Dobutamine and milrinone acceptable for in-home hospice care
But high cost may prevent hospices from using them
Dobutamine has long been used to help patients suffering from heart failure. Cardiologists have used it and milrinone to help a weakened heart pump more efficiently. Unfortunately, it is not a cure for patients suffering from heart failure, leaving many eligible for hospice care after the heart has deteriorated beyond repair and a heart transplant is not an option.
But there is considerable debate over whether hospices can accept patients on dobutamine, which is marketed as Dobutrex, or milrinone, which is marketed under the name Primacor. For one thing, dobutamine, which is administered intravenously, is prohibitively expensive. Without the ability to seek reimbursement for the drug separate from Medicare’s per diem payment, a hospice could lose thousands of dollars per patient.
There also is concern over how appropriate it is to use these drugs in the home, given the amount of patient monitoring they require. Lastly, some question whether the use of these drugs fosters the principles of palliative care, which stress not only symptom management but also spiritual and emotional care.
Like many hospices around the country, officials at Hospice Caring Project in Aptos, CA, have been pondering these very same questions. Recently, the hospice has received requests from referring cardiologists to continue patients on dobutamine as the patients are moved from hospital care to hospice care.
"Dobutamine needs constant monitoring," says Salima Cobb, RN, BSN, community liaison for Hospice Caring Project. "At home, it would place a lot of pressure on the caregiver and hospice staff."
Hospice Atlanta had been receiving overtures from Atlanta’s Emory Clinic cardiologists regarding the use of dobutamine and milrinone, but the hospice had resisted because officials there believed that the drugs were an aggressive therapy that did not have a place in hospice care.
"We had always thought [dobutamine and milrinone] was an aggressive therapy, but after Emory talked to us about how it can be used in palliative care and that it was helping people feel more comfortable, we agreed," says Pamela Melbourne, RN, MN, director of clinical services for Hospice Atlanta. "We found that it wasn’t life-prolonging, but we couldn’t afford it."
For a time, Hospice Atlanta was able to experiment with in-home use of dobutamine and milrinone, with the cost of the drugs covered by Emory. But once funding ran out, hospice-eligible patients on dobutamine or milrinone could not be admitted to hospice. Instead, patients are admitted to their sister home care agency’s palliative care program, where the cost of the drug is reimbursable.
Potential patients of Hospice Caring Project who are on dobutamine were also diverted, says Cobb. If patients want to continue taking dobutamine, they cannot be admitted. To add to the patient’s difficulties, home care agencies in the area are unable to provide home infusion of dobutamine. The only alternative, says Cobb, is to refer patients to an inpatient facility where dobutamine can be administered.
For now, both Hospice Atlanta and Hospice Caring Project remain undecided about the future of dobutamine and milrinone use in their own facilities.
Symptom management capabilities’
Despite the reservations of some, there are others who say dobutamine is appropriate in the hospice setting, including some who provide in-home care. Some experts say the use of dobutamine in the home is a way to shift care from an inpatient facility to the hospice setting.
"Dobutamine does have some definite symptom management capabilities," says John Mulder, MD, vice president of clinical services and medical director of Alive Hospice in Nashville, TN. "In stabilizing hemodynamic parameters and enhancing cardiac function, it relieves dyspnea and improves functional capacity. So does milrinone. With that perspective, they are very much hospice-appropriate medications, if the goal is symptom control. Without question, in the process of this treatment, life may be prolonged. It may also be shortened in view of its arrhythmogenic potential. I suspect that the motivating factors in questioning the appropriateness of the drug relate to the cost. While a pragmatic consideration, this may obscure the potential for palliative benefit."
Knowing how the drugs are used is helpful in deciding whether to use dobutamine and milrinone in the hospice setting. The drugs are direct-acting inotropic agents whose primary activity results from stimulation of the beta receptors of the heart. In short, it helps the heart pump blood as if the body was undergoing vigorous exercise.
Both are indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractibility resulting either from organic heart disease or cardiac surgical procedure. The use of dobutamine is also a generally accepted practice as a cardiac stressing agent in echocardiography.
LMRPs provide clues for use
The dobutamine stress echo test involves taking dobutamine while being closely monitored. The medication stimulates the heart to simulate stress from exercising. The test is used to evaluate heart and valve function in those who are unable to exercise on a treadmill or stationary bike.
Additional indicators of how dobutamine and milrinone are supposed to be used can be found in local medical review policies (LMRPs). While LMRPs are used to determine reimbursement, they also illustrate what payers consider medically necessary use of drugs and procedures. Medicare carriers generally provide coverage for dobutamine and milrinone therapy only for those patients who have been accepted for heart transplant and require dobutamine or milrinone therapy while awaiting a donor heart.
Additionally, physicians and hospitals can seek reimbursement when dobutamine is used in cardiac stress testing and billed in conjunction with cardiac stress testing.
Perhaps even more relevant are Medicare regulations for home infusion of dobutamine for home care agencies. Home intravenous infusion is reimbursed under the following limited coverage criteria:
- when inotropic drug support is needed for patients awaiting cardiac transplantation;
- for patients who are unresponsive to all other forms of drug therapy;
- for patients who had a successful trial of the drug in an ICU environment with documented hemodynamic response;
- to control adverse arrhythmias;
- for management of patients with chronic congestive heart failure that has not responded to conventional means and who are not surgical candidates for transplantation.
Home use OK
The presence of guidelines for home infusion of dobutamine is an indication that there is significant experience with inotropic drugs at home. Because the drugs have been used in the home for several years now, there is enough evidence to show that they can be safely administered by nurses who have been properly trained, says Brad Stuart, MD, medical director for Sutter VNA and Hospice in Emeryville, CA.
Ruling out dobutamine and milrinone use because of a perception that they are not appropriate in the home is not a sufficient reason, Stuart says. Use in the home, however, is predicated on the notion that patients on dobutamine at home have been receiving the drug long before in-home use was begun. Because of the intricacies of starting a patient on dobutamine — chiefly, ensuring the patient responds well to the drug — hospices should not be expected to start dobutamine after hospice admission.
Use of dobutamine will cause other pressures on your staff. Additional training will be needed to educate nurses on how to monitor a patient during infusion of the drug and how to monitor a patient’s progress following administration of either dobutamine or milrinone, says Stuart.
Aside from the question of in-home appropriateness, the debate also raises the question of whether dobutamine is a life-prolonging drug. According to Stuart, inotropic drugs are both life-prolonging and life-shortening, depending on one’s perspective. In the short term, dobutamine and milrinone can prolong life. They can add days or weeks to the patient’s life.
Still, that isn’t a reason to rule out hospice use of dobutamine or milrinone, says Mulder. "The patient is going to die of heart failure whether or not the patient is on dobutamine," says Mulder. "Our goal in palliative medicine is to improve quality of life, and if dobutamine extends someone’s life for a few days and no other drugs are as effective in improving quality of life, then so be it."
Long-term use of dobutamine, Stuart says, is actually a life-shortening therapy. Eventually, the drug will lose its effect, leaving the heart unable to pump as it did while on the drug. "After a patient flunks on dobutamine, the patient can be stabilized by using morphine," Stuart says.
Perhaps the largest hurdle is cost. While most hospices that shy away from use of the drugs cite cost as a reason, it is a legitimate excuse. Most hospices can’t afford dobutamine and milrinone, says Stuart, whose own hospice doesn’t accept patients on dobutamine.
Some large hospices are able to accept patients on dobutamine and milrinone because they can spread the additional cost associated with the therapy across a larger population, but smaller hospices do not have that luxury.
There is no shame in not accepting dobutamine patients, says Stuart. It would be unethical to refuse patients if there were no alternatives to their current care. In the case of dobutamine and milrinone, patients can be treated effectively with morphine at the end of life.
The bottom line, experts say, is that there isn’t any right answer when it comes to deciding whether to include dobutamine and milrinone as parts of a hospice’s stable of therapies. "Hospices would be justified in refusing people on dobutamine or waiting until they flunk dobutamine treatment and are ready for morphine," says Stuart.
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