over 50% or near normal LVEF (41-49%) - incidence about 50% of HF pt pop
  • clinical features of volume overload - decreased activity tolerance
  • morbidity/mortality nearly same as those w/ low EF heart failure
  • HFpEF almost always assoc w/ diastolic dysfxn -
    diastolic dysfxn: increased LV wall stiffness and decreased compliance/impaired relaxation, decreased CO
  • pulmonary HTN almost always present, RV dysfxn equal to or greater than 25%
10
Q

3 stages of diastole?

A
  • isovolemic (active) relaxation and rapid early filling (reqr ATP)
  • diastasis (passive) filling: - dictated by how compliant the ventricle is, there is slowed LV relaxation and rise in LV diastolic pressure, stage worsens w/ age
  • active filling during atrial contraction, dependent on LV diastolic pressure
  • all phases affected by preload, afterload, HR and contractility: systolic flow greater than diastolic flow until diastolic dysfxn due to stiff ventricle and decreased atrial emptying
11
Q

Grading of diastolic dysfxn?

A
  1. grade 1: impaired relaxation (suckers - normal DF and mild DD)
  2. grade 2: pseudomonal, usually concomitant LAE, LVH, and/or decreased LVEF
  3. grade III/IV: restrictive/constrictive - diff b/t III and IV is reversibility w/ medical therapy
    (grade II, III/IV: pushers - impaired LV relaxation, increased LV stiffness, increased LA pressures
12
Q

What is cardiac remodeling - (HFrEF)?

A
  • dilation- compensate for poor cardiac output, ventricle dilates, becomes thinned and weakened
  • LVSD: impairment of LV myocardial contraction
  • EF less than 40%
  • decreased stroke volume
  • decreased cardiac output
  • backward failure due to decreased contractility, fluid buildup, engorgement of systemic veins
  • forward failure: secondary to inadequate cardiac output resulting in decreased perfusion to vital organs
13
Q

Definition of HFrEF?

A
  • EF: less than or equal to 40%

- also called systolic HF

14
Q

Definition of of HFpEF?

A
  • EF: 50% or greater, diastolic HF
15
Q

Definition of HFpEF, borderline?

A
  • 41-49%

- outcomes similar to those of pts w/ HFpEF

16
Q

Definition of HFpEF, improved?

A
  • over 40%

- subset of pts w/ HFpEF previously had HFrEF.

17
Q

PP of arrhythmias?

A
  • weakened heart susceptible to arrhythmias
  • contribute to sxs and increased risk of sudden risk
  • AF: can lead to acute decompensated state, common cause of sxs - fatigue, dyspnea, especially in preserved EF pts
  • ventricular arrhythmias and bradycardia primary causes of syncope and sudden death
  • factors that contribute to arrhythmias: cardiac chamber enlargement, conduction system and anatomical heart abnormalities, adaptations of SNS, adverse responses to meds, electrolyte abnormalities
18
Q

HF disease progresion: ACC/AHA stages? Tx?

A
  • A: high risk - HTN, CAD, diabetes, family hx of cardiomyopathy - tx: HTN and lipids, smoking cessation, exercise, limit ETOH, ACEI
  • B: asx LVD: previous MI, LV systolic dysfxn, asx valvular diseaes - tx: plus ACEI, BB
  • C: sx HF: known structural heart disease, SOB and fatigue, reduced exercise tolerance - tx: plus ACEI, BB, diuretics, digoxin, aldosterone receptor antagonists, dietary salt restriction
  • D: refractory end stage: marked sxs at rest despite max medical therapy - tx: plus inotropes, transplant, VAD
19
Q

New York heart assoc fxnl classification?

A
  • class I: minimal (ordinary physical activity doesn’t cause undue sxs, no limitations)
  • class II: mild (ordinary activity causes sxs, no strenous exercise)
  • class III: moderate (less than ordinary activity causes sxs, activity limited to ADLs)
  • class IV: severe (sxs w/ any physical activity)
20
Q

CV status assessment involves what?

A

Broken down into 2 parts:

  • determination whether pt is wet or dry by assessing fluid status and congestion (indicates elevated filling pressure)
  • determination of whether pt is warm or cold by assessing indicators of perfusion
  • combo of these parameters equal 4 possible hemodynamic profiles
21
Q

Signs/sxs of congestion (wet) Heart failure:

A
  • orthopnea/PND
  • JVD
  • ascites
  • edema
  • rales (rare in HF)
  • S3
  • hepato-jugular reflex
22
Q

Possible evidence of low perfusion (cold)?

A
  • narrow pulse pressure
  • sleepy/obtunded
  • low serum sodium
  • cool extremities
  • hypotension w/ ACEI
  • renal dysfxn
23
Q

What questions should you ask in H and P?

A
  • SOB: at rest or exertion, waken you from sleep, increasing w/ daily activities now as opposed to 1 month ago, 6 months ago
  • cough:
    is it productive, non productive, worse w/ exertion or when lying down, taking ACEI
  • CP: sharp, dull, stabbing, localized, radiating to jaw, teeth, arms, accomp by diaphoresis, SOB, N/V, w/ or w/o exertion
    -palpitations: duration and description, accomp by dizziness, LOC, shock from ICD
  • dizziness, lightheadedness, syncope: does it occur w/ position changes, while bending over, accomp by palpitations, LOC
  • abdominal fullness: wt change, experiencing RUQ tenderness, feeling of pressure
  • dietary habits: is salt added to meals, processed meals, canned foods, restaurants
  • edema: resolve at noc, skin painful or seeping
  • sleep: able to lay flat, frequency of urination
  • mentation: diff thinking, concentration
  • substance abuse: smoking, ilicit drugs, ETOH
  • past disease/tx: recent infections, sxs, tx, rheumatic fever, chemo
24
Q

Dx testing for HF?

A
  • CXR
  • Lab (include BNP)
  • ECG
  • echo, MUGA, MRI (infiltrative)
  • risk stratification for CAD:
    noninvasive imaging: nuclear stress test, stress echo
    invasive imaging: cardiac cath
  • risk stratification for HF
25
Q

Lab testing done initially and as indicated?

A
  • renal fxn and electrolytes; magnesium
  • BNP (ni clinical uncertainty, to est prognosis/disease severity)
  • blood glucose: A1C
  • CBC w/o diff
  • TSH
  • serum albumin
  • LFTs
  • lipid panel
  • proteinuria, RBCs)
  • uric acid
  • CXR in suspected or new onset HF
26
Q

Assoc BNP with probable HF?

A

pt presents w/ dyspnea - PE, CXR, ECG, BNP level

  • BNP: less than 100 - HF very improbable
  • 100-500: clinical suspicion of HF or past hx of HF - 90%
  • BNP: over 500 - HF very probable (95%)
27
Q

General management of HF?

A
  • stabilize pt w/ diuretic
  • stabilize disease: ACEI + BB
  • can also use digoxin to tx residual sxs if needed
28
Q

Guidelines for diuretics use?

A
  1. diuretics: used in sx pts to reduce fluid, no survival benefit
  2. increase initial dose as necessary to relieve congestion. After effective diuretic is achieved w/ short acting loop diuretics, increasing admin to 2-3x a day may provide more diuresis w/ less physiologic upset than a larger single dose
  3. torsemide and bumetanide which have higher bioavailability can be effective in pts w/ por absorption of oral meds or erratic diuretic effect, esp in right sided HF and refractory retention despite high doses of other loop diuretics
  4. IV diuretics may be necessray to relieve congestion
  5. add chlorthiadone or metolazone when high dose loop diuretic not effective - avoid chronic use
  6. selected pts may be educated to adjust daily dose of diuretic in response to wt gain from fluid overload
  7. diuretic refractoriness may represent pt non-adherence, a direct effect of diuretic use on kidney or profession of underlying cardiac dysfxn
  8. observe for SEs including electrolyte abnormalities, sx hypotension, renal dysfxn, or worsening renal fxn
29
Q

Use of ACEIs? Examples?

A
  • captopril, enalapril, lisinopril, ramipril
  • inhibits conversion of angiotensin I-II (dilates blood vessels and decrease SVR and BP)
  • reduces morbidity and mortality
  • improves cardiac fxn, sxs, and clinical status
  • all pts w/ LVEF less than 40% should receive an ACEI, ARBs used when intolerant of ACEI (Diovan, Atacand, losartan) for reasons other than hyperkalemia, renal insufficiency
30
Q

CIs of ACEI/ARBs?

A
  • hx of intolerance, CI in pregnancy
  • serum K+ greater than 5 mEq/L
  • sx hypotension: asx SBP less than 80 or sx orthostatic BP when pt is euvolemic
  • caution in pts w/ Cr over 3.0 mg/dL
31
Q

Surveillance for pts on ACEI/ARBs?

A
  • monitor BP, renal fxn and K+ w/in 1 wk of initiation of therapy and w/ med titration
  • modify Rx if increase in Cr of 0.5 mg/dL, if BUN/Cr increase less than 50%, maintain dose, if increases by 100% switch HYDZ/ISOS
  • assess vol status if pt develops renal insufficiency or hypotension
  • physicians/pt may need to toelrate mild to moderate renal insufficiency to maintain ACEI/ARB therapy
32
Q

Use of BB in HF tx?

A
  • metoprolol XL, carvedilol, bisoprolol. toprol and zebeta may be better tolerated in pts w/ SBP
  • start when pt isn’t significantly congested - titrate q 2 wks, slower titration may be required
  • 1st line therapy:
    increase LVEF
    global sx improvement
    decrease hosp and mortality
    decrease sympathetic tim: antiarrhythmic activity benefit
  • all pts w/ stable HF w/ LVEF less than 40% should receive a BB, beneficial in those w/ or w/o DM2 or CAD, ok use in COPD, PAD
33
Q

SEs w/ BB up-titration?

A
  • coreg: vasodilator SEs:
    usually temporary, sep dosing of BB and ACEI, if persistent, reduce vasodilators
  • fluid retention:
    increase diuretic to restore baseline wt, delay up titration until wt is at baseline
  • bradycardia/AV block:
    check dig level, if persistent, consider cardiac pacing
34
Q

When is digoxin useful?

A
  • beneficial in pts w/ HFrEF, to decrease hospitalization for HF, no survival benefit
  • HF pts w/ AF, BB therapy usually more effective than digoxin in controlling ventricular rate, especially during exercise
  • don’t give in sig sinus or AV block unless pt has permanent pacemaker
  • reduce digoxin dose by 1/2 when used w/ amiodorone or BB therapy
  • lean body mass and impaired renal fxn can increase dig levels, toxcity may occur w/ lower dig levels w/ hypokalemia, hypomagnesmia, or hypothyroidism
  • ## most often dose should be 0.125 mg qd
35
Q

Use of Hydralazine/Nitrates?

A
  • Isosorbide dinitrate: NO donor, large and small artery dilator, venous dilator
  • Hydralazine: antioxidant (inhibits destruction of NO), arteriolar dilator, NO enhancer
  • combo of HYDZ/ISOS recommended to improve outcomes:
    african-americans w/ HFrEF NYFC III-IV HF on optimal therapy w/ ACEI/ARB, BB
  • non-african american pts w/ HFrEF who remains sx despite optimized therapy
  • non african-americans, HYDZ/ISOS can be useful to decrease morbidity or mortality in pts w/ current or prior sx HFrEF who cannot be given ACEI/ARB b/c hypotension, renal insufficiency, unless CI
36
Q

Use of aldosterone antagonists?

A
  • aldosterone has adverse effects on cardiac structure and fxn
  • low dose spironolactone/eplerenone (aldosterone antagonist) reduces mortality in moderate to severe heart failure pts
  • addition of aldosterone antagonist recommended in NYHA-FC II-IV and EF less than 35% who can be carefully monitored for renal fxn and normal K+ level
37
Q

PT selection for aldosterone antagonists?

A
  • pt already on ACEI/ARB and BB therapy
  • K+ less than 5, Cr less than 2.5 in men and 2.0 in women
  • aldosterone antagonist in absence or concomitant loop diuretic not recommended
  • monitor renal fxn and K+
  • diarrhea or other cause of dehydration should be addressed urgently, stop aldosterone antagonists during dehydration or while loop diuretics is interrupted
38
Q

WHat is Entresto? Indications, MOA?

A
  • new CHF drug
  • decreases CV deaths and morbidity from HF
  • indication: chronic HFrEF, HYHA-FC II-IV, used w/ other HF meds in place of ACEI or ARB
  • MOA: sacubitril - inhibits breakdown of vasoactive peptides including BNP, bradykinin - results in natriuresis, diuresis
    valsartan: ARB, antagonizes angiotensin II at ATI recepotr, decrease in ATII dependent aldosterone release, increase vasodilation
  • monitor: BP, vol status, BUN/SCr
  • adverse effects: decrease in BP, hyperkalemia, cough, dizziness, ARF, angioedema
39
Q

What is Corlanor? Indications? CI, SE?

A
  • just approved in 04/15
  • reduces slow diastolic depolarization phase
  • indications:
    reduce risk of hospitalization for worsening HFrEF
  • SR w/ HR resting of over 70 bpm on max BB or CI for BB use
  • CI: ADHF, BP: less than 90/50, SSS, SA block, CHB, HR resting of less than 60, severe hepatic impairment
  • relative CI: negative chronotropes - amiodarone, digoxin, increased bradycardia
  • SE: AF, bradycardia, HTN, dizziness, fatigue, CHB
40
Q

Other meds used for CHF?

A
  • vasodilators (nitro)
  • inotrope infusion:
    dobutamine: stim B-adrenergic receptors, can’t be used w/ B blcokers, dopamine: NE release, promotes diuresis on receptors in renal vasculature
  • anticoag
  • dysrhythmics
  • lipid management, omega 3
  • screen for sleep disordered breathing
41
Q

Managing co-morbidities of HFpEF dysfxn?

A
  • control BP (less than 130/80)
  • rate control in AF
  • alleviation of MI
  • managemnt of DM2
  • screen for sleep disordered breathing
  • Na+ restriction
42
Q

Tx for R sided heart failure?

A
  • O2 therapy: increase RV fxn (SV), decrease RV after load, increase survival
  • inhalers: CPAP if indicated
  • digoxin: tx for rhythm problems that occur in R atria
  • diuretics
  • R sided HF often accompanied w/ preserved LV heart failure, occasionally low LVEF heart failure
  • tx sfor pulmonary HTN
43
Q

Drugs that may hurt HF?

A
  • antiarrhymic drugs increase arrhythmias and negative inotropic affects (amiodorone doesn’t have these effects)
  • megestrol acetate - may exacerbate HF
  • NSAIDs, including COX2 inhibitors, ibuprofen, indocin
  • corticosteroids - cause Na and fluid retention, Dexamethasone causes min Na retention and may be safer alt
44
Q

Early intervention: surgeries and medical devices for HF?

A
  • CABG, TAVR
  • cardiac transplantation
  • CRT (bi ventricular pacing)
  • ICD
  • LVAD - destination or bridge
45
Q

VADs characteristics?

A
  • device sufficient to replace/assist pumping fxn of LV, rx for end stage HF
  • heartmate, Jarvik, heartware
  • MRI CI
  • continuous flow like water out of hose
  • narrowed or no pulse pressure
  • in case of emergency - get LVAD running if not, CPR can only be done if LVAD not running and cant be started
  • defibrillation can be done
  • complications: arrhythmias, RHF, hypovolemia, bleeding, infection, thrombus/stroke
46
Q

Recommended Na restriction?

A
  • Na homeostasis alt in HF pts
  • HFrEF: study showeed lower Na intake assoc w/ worse outcomes in pts w/ HFrEF
  • HTN, LVH and CVD: 1500mg/day for most pts, stage A and B HF
    stage C and D: less than 3 gm/day for sx improvement
  • food processing contains majority of the source of salt
47
Q

Fluid restrictions for HF pts?

A
  • limit fluids in hyponatremic pts (gen 130 mg/dL or less)
  • common recommendation - 6-8 cups/day
  • any food that melts at room temp is considered a fluid
  • gelatin desserts, and frozen deserts (melted less vol than frozen)
48
Q

Sleep disordered breathing assoc w/ HF?

A
  • 75% of HF pts have poor sleep pattern
  • SDB: cheyne stokes - Central sleep apnea - CSB-CSA:
    consequence of HF, more common in decompensated HF, more common in men, AF, HFrEF, white, ischemic
  • OSA:
    possible cause of HF, more common in HFpEF (50%)
    linked to increased CV morbidity and mortality
    RFs: obesity, male gender, post menopausal women, neck larger than 16 inches, in men and 15 in women
  • CSB-CSA and OSA often co-exist - exacerbate MI, increase risk for arrhythmias (AF, ventricular arrhythmias, and SCD), fatigue, excessive daytime sleepiness, mood disturbance, decrease daytime FC, may decrease QOL, may worsen cog fxn, CSB-CSA not assoc w/ cognitive decline
49
Q

Use of CPAP - in tx of SDB?

A
  • can be beneficial to improve heart fxn and fxnl status in HF pts w/ sleep apena
  • decrease apnea-hypopnea index, increase nocturnal O2, increase LVEF, decrease NE levels, increase 6 min walk test distance
  • berlin questionnaire: screen for SDB
50
Q

Wt correlation w/ HF?

A
  • HF pts w/ BMI 30-35 kg/m2 -lower mortality, morbidity than normal range
  • wt loss:
    cachexia - predicts worse prognosis, wt loss of more than 5% in 12 months or BMI of less than 20 w/ muscle wasting, fatigue, anorexia, anemia, low albumin, increased inflammation markers
  • morbidly obese pts may have worse outcomes
  • U shaped distribution curve suggested - mortality greates in cachectic pts, lower in normal, overt, and mildly obese pts and higher in severely obese pts
51
Q

Exercise for HF pts?

A
  • exercise training (or regular physical activity) is recommended as safe/effective for pts w/ HF who are able to participate to improve fxnl status
  • cardiac rehab can be useful in clinically stable HFrEF (less than 35%) pts to improve fxn; capacity, exercise duration, QOL, mortality
  • stop exercise: rapid pulse, CP/pressure, unusual SOB, irregular or slow HR, weakness, faintness or dizziness, extreme fatigue
52
Q

Possible mechanisms through which HF self care influences health outcomes?

A
  • neuro-hormonal deactivation: maintenacne of optimal vol, effectiveness of meds: NE, RAAS
  • limited inflammation: decrease in shear mechanical stress, decrease in tissue ischemia, decrease in TNF, CRP
  • avoidance of pharm: decrease likelihood of high dose diuretics, BB reduction
  • limited myocardial hibernation - decreased wall tension, decreased ischemic events, increased sub endocardial perfusion, increased myocardial viability
53
Q

Self care for HF?

A
  • meds: take, don’t stop
  • follow lower Na diet: ADA. low fat diet, know how to shop, cook, eat out, adapt family customs
  • monitoring sxs of worsening HF: sx recognition and what to do/whom to call, which sxs are impt, when to act w/ sxs escalation
  • daily weighing
  • phsyical activity
  • alcohol, smoking, fluid intake
54
Q

When should hosp be considered w/ CHF?

A
  • worsened congestion even w/o dyspnea
  • signs and sxs of pulmonary or systemic congestion even in absence of wt gain
  • major electrolyte disturbance
  • assoc comorbid conditions (pneumonia, PE, diabetic ketoacidosis)
  • sxs suggestive of TIA or stroke
  • Repeated ICD firings
  • previously undx HF w/ signs/sxs of systemic or pulmonary congestion
55
Q

Emergency department care for CHF?

A
  • challenges: many co-morbidities
  • SOB pie: pneumonia, influenza, COPD, HF
  • tx: O2, lasix, nitrates, inotropes, admission
56
Q

MOA of basic HF drugs?

A
  • diuretics: reduce fluid vol
  • vasodilators: decrease preload and or afterload
  • inotropes: augment contractility
57
Q

Top 3 predictors of mortality for pts admitted w/ acute CHF?

A
  • BUN, SBP, SCr
58
Q

When can HF pt leave hosp?

A
  • near optimal volume: stable wt, VS, adequate urine output, absence of crackles, S3, edema, HR under 100
  • stable after transition from IV to oral diuretics for at least 24 hrs
  • exacerbating factors addressed (non-adherence w/ diet, meds)
  • LVEF documented
  • near optimal med therapy - ACEI, BB, diuretic
  • pt and family ed initiated
  • FU clinic visit scheduled ideally w/in 7 days after d/c
  • additional criteria for advanced HF: no IV vasodilator or inotropic agents in 24 hrs, stable on oral meds for 24 hrs, ambulation b/f discharge, plan for post-d/c management at home
59
Q

What are the factors that put HF pts at highest risk for readmission?

A
  • advanced age
  • comorbidities: renal disease, DM2, COPD, HF severity, psych dx (esp depression), frailty
  • low education/literacy level
  • prior admissions for HF
  • pt behaviors: lacking self care skills, adherence issues, substance abuse
  • not ready for D/C
  • absence of friends, family, religious, social, and financial support, access to transportation
60
Q

What are the 3 phases of progressive HF?

A
  • chronic disease management: dx, focus on extended survival, concurrent palliation of sxs, promoting self care (NYFC I-III)
  • supportive and palliative care phase: approp when pts reqr recurrent hospitalizations, focus on promoting comfort and QOL, palliation of sxs and advanced care planning (NYFC III-IV)
  • terminal care phase: pt has poor response despite max appropriate intervention (renal insufficiency, hypotension, fatigue, cachexia, diuretic resistance), focus on clarificaiton of tx decisions, advanced directives, comfort, QOL, support pt, family, prep for EOL and bereavement
61
Q

What are barriers to use of palliative care? Proposed Model of palliative care?

A
  • traditional model of medicine: cure and comfort are mutually exclusive, EOL discussions uncommon until days b/f death, half of DNR orders were written w/in 24 hrs of death
  • proposed integrated model of palliative care:
  • focus on sxs dosen’t preclude cont aggressive tx of disease
  • illness progresses, palliative care assumes larger role, is replaced w/ hospice at EOL
  • continues w/ bereavement care for survivors