A Comparison of Hospitalized Patients With Heart Failure and Cancer Referred to Palliative Care

Elements of effective palliative care interventions in advanced heart failure: A narrative review

People with advanced heart failure experience significant biopsychosocial needs and have a poor prognosis. International guidelines have called for integrating palliative care in heart failure management. This review explores the elements of effective palliative care interventions in advanced heart failure. PubMed, Embase, CINAHL and Cochrane Reviews were searched following an a priori review protocol for clinical trials of advanced heart failure and palliative care. The risk of bias was assessed using Risk of Bias 2 (RoB2). A qualitative, emergent approach was used to synthesize context + mechanism = outcome. Twenty-one papers from 18 studies were the data source. The efficacy of palliative care in advanced heart failure was mixed. Five studies reported significant improvement in health outcomes compared with the usual care control group. Timing may be necessary in accounting for improvement in quality of life (occurring on or about 3 months) and functional and symptomatic improvements (occurring on or about 6 months or longer). Effective models of secondary palliative care in advanced heart failure include interdisciplinary teams comprising primary care, cardiology and palliative care, routine check-ins, personalized care plans that explore goals, evidence-based symptom management and counselling. Integrating palliative care with heart failure management could improve patient outcomes. Future research and policy development may wish to consider when, how and what palliative care modalities are to be incorporated into the care of patients with advanced heart failure.

Identifying Palliative Care Needs in Heart Failure Patients With Nurse-Led Screening

Patients with heart failure benefit from specialty palliative care but are often not evaluated for these services. The lack of standardized screening tools and limited nurse training for assessing palliative care needs are contributing factors. This quality improvement project aimed to improve the identification of unmet palliative care needs in patients with heart failure admitted to a progressive care unit by implementing a standardized nurse-administered palliative care screening tool. The nursing staff administered the Integrated Palliative Care Outcome Scale (IPOS) tool. The number of palliative consultations before project implementation was compared with those during the project. Spearman ρ was assessed for correlation between screening tool score and New York Heart Association (NYHA) heart failure class. Thirty-eight patients completed the screening tool. NYHA class was documented in 29% of patients. Among all patients, those categorized as NYHA III with heart failure with reduced ejection fraction demonstrated the highest need scores. Spearman ρ indicated a nonsignificant ( P > .05), very weak negative correlation between the IPOS scores and NYHA class ( rs = -0.18, P = .60). Implementing a nurse-administered screening tool effectively identified unmet palliative care needs among patients with heart failure with reduced ejection fraction and NYHA III. Despite low rates of palliative consults, standardization using IPOS could increase screening, contribute to institutional triggering palliative consultations, and improve awareness of unmet needs.

Using the 5Ms Framework to Advance Aging-Responsive Care for Heart Failure with Reduced Ejection Fraction

Complexity of care is the inevitable consequence of an aging population and is particularly true in instances where patients are managing chronic conditions such as heart failure with reduced ejection fraction (HFrEF). HFrEF itself is complex, with an undulating course of illness, increased risk of sudden cardiac death, and myriad accompanying treatment considerations. Generalist management of HFrEF among older patients is further complicated by competing comorbidities, potential for financial toxicity, potential for mental health symptoms, and risk of care with does not align with goals and preferences. The 5Ms (multicomplexity, mind, mobility, medications, and matters most) is a holistic conceptualization of care that has been applied to the care of older adults, including in gastroenterology, ICU care, oncology, and dentistry. In this narrative review, we present 5Ms Model of care for older adults with HFrEF.

Self-Study-Based Informed Decision-Making Tool for Empowerment of Treatment Adherence Among Chronic Heart Failure Patients-A Pilot Study

Background: Adherence to drug prescriptions is often suboptimal among heart failure (HF) patients. Informed decision-making may improve patients' adherence to HF drug prescriptions. Aims of the study: We aimed to test whether a self-study-based informed decision-making tool could improve adherence to drug prescriptions among ambulatory HF patients. Methods: A tool and a statement-based questionnaire were developed to evaluate drug adherence willingness based on COMPAR-EU recommendations. The test group (n = 40) was exposed to the tool + questionnaire; controls (n = 40) answered the questionnaire only. Agreement with statements of the questionnaire was graded on a scale of 0 to 4 points, reflecting no to full agreement. Results: The median age of controls was younger (56 vs. 61 years; p = 0.04); test and control group patients did not differ across other parameters (always p > 0.05). Patients in both groups agreed that "HF is a life-long disease" (3.5 vs. 4; p = 0.19) and that "only life-long drug treatment provides benefit" (4 vs. 4; p = 0.22). More test group patients confirmed improved comprehension of HF disease (3 vs. 2; p = 0.03) and greater acceptance that "achievement of benefit asks for a combination of HF drugs" (4 vs. 3; p = 0.009) and "daily intake" (4 vs. 3; p = 0.004). In test group patients, questions remained, resulting in less agreement that "all aspects of my heart disease" are understood (1 vs. 3; p < 0.001). Willingness to adhere to HF-drug treatment was not different between the groups (3 vs. 3.5; p = 0.28). Conclusions: The self-study-based informed decision-making tool improved the comprehension of HF and the need for HF treatment, but did not improve willingness to adhere since questions remained unanswered.

Variation in Palliative Care Program Performance for Patients With Metastatic Cancer

CONTEXT

While specialist palliative care is associated with improved end-of-life quality metrics for patients with advanced cancer, its effectiveness may differ between hospitals.

OBJECTIVES

To examine variation in palliative care program performance on end-of-life care quality metrics.

METHODS

Retrospective cohort study of palliative care programs that participated in the National Palliative Care Registry, 2018-2019. Medicare data for patients age ≥65 who died with metastatic cancer were aggregated on a program-level. Variation in program performance on outcomes (use of hospice, hospice enrollment ≥3 days, use of intensive care in the last 30 days of life, and use of chemotherapy in the last 14 days of life) was quantified by risk-standardized outcome rates (RSOR) and adjusted median odds ratios (aMOR).

RESULTS

The cohort comprised 235 palliative care programs who delivered care to 33,015 patients. There was substantial variation in use of hospice (median RSOR 65.6%, interquartile range (IQR) 57.5%-74.3%), hospice enrollment ≥3 days (median RSOR 53.6%, IQR 48.6%-58.2%), and use of intensive care (median RSOR 14.1%, IQR 13.1%-15.3%), but not use of chemotherapy (median RSOR 1.5%, IQR 1.4%-1.5%). Variation was greatest for hospice use (aMOR 1.48 [1.39-1.57]), suggesting that patients at programs with high hospice use would be 48% more likely to use hospice than if they received care at programs with low use.

CONCLUSION

We found variation in most end-of-life quality metrics for patients with metastatic cancer. Further work is needed to better understand why variations exist and whether such variations reflect a difference in quality of care.

Implantable cardioverter defibrillators in people dying with cancer: A SEER-Medicare analysis of ICD prevalence and association with aggressive end-of-life care

INTRODUCTION

The shared risk profiles for cancer and heart disease suggest many individuals with cancer may have an implantable cardioverter defibrillator (ICD). ICDs can have dramatic cancer end-of-life care implications including painful and distressing shocks. ICD prevalence and association with aggressive end-of-life care among individuals with breast, colorectal, and pancreatic cancer was evaluated using the Surveillance, Epidemiology, and End Results-Medicare dataset.

METHODS

A total of 37,306 Medicare beneficiaries aged ≥66 years with stage 3 or 4 cancer who died between 2005 and 2016 were identified. ICD prevalence, ICD-related care utilization that might present opportunities to discuss end-of-life implications and association with aggressive end-of-life care (>1 emergency department visit, intensive care unit admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive or life-extending procedures) in the last month of life was assessed using multivariable logistic regression.

RESULTS

Among cancer decedents, 6% had an ICD. More individuals with an ICD (31%) died in the hospital than individuals without an ICD (25%; p < .001). Half (46%) of individuals with an ICD had device programming or interrogation visits that could be an opportunity for device discussion. In adjusted models, ICD presence was associated with higher odds of every indicator of aggressive end-of-life care other than chemotherapy.

CONCLUSION

Many older cancer decedents in the United States had an ICD, and those with ICDs received more aggressive care at the end of life. Results suggest there are opportunities to discuss ICD and goals of care, raise awareness and encourage shared decision-making for this population to ensure goal-concordant care, and improve end-of-life care quality.

Registry study of cardiovascular death in Sweden 2013-2019: Home as place of death and specialized palliative care are the preserve of a minority

Background

Palliative care needs in patients with cardiovascular diseases (CVD) are expected to increase. For the planning of equitable palliative care, it is important to understand where people with CVD die. The aim was to examine trends in place of death, associated factors including utilization of specialized palliative services, and to what extent longitudinal development is influenced by national policy.

Methods

A population-level registry study of place of death for adults deceased due to CVD (n = 209 671) in Sweden 2013-2019. Linear regression analysis was applied.

Results

The predominant place of death was nursing home (39.1 %) and hospital (37.6 %), followed by home (22.0 %). From 2013 to 2019 home deaths increased by 2.8 % and hospital deaths decreased by 3.0 %. An overall downward trend was found for dying in hospital compared to dying at home. With variations, this trend was seen in all healthcare regions and for all CVD types, except Stockholm and cerebrovascular disease, with no significant trend. Overall, but with cross-regional variations, 2.1 % utilized specialized palliative services, while 94.2 % had potential palliative care needs. Other variables significantly influencing the trend were age and having had an unplanned healthcare visit.

Conclusion

Despite a slight positive trend, only a minority of people with CVD die in their own home. Regional variations in place of death and the low and varied utilization of specialized palliative services indicate inequity in access to palliative care. Hence, the impact of current national policies is questionable and calls for strengthening through inclusion of early palliative care in specific CVD policies.

Multicenter exploration of specialist palliative care in patients with left ventricular assist devices - a retrospective study

BACKGROUND

The number of advanced heart failure patients with left ventricular assist devices (LVAD) is increasing. Despite guideline-recommendations, little is known about specialist palliative care involvement in LVAD-patients, especially in Europe. This study aims to investigate timing and setting of specialist palliative care in LVAD-patients.

METHODS

We conducted a retrospective multicenter study in 2022. Specialist palliative care services in German LVAD-centers were identified and invited to participate. Forty adult LVAD-patients (mean age 65 years (SD 7.9), 90% male) from seven centers that received a specialist palliative care consultation during hospitalization were included.

RESULTS

In 37 (67.3%) of the 55 LVAD-centers, specialist palliative care was available. The median duration between LVAD-implantation and first specialist palliative care contact was 17 months (IQR 6.3-50.3 months). Median duration between consultation and death was seven days (IQR 3-28 days). 65% of consults took place in an intensive/intermediate care unit with half of the patients having a Do-Not-Resuscitate order. Care planning significantly increased during involvement (advance directives before: n = 15, after: n = 19, p < 0.001; DNR before: n = 20, after: n = 28, p < 0.001). Symptom burden as assessed at first specialist palliative care contact was higher compared to the consultation requests (request: median 3 symptoms (IQR 3-6); first contact: median 9 (IQR 6-10); p < 0.001) with a focus on weakness, anxiety, overburdening of next-of-kin and dyspnea. More than 70% of patients died during index hospitalization, one third of these in a palliative care unit.

CONCLUSIONS

This largest European multicenter investigation of LVAD-patients receiving specialist palliative care shows a late integration and high physical and psychosocial symptom burden. This study highlights the urgent need for earlier integration to identify and address poorly controlled symptoms. Further studies and educational efforts are needed to close the gap between guideline-recommendations and the current status quo.

Racial Differences in Palliative Care Use in Heart Failure Decedents

BACKGROUND

Minoritized individuals experience greater heart failure (HF) incidence and mortality rates, yet racial disparities in palliative care (PC) in HF are unknown.

METHODS

This retrospective study used electronic medical records to identify adults who were hospitalized at an academic health system and died due to HF between 2012 and 2018. Using multivariable logistic regression, we examined associations between decedents' characteristics and PC consultations (PCCs).

RESULTS

Of 1987 decedents, 45.8% (n = 911) received PCCs. Black decedents had 60% greater odds of receiving PCCs (OR = 1.60; 95% CI = 1.21-2.11) than whites. Median time from PCC to death was shorter among white than Black decedents (31.2 vs 51.5 days; P = .001). Mean age at death was younger among Black than white decedents (71.3 [14.8] vs 81.8 [12.3]; P < .001) and decedents of "other" races (71.3 [14.8] vs. 80.3 [10.4]; P = .001). Black decedents were more likely than whites to receive inotropes (54.4% vs 42.3%; P < .001) and to be admitted to hospitals (39.5% vs 29.7%; P < .001) and intensive care units in their last month (30.3% vs 18.3%; P < .001).

CONCLUSIONS

Findings suggest greater recognition of palliative-care needs among Black individuals with HF; however, most referrals to PC occur late in the disease trajectory.

Palliative care in the cardiovascular intensive care unit: A systematic review of current literature

BACKGROUND

There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice.

METHODS

PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions - acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism - admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity.

RESULTS

Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality.

CONCLUSIONS

Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU.

New Disease Trajectories of Heart Failure: Challenges in Determining the Ideal Timing of Palliative Care Implementation

Background: The disease trajectory of heart failure (HF), along with other organ failures, is still being elucidated. The trajectory is represented as a descending saw-tooth curve, indicating the frequent exacerbations and hospitalizations and slow progression to death. However, the clinical pattern of HF is no longer unique because of the definition of three distinct phenotypes, according to different values of ejection fraction (EF): HF with reduced EF (HFrEF), mildly reduced EF (HFmEF), and preserved EF (HFpEF). Patients with HFrEF have access to pharmacological and nonpharmacological treatments that have been shown to reduce mortality, unlike the other two classes for which no effective therapies are present. Therefore, their disease trajectories are markedly different. Methods: In this study, multiple new disease trajectories of HFrEF are being proposed, ranging from a complete and persistent recovery to rapid clinical deterioration and premature death. These new trajectories pose challenges to early implementation of palliative care (PC), as indicated in the guidelines. Results: From these considerations, we discuss how the improved prognosis of HFrEF because of effective treatment could paradoxically delay the initiation of early PC, especially with the insufficient palliative knowledge and training of cardiologists, who usually believe that PC is required only at the end of life. Conclusions: The novel therapeutic approaches for HF discussed in this study highlight the clinical specificity and peculiar needs of patients with HF. The changing model of disease trajectories of patients with HF will provide new opportunities for the early implementation of PC.

Design, Creation, and 13-Month Performance of a Novel, Web-Based Activity for Education in Primary Cardiology Palliative Care

Cardiovascular disease (CVD) clinicians who care for seriously ill patients frequently report that they do not feel confident nor adequately prepared to manage patients' palliative care (PC) needs. With the goal, therefore, of increasing PC knowledge and skills amongst interprofessional clinicians providing CVD care, the ACC's PC Workgroup designed, developed, and implemented a comprehensive PC online educational activity. This paper describes the process and 13-month performance of this free, online activity for clinicians across disciplines and levels of training, "Palliative Care for the Cardiovascular Clinician" (PCCVC). A key component of PCCVC is that it is tailored to the lifelong learner; users can choose and receive credit for the activities that meet their individual learning needs. This webinar series was well-subscribed, and upon completion of the modules, learners reported better self-perceived abilities related to palliative care competencies. We propose PCCVC as a model for primary PC education for clinicians caring for individuals with other serious or life-shortening illnesses.

Bereaved family members' perspectives on quality of death in deceased acute cardiovascular disease patients compared with cancer patients - a comparison of the J-HOPE3 study and the quality of palliative care in heart disease (Q-PACH) study

BACKGROUND

Outcome measures during acute cardiovascular disease (CVD) phases, such as quality of death, have not been thoroughly evaluated. This is the first study that compared the family members' perceptions of quality of death in deceased CVD patients and in deceased cancer patients using a bereaved family survey.

METHODS

Retrospectively sent questionnaire to consecutive family members of deceased patients with CVD from ten tertiary hospitals from October 2017 to August 2018. We used the short version of the Good Death Inventory (GDI) and assessed overall care satisfaction. Referencing the GDI, the quality of death was compared between CVD patients admitted to a non-palliative care unit (non-PCU) and cancer patients in palliative care units (PCU) and non-PCUs in the Japan Hospice and Palliative Care Evaluation Study (J-HOPE Study). Additionally, in the adjusted analysis, multivariable linear regression was performed for total GDI score adjusted by the patient and participant characteristics to estimate the difference between CVD and other patients.

RESULTS

Of the 243 bereaved family responses in agreement (response rate: 58.7%) for CVD patients, deceased patients comprised 133 (54.7%) men who were 80.2 ± 12.2 years old on admission. The GDI score among CVD patients (75.0 ± 15.7) was lower (worse) than that of cancer patients in the PCUs (80.2 ± 14.3), but higher than in non-PCUs (74.4 ± 15.2). After adjustment, the total GDI score for CVD patients was 7.10 points lower [95% CI: 5.22-8.97] than for cancer patients in PCUs and showed no significant differences compared with those in non-PCUs (estimates, 1.62; 95% CI [-0.46 to 5.22]).

CONCLUSIONS

The quality of death perceived by bereaved family members among deceased acute CVD patients did not differ significantly from that of deceased cancer patients in general wards, however, was significantly lower than that of deceased cancer patients admitted in PCUs.

Palliative Care Utilisation and Outcomes in Patients Admitted for Heart Failure in a Victorian Healthcare Service

BACKGROUND

Heart failure (HF) has high mortality and healthcare utilisation. It has a complex and unpredictable trajectory, which is often interpreted as a barrier to guideline recommended early integration of palliative care (PC). In particular, lack of referral criteria and misconceptions around PC affect inpatient specialist PC referrals.

AIMS

The main objective was to characterise the pattern and predictors of referral of HF patients to the specialist inpatient PC consultative service at our healthcare service.

METHODS

A retrospective, single-centre cohort study was performed on consecutive patients admitted across the hospital with HF over a 12-month period (July 2019-June 2020). Mortality data were checked against state death registry data.

RESULTS

The 502 patients admitted for HF were elderly (mean age 78±14 years), had high dependency (54% Australian-modified Karnofsky Performance Status (AKPS) 50-70, 29% AKPS 10-40), and high mortality (53% within median 32 months at death registry data linkage). Seven per cent (7%) were referred to inpatient specialist PC. AKPS 10-40 (62% of those referred vs 26% not referred, p<0.01), reliance on carers (65% vs 36%, p<0.01), and New York Heart Association (NYHA) class III-IV symptoms (86% vs 42%, p<0.01) were associated with referral, but two or more admissions in the last 12 months for HF were not (16% vs 10%, p=0.21). Many PC domains, such as symptom burden, distress, and preferred care, were not adequately assessed.

CONCLUSIONS

Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients.

Scheduled and Breakthrough Opioid Use for Cancer Pain in an Inpatient Setting at a Tertiary Cancer Hospital

Background: Our aim was to examine the frequency and prescription pattern of breakthrough (BTO) and scheduled (SCH) opioids and their ratio (BTO/SCH ratio) of use, prior to and after referral to an inpatient supportive care consult (SCC) for cancer pain management (CPM). Methods and Materials: Patients admitted at the MD Anderson Cancer Center and referred to a SCC were retrospectively reviewed. Cancer patients receiving SCH and BTO opioids for ≥24 h were eligible for inclusion. Patient demographics and clinical characteristics, including the type and route of SCH and BTO opioids, daily opioid doses (MEDDs) of SCH and BTO, and BTO/SCH ratios were reviewed in patients seen prior to a SCC (pre-SCC) and during a SCC. A normal BTO ratio was defined as 0.5-0.2. Results: A total of 665/728 (91%) patients were evaluable. Median pain scores (p < 0.001), BTO MEDDs (p < 0.001), scheduled opioid MEDDs (p < 0.0001), and total MEDDs (p < 0.0001) were higher, but the median number of BTO doses was fewer (2 vs. 4, p < 0.001), among patients seen at SCC compared to pre-SCC. A BTO/SCH ratio over the recommended ratio (>0.2) was seen in 37.5% of patients. The BTO/SCH ratios in the pre-SCC and SCC groups were 0.10 (0.04, 0.21) and 0.17 (0.10, 0.30), respectively, p < 0.001. Hydromorphone and Morphine were the most common BTO and SCH opioids prescribed, respectively. Patients in the early supportive care group had higher pain scores and MEDDs. Conclusions: BTO/SCH ratios are frequently prescribed higher than the recommended dose. Daily pain scores, BTO MEDDs, scheduled opioid MEDDs, and total MEDDs were higher among the SCC group than the pre-SCC group, but the number of BTO doses/day was lower.

Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial

Importance

Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking.

Objective

To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes.

Design, Setting, and Participants

A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019.

Intervention

Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care.

Main Outcomes and Measures

The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality.

Results

Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]).

Conclusions and Relevance

Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02505035.

End-Of-Life Care for Patients With End-Stage Heart Failure, Comparisons of International Guidelines

Heart failure (HF) is a chronic, debilitating condition associated with significant morbidity, mortality, and socioeconomic burden. Patients with end-stage HF (ESHF) who are not a candidate for advanced therapies will continue to progress despite standard medical therapy. Thus, the focus of care shifts from prolonging life to controlling symptoms and improving quality of life through palliative care (PC). Because the condition and prognosis of HF patients evolve and can rapidly deteriorate, it is imperative to begin the discussion on end-of-life (EOL) issues early during HF management. These include the completion of an advance directive, do-not-resuscitate orders, and policies on device therapy and discontinuation as part of advance care planning (ACP). ESHF patients who do not have indications for advanced therapies or those who wish not to have a left ventricular assist device (LVAD) or heart transplant (HT) often experience high symptom burden despite adequate medical management. The proper identification and assessment of symptoms such as pain, dyspnea, nausea, depression, and anxiety are essential to the management of ESHF and may be underdiagnosed and undertreated. Psychological support and spiritual care are also crucial to improving the quality of life during EOL. Caregivers of ESHF patients must also be provided supportive care to prevent compassion fatigue and improve resilience in patient care. In this narrative review, we compare the international guidelines and provide an overview of end-of-life and palliative care for patients with ESHF.

Palliative Care for Patients With Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) has become the leading form of heart failure worldwide, particularly among elderly patient populations. HFpEF is associated with significant morbidity and mortality that may benefit from incorporation of palliative care (PC). Patients with HFpEF have similarly high mortality rates to patients with heart failure with reduced ejection fraction. PC trials for heart failure have shown improvement in quality of life, quality of death, and health care utilization, although most trials defined heart failure clinically without differentiating between HFpEF and heart failure with reduced ejection fraction. As such, the timing and role of PC for HFpEF care remains uncertain, and PC referral rates for HFpEF are very low despite potential improvements in important patient-centered outcomes. Specific barriers to referral include limited data, prognostic uncertainty, provider misconceptions about PC, inadequate specialty PC workforce, complexities of treating multimorbidity, and limited home care options for patients with heart failure. While there are many barriers to integration of PC into HFpEF care, there are multiple potential benefits to patients with HFpEF throughout their disease course. As this population continues to grow, targeted efforts to study and implement PC interventions are needed to improve patient quality of life and death.

The Lived Experience of Frailty in Patients Aged 60 Years and Older with Heart Failure: A Qualitative Study

PURPOSE

The prevalence of frailty among patients with heart failure is about 45%. Frailty may result in patients' functional decline, falls, disability, and decreased quality of life. Qualitative studies can explore older patients' perceptions of frailty and help patients cope with it. However, a qualitative approach that explores the experience of frailty in older patients living with heart failure is lacking. This study aimed to explore the lived experience of frailty in older patients with heart failure.

METHODS

This qualitative study applies Giorgi's phenomenological method. Data were collected from October 2019 to August 2020. Thirteen older patients with heart failure aged at least 60 years were recruited using purposive sampling from a medical center in Taiwan. The participants participated in an in-depth interview using a semistructured interview guide.

RESULTS

Seven themes were identified: "being reborn at the end of the road but having difficulty recovering", "living with a disease with an ineffable feeling", "feeling like being drained: physical weakness and a dysfunctional body", "struggling with impaired physical mobility and facing unexpected events", "suffering from mental exhaustion", "receiving care from loved ones", and "turning over a new leaf".

CONCLUSIONS

Frailty in older patients with heart failure was obscure and difficult to describe. Frailty could be improved by medical intervention, self-management, and social support but was difficult to reverse. Patients with heart failure should be evaluated for frailty using multidimensional assessment tools at first diagnosis and provided frailty-related information so that patients have proper insight into their disease as early as possible.

Expanding the Paradigm for Cardiovascular Palliative Care

Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite medical advances, patients with CVD experience high morbidity and mortality rates, affecting their quality of life and death. Among CVD conditions, palliative care has been studied mostly in patients with heart failure, where palliative care interventions have been associated with improvements in patient-centered outcomes, including quality of life, end-of-life care, and health care use. Although palliative care is now incorporated into the American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines for heart failure, the role of palliative care for non-heart failure CVD remains uncertain. Across all causes of CVD, palliative care can play an important role in all domains of CVD care from initial diagnosis to terminal care. In addition to general cardiovascular palliative care practices applicable to all areas, disease-specific palliative care needs may warrant individualized palliative care models. In this review, we discuss the role of cardiovascular palliative care for ischemic heart disease, valvular disease, arrhythmias, peripheral artery disease, and adult congenital heart disease. Although there are multiple barriers to cardiovascular palliative care, we recommend a framework for studying and developing cardiovascular palliative care models to improve patient-centered goal-concordant care for this underserved patient population.

Impact of a financial incentive scheme for team-based palliative care in patients with heart failure in Japan: A nationwide database study

BACKGROUND

Palliative care provided to patients with heart failure (HF) are reported to be inadequate. Herein, we examined the impact of the recently introduced financial incentive scheme for team-based palliative care for patients with HF in acute care hospitals in Japan.

METHODS

Using a nationwide inpatient database, we identified patients aged ≥65 years with HF who had died between April 2015 and March 2021. Interrupted time-series analyses were used to compare practice patterns in end-of-life care (symptom management and invasive medical procedures within one week before death) before and after the financial incentive scheme issuance in April 2018.

RESULTS

Overall, 53,857 patients in 835 hospitals were eligible. The adoption of the financial incentive was 1.10 to 1.22% after the introduction. There were upward pre-trends in opioid use (+0.11% per month; 95% confidence interval [CI], 0.06 to 0.15) and antidepressant use (+0.06% per month; 95% CI, 0.04 to 0.09). Opioid use showed a downward slope change during the post-period (-0.07% change in trend; 95% CI, -0.13 to -0.01). Intensive care unit stay showed a downward pre-trend (-0.09% per month; 95% CI, -0.14 to -0.04) and upward slope changes during the post-period (+0.12% change in trend; 95% CI, 0.04 to 0.19). Invasive mechanical ventilation showed downward slope changes during the post-period (-0.11% change in trend; 95% CI, -0.18 to -0.04).

CONCLUSIONS

The financial incentive scheme for team-based palliative care was rarely adopted and not associated with changes in end-of-life care. Further multifaceted strategies to promote palliative care for HF are warranted.

Recent Developments in the Evaluation and Management of Cardiorenal Syndrome: A Comprehensive Review

Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.

Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care?

Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.

Ten Questions and Some Reflections about Palliative Care in Advanced Heart Failure Patients

Heart failure is a clinical syndrome with increasing prevalence, high morbidity and mortality. It is characterized by high symptom burden, poor quality of life and high economic costs. This implies that the heart failure (HF) patients who receive palliative care (PC) have needs similar to cancer patients, but which are often unmet. This paper analyzes the main unresolved issues regarding the relationship between HF patients and the referral to an early PC program. These issues are presented as ten questions related to which patients should be admitted to PC and at what stage of their disease. Furthermore, the barriers opposing to referral to PC, the role of cardiologists and PC physicians within the care team, the gap between the scientific societies' suggestions and the real world, the right time to promote patients' awareness and shared decision making, regarding prognosis, end of life wishes and choices, with reference also to cardiac implantable devices' deactivation, are discussed. These unresolved questions support the need to reevaluate programs and specific models in achieving equal access to palliative care interventions for HF patients, which is still mainly offered to patients with cancer.

Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure

Aim: To determine the association between inpatient palliative care encounter (PCE) and 30-day rehospitalization. Materials & methods: The Nationwide Readmission Database was used in a cross-sectional design study. Comorbidities and a palliative care encounter (PCE; V66.7) were defined using ICD-9 codes. Results: Overall, 21.28% of 3,534,480 index hospitalizations were readmitted. PCE occurred in 1.66% of index hospitalizations and was associated with a lower odds of 30-day rehospitalization (adjusted odds ratio, 0.38; 95% CI: 0.35-0.40). This association remained significant when assessed by discharge destination. Conclusion: PCE was associated with a lower relative odds of 30-day rehospitalization. A 73% decrease in the relative odds of 30-day rehospitalization among discharges to a facility, 64% for home with home health, and 22% for discharges to home.

Palliative Care for Patients With Heart Failure: An Integrative Review

Palliative care should be integrated into routine disease management for all patients with serious illness, regardless of settings or prognosis. The purposes of this integrative review were to identify the features of randomized controlled trials for adult patients with heart failure and to provide basic references for the development of future trials. Using Whittemore and Knafl's integrative literature review method, comprehensive searches of the PubMed, Cochrane Library, CINAHL, EMBASE, and Korean databases were conducted, integrating keywords about heart failure and palliative care interventions. Quality appraisal was assessed using Cochrane risk-of-bias tools. In total, there were 6 trials providing palliative care interventions integrating team-based approaches between palliative care specialists and nonpalliative clinicians, such as a cardiologist, cardiac nurse, and advanced practice nurse across inpatient and outpatient settings. The different types of interventions included home visits, symptom management via phone calls or referral to a specialist team, and the establishment of treatment planning. Patient-reported outcome measures included positive effects of palliative interventions on symptom burden and quality of life. Given that most of the selected studies were conducted in Western countries, palliative care should be culturally tailored to assist heart failure patients worldwide.

A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease

Background

The impetus to develop and implement tools for non-malignant patient groups is reflected in the increasing number of instruments being developed for heart failure and chronic respiratory diseases. Evidence syntheses of psychometric quality and clinical utility of these tools is required to inform research and clinical practice.

Aims

This systematic review examined palliative care needs tools for people diagnosed with advanced heart failure or chronic respiratory diseases, to determine their: (1) psychometric quality; and (2) acceptability, feasibility and clinical utility when implemented in clinical practice.

Methods

Systematic searches of MEDLINE, CINAHL, Embase, Cochrane and PsycINFO from database inception until June 2021 were undertaken. Additionally, the reference lists of included studies were searched for relevant articles. Psychometric properties of identified measures were evaluated against pre-determined and standard criteria.

Results

Eighteen tools met inclusion criteria: 11 were developed to assess unmet patient palliative care needs. Of those, 6 were generic, 4 were developed for heart failure and 1 was developed for interstitial lung disease. Seven tools identified those who may benefit from palliative care and include general and disease-specific indicators. The psychometric qualities of the tools varied. None met all of the accepted criteria for psychometric rigor in heart failure or respiratory disease populations. There is limited implementation of needs assessment tools in practice.

Conclusion

Several tools were identified, however further validation studies in heart failure and respiratory disease populations are required. Rigorous evaluation to determine the impact of adopting a systematic needs-based approach for heart failure and lung disease on the physical and psychosocial outcomes of patients and carers, as well as the economic costs and benefits to the healthcare system, is required.

Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation

Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.

Predictors, Treatments, and Outcomes of Do-Not-Resuscitate Status in Acute Myocardial Infarction Patients (from a Nationwide Inpatient Cohort Study)

Little is known about how frequently do-not-resuscitate (DNR) orders are placed in patients with acute myocardial infarction (AMI), the types of patients in which they are placed, treatment strategies or clinical outcomes of such patients. Using the United States (US) National Inpatient Sample (NIS) database from 2015 to 2018, we identified 2,767,549 admissions that were admitted to US hospitals and during the hospitalization received a principle diagnosis of AMI, of which 339,270 (12.3%) patients had a DNR order (instigated both preadmission and during in-hospital stay). Patients with a DNR status were older (median age 83 vs 65, p < 0.001), more likely to be female (53.4% vs 39.3%, p < 0.001) and White (81.0% vs 73.3%, p < 0.001). Predictors of DNR status included comorbidities such as heart failure (OR: 1.47, 95% CI: 1.45 to 1.48), dementia (OR: 2.53, 95% CI: 2.50 to 2.55), and cancer. Patients with a DNR order were less likely to undergo invasive management or be discharged home (13.5% vs 52.8%), with only 1/3 receiving palliative consultation. In hospital mortality (32.7% vs 4.6%, p < 0.001) and MACCE (37.1% vs 8.8%, p < 0.001) were higher in the DNR group. Factors independently associated with in-hospital mortality among patients with a DNR order included a STEMI presentation (OR: 2.90, 95% CI: 2.84 to 2.96) and being of Black (OR: 1.29, 95% CI: 1.26 to 1.33), Hispanic (OR: 1.36, 95% CI: 1.32 to 1.41) or Asian/Pacific Islander (OR: 1.56, 95% CI:1.49-race. In conclusion, AMI patients with a DNR status were older, multimorbid, less likely to receive invasive management, with only one third of patients with DNR status referred for palliative care.

Evaluation of automated specialty palliative care in the intensive care unit: A retrospective cohort study

Introduction

Automated specialty palliative care consultation (SPC) has been proposed as an intervention to improve patient-centered care in the intensive care unit (ICU). Existing automated SPC trigger criteria are designed to identify patients at highest risk of in-hospital death. We sought to evaluate common mortality-based SPC triggers and determine whether these triggers reflect actual use of SPC consultation. We additionally aimed to characterize the population of patients who receive SPC without meeting mortality-based triggers.

Methods

We conducted a retrospective cohort study of all adult ICU admissions from 2012–2017 at an academic medical center with five subspecialty ICUs to determine the sensitivity and specificity of the five most common SPC triggers for predicting receipt of SPC. Among ICU admissions receiving SPC, we assessed differences in patients who met any SPC trigger compared to those who met none.

Results

Of 48,744 eligible admissions, 1,965 (4.03%) received SPC; 979 (49.82%) of consultations met at least 1 trigger. The sensitivity and specificity for any trigger predicting SPC was 49.82% and 79.61%, respectively. Patients who met no triggers but received SPC were younger (62.71 years vs 66.58 years, mean difference (MD) 3.87 years (95% confidence interval (CI) 2.44–5.30) p<0.001), had longer ICU length of stay (11.43 days vs 8.42 days, MD -3.01 days (95% CI -4.30 –-1.72) p<0.001), and had a lower rate of in-hospital death (48.68% vs 58.12%, p<0.001).

Conclusion

Mortality-based triggers for specialty palliative care poorly reflect actual use of SPC in the ICU. Reliance on such triggers may unintentionally overlook an important population of patients with clinician-identified palliative care needs.

An Emergency Department Clinical Algorithm to Increase Early Palliative Care Consultation: Pilot Project

Introduction: The emergency department (ED) is a primary entry point of hospitals but does not have a system to identify and consult palliative care (PC) early in patients who meet criteria. Objectives: To determine the measurable effects of an ED PC consultation on patients who meet criteria, hypothesizing that ED PC consultation would lead to decreased average length of stay (ALOS), average direct cost per patient, decreased number of surgeries, and radiological tests performed per patient. Materials and Methods: A physician-led data-driven evidence-based algorithm was designed and piloted with implementation in two hospitals during January-March 2019 in Orlando, FL. A retrospective review of health record data was completed, comparing patients receiving PC consultation ordered in the ED versus those ordered after admission. Results: ED patients (n = 662) met PC criteria. PC consultation was ordered in ED for 80 (12.1%) cases. The following outcomes were lower for patients who received ED PC consultation than those who did not: ALOS by 6.4 days (6.74 vs. 13.14 days; p < 0.001), in-hospital mortality (12.5% vs. 19.1%; p = 0.11), surgery (11% vs. 37%; p < 0.01), radiological tests per patient (4.01 vs. 10.57; p < 0.001), and average direct cost per patient ($7,193 vs. $22,354). However, 30-day hospital revisit rates were relatively higher in those who did receive ED PC consultation than those who did not (20% vs. 13% p = 0.15). Conclusions: In this pilot project, PC patients can be identified in the ED with an algorithm that leads to earlier consultation and improved patient outcomes. Larger research trials are needed to replicate this strategy and results.

[Palliative care in patients with left ventricular assist devices: systematic review]

Hintergrund

Bei terminal herzinsuffizienten Patienten gewinnt die Implantation von Linksherzunterstützungssystemen (LVAD) als Therapieoption zunehmend an Bedeutung. Diese Systeme werden als Überbrückung bis zu einer Herztransplantation (BTT) oder als definitive Therapie (DT) eingesetzt. Sie können die Lebensqualität verbessern und die Lebenszeit verlängern. Trotzdem bleibt die Prognose besonders bei DT oder bei Wechsel von BTT zu DT mit Blick auf die Lebenszeit und auftretende Komplikationen ungünstig. Bisher ist ungeklärt, ob eine LVAD-Implantation eine Indikation für eine frühzeitige Integration von Palliativmedizin darstellt.

Ziel der Arbeit

Erfassung der aktuellen Studienlage über den Einfluss einer palliativmedizinischen Behandlung bei LVAD-Patienten.

Material und Methoden

Im Mai 2020 wurde eine systematische Literaturrecherche in 6 verschiedenen Datenbanken durchgeführt.

Ergebnisse

Von den 491 Treffern der Literaturrecherche wurden 21 Arbeiten in diese Übersichtsarbeit eingeschlossen. Durch die frühzeitige Integration der Palliativmedizin vor LVAD-Implantation erhöhte sich die Anzahl der Patienten mit vorausschauender Versorgungsplanung und Vorsorgeinstrumenten. Außerdem zeigte sich ein positiver Einfluss auf das familiäre Umfeld, das Symptommanagement und die Umstände des Versterbens. Es gibt verschiedene Formate für die Integration palliativmedizinischer Konzepte in die LVAD-Therapie.

Diskussion

Die frühzeitige und kontinuierliche Einbindung der Palliativmedizin im Verlauf einer LVAD-Therapie kann die Behandlungsqualität verbessern. Die Ausarbeitung von spezifischen Handlungsempfehlungen ist in Abhängigkeit vom Therapieziel (BTT oder DT) sinnvoll. Empfohlen werden Schulungen für Palliativmediziner und LVAD-Spezialisten.

Differences between patients with cardiovascular disease and cancer referred for palliative care

Our analysis from a national registry shows that compared to cancer, cardiovascular disease patients referred to palliative care are a decade older, have worse functional status and clinician-estimated prognosis. Both groups have very high symptom burden, with cardiovascular disease patients experiencing more dyspnea while pain, nausea, and fatigue are more common in cancer.

Palliative Care for People Living With Heart Disease-Does Sex Make a Difference?

The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.