Hospital resource utilization and presence of advance directives at the end of life for adults with congenital heart disease

Advance Care Planning Challenges in Adult Congenital Heart Disease

Due to advances in congenital heart disease management, there are now more adults than children living with congenital heart disease in the United States. This population of over 1.4 million people is expected to continue to grow rapidly as a result of improving survival. However, patients with adult congenital heart disease continue to face increased rates of morbidity, hospitalizations, and medical interventions compared to the general population, in addition to elevated mortality. Therefore, comprehensive advance care planning is integral to caring for this patient population. Yet despite recommendations for early advance care planning in adult congenital heart disease, evidence suggests that it is rarely performed prior to patients' end-of-life. As demonstrated in this case, there are several challenges to advance care planning in this population which may account for this finding. Difficulty with accurate prognostication combined with the relatively young age of these patients has been reported to contribute to clinician hesitancy in initiating advance care planning prior to the onset of serious illness. Patients may have difficulty grasping their shortened life expectancy and may not feel ready to discuss serious illness care ahead of its onset. Furthermore, comorbid poor mental health and other psychosocial challenges are frequently prevalent in this population, further complicating matters. Therefore, patients with adult congenital heart disease may need more directed support with the advance care planning process, and early involvement with specialist Palliative Care can be invaluable. Further research specific to this population is needed to create a framework for successful palliative care delivery.

Presence and Content of Goals-of-Care Documentation for Patients With Adult Congenital Heart Disease at End-of-Life

BACKGROUND

Patients with adult congenital heart disease (ACHD) are prone to various health challenges and premature death. Palliative care needs have been demonstrated, yet little is known about patients' goals of care (GOC) near end-of-life.

OBJECTIVES

The aim of this study was to describe the presence and content of GOC documentation in the electronic health record for patients with ACHD at the end-of-life.

METHODS

We conducted a retrospective study of decedent patients with moderate or complex ACHD who received care from 2010 to 2021. Study team members manually reviewed electronic health records created within patients' last 6 months of life for the presence and content of GOC documentation.

RESULTS

Of the 114 patients included, 57 (50%) had at least one GOC discussion documented within the last 6 months of life from 544 total notes. Palliative care consultation notes occurred within the last 6 months of life for 36 (32%) patients. Presence of GOC discussion documentation within the last 6 months of life was associated with risk of in-hospital death (OR: 2.58; 95% CI: 1.19-5.61; P = 0.017), diagnosis of heart failure (OR: 3.57; 95% CI: 1.42-8.97; P = 0.007), and later era (2017-2021) (OR: 3.20; 95% CI: 1.48-6.91; P = 0.003). Qualitatively, patients were split between wishing to be comfortable at home vs prolonging life with aggressive treatment.

CONCLUSIONS

GOC documentation for patients with ACHD near end-of-life is suboptimal, yet when present contains information about patients' wishes. Future work should promote early GOC discussion and enhanced documentation to guide clinical care in this population.

Advance Care Planning for Adults With Moderate-to-Severe Congenital Heart Disease: Readiness Trial

Background

Adults with congenital heart disease (CHD) are growing in number and living longer with complex lesions; however, many are at risk of death in midlife. Conversations about advance care planning (ACP) in this population have been found to be infrequent and not part of regular outpatient care. The intent of this study was to explore readiness of patients with adult CHD (ACHD) to discuss ACP and assess the impact of interventions to support ACP conversations.

Methods

We conducted a prospective, randomized, single-centre trial of adults with moderate to severe CHD. Simply, the control group was asked if they were ready to discuss their wishes if they were to become seriously ill. The intervention group was provided 2 additional resources with the readiness question, the modified Lyon Family-Centered ACP survey and a patient-partner created ACHD-ACP video.

Results

A total of 111 responses (control [n = 59] and intervention group [n = 52]) were collected for analysis. Women represented 59.0% of the participants. The mean age was 39.6 years (standard deviation = 14.8 years). No significant difference was found between the control and experimental groups' readiness (94.9% and 90.4%, respectively). Most participants (92.8%) responded positively towards initiating conversations related to end-of-life and ACP discussions.

Conclusions

We found that adults with CHD are ready to have ACP conversations as part of their outpatient care. Patient preferences and values should guide ACP conversations; further research is needed to determine whether the modified Lyon Family-Centered ACP survey and ACHD-ACP video are helpful adjuncts for ACP in outpatient clinics.

Rationale and design of a randomized controlled clinical trial of a resilience-building intervention in adults with congenital heart disease

BACKGROUND

Adults with congenital heart disease (ACHD) are at risk for lower quality of life (QOL) and psychological health. Behavioral interventions to meet their psychosocial needs are lacking. The aim of this study is to evaluate the feasibility of implementing the Promoting Resilience in Stress Management (PRISM) intervention in ACHD and its efficacy in increasing resilience in this population.

METHODS

We designed a phase II randomized controlled clinical trial of patients with moderate or complex ACHD, physiological stages C or D. Enrolled participants will be randomized to receive PRISM or usual care. PRISM is a manualized, skills-based behavioral intervention comprised of four one-on-one sessions targeting resilience resources (stress-management, goal-setting, cognitive reframing, meaning making), an optional session on advance care planning, and a facilitated family meeting. Participants in both groups will complete study questionnaires at enrollment and 3-months later. The primary aim is to describe feasibility, namely the proportions of patients who a) enroll in the study among those eligible, and b) complete the PRISM intervention among those randomized to that arm. We will also evaluate PRISM's efficacy by using linear regression models to compare changes in mean resilience scores between assigned groups. In exploratory analyses, we will evaluate effects on QOL, psychological distress, perceived competence for health care management, and comfort with advance care planning.

DISCUSSION

This study will provide rigorous evidence to determine the feasibility and efficacy of a brief intervention to promote resilience and psychosocial health in ACHD. Findings may guide the development of a future multi-site effectiveness study.

CLINICAL TRIAL REGISTRATION

NCT04738474.

Evaluating YouTube as a Good Resource for Enhancing Patient Understanding of Heart Failure

OBJECTIVE

The aim of our study was to evaluate the content and quality of heart failure posts on the video-sharing site YouTube, which is an easily accessible source of information and is becoming increasingly popular in society for obtaining health information.

METHODS

In December 2023, we evaluated 162 videos after applying the exclusion criteria as a result of our search with the keyword "Heart Failure" on English-sharing sites. In addition to the technical data of the videos, such as views, duration, upload day, likes, and dislikes, we also used indices such as power index and popularity score in the analyses. We evaluated the quality of the videos using the DISCERN and global quality score scales, and the content using our content score scale. We classified the videos in the study into three quality subgroups according to the scores they received on all three scales.

RESULTS

The median number of views of the videos included in our study was 31092 (interquartile range (IQR): 3929-127758) and the median video duration was 336 (IQR: 189-843) seconds. The median popularity score was 28.25 (IQR: 4.7-143) and the median power index was 35139 (2061-308128). Group 1 (low quality) included 54 videos with a total score between 10 and 14, group 2 (medium quality) included 54 videos with a total score between 15 and 22, and group 3 (high quality) included 54 videos with a total score between 23 and 30. Views, upload day, and video duration were significantly higher for group 3 videos (p = 0.008, p = 0.001, and p < 0.001, respectively). Likes and dislikes were not significantly different between groups. The popularity score was significantly higher for group 1 videos (39.5 (IQR: 6.5-200), p = 0.023), while the power index was significantly higher for group 3 videos (74206 (IQR: 9477-221408), p = 0.006).

CONCLUSIONS

Our findings confirm that YouTube, a video-sharing website, is essential for easily sharing and spreading health-related information to a broad audience. Increased attention to videos with scientific content and high-quality scores suggests that YouTube provides accurate and quality information about heart failure. While the number of quality posts tends to increase daily, healthcare professionals should be encouraged to share high-quality scientific videos more frequently.

In-Hospital Death and End-of-Life Status Among Patients With Adult Congenital Heart Disease - A Retrospective Study Using the JROAD-DPC Database in Japan

BACKGROUND

The end-of-life (EOL) status, including age at death and treatment details, of patients with adult congenital heart disease (ACHD) remains unclear. This study investigated the EOL status of patients with ACHD using a nationwide Japanese database.

METHODS AND RESULTS

Data on the last hospitalization of 26,438 patients with ACHD aged ≥15 years, admitted between 2013 and 2017, were included. Disease complexity (simple, moderate, or great) was classified using International Classification of Diseases, 10th Revision codes. Of the 853 deaths, 831 patients with classifiable disease complexity were evaluated for EOL status. The median age at death of patients in the simple, moderate, and great disease complexity groups was 77.0, 66.5, and 39.0 years , respectively. The treatments administered before death to patients in the simple, moderate, and great complexity groups included cardiopulmonary resuscitation (30.1%, 35.7%, and 41.9%, respectively), percutaneous cardiopulmonary support (7.2%, 16.5%, and 16.3%, respectively), and mechanical ventilation (58.7%, 72.2%, and 75.6%, respectively). Overall, 70% of patients died outside of specialized facilities, with >25% dying after ≥31 days of hospitalization.

CONCLUSIONS

Nationwide data showed that patients with ACHD with greater disease complexity died at a younger age and underwent more invasive treatments before death, with many dying after ≥1 month of hospitalization. Discussing EOL options with patients at the appropriate time is important, particularly for patients with greater disease complexity.

Palliative Care in Adult Congenital Heart Disease-Associated Advanced Heart Disease

The practice of palliative care (PC) strives to mitigate patient suffering through aligning patient priorities and values with care planning and via improved understanding of complex physical, psychosocial, and spiritual stressors and dynamics that contribute to patient-centered outcomes. Through representative 'case examples' and supportive data, the role and value of a PC consultant, within the framework of a comprehensive adult congenital heart disease (ACHD) team caring for ACHD with advanced heart disease, are reviewed.

Healthcare Resources Utilization throughout the Last Year of Life after Acute Myocardial Infarction

Healthcare resource utilization (HRU) peaks in the last year-of-life, and accounts for a substantial share of healthcare expenditure. We evaluated changes in HRU and costs throughout the last year-of-life among AMI survivors and investigated whether such changes can predict imminent mortality. This retrospective analysis included patients who survived at least one year following an AMI. Mortality and HRU data during the 10-year follow-up period were collected. Analyses were performed according to follow-up years that were classified into mortality years (one year prior to death) and survival years. Overall, 10,992 patients (44,099 patients-years) were investigated. Throughout the follow-up period, 2,885 (26.3%) patients died. The HRU parameters and total costs were strong independent predictors of mortality during a subsequent year. While a direct association between mortality and hospital services (length of in-hospital stay and emergency department visits) was observed, the association with ambulatory services utilization was reversed. The discriminative ability (c-statistics) of a multivariable model including the HRU parameters for predicting the mortality in the subsequent year, was 0.88. In conclusion, throughout the last year of life, hospital-centered HRU and costs of AMI survivors increase while utilization of ambulatory services decrease. HRUs are strong and independent predictors of an imminent mortality year among these patients.

Last year of life of adults with congenital heart diseases: causes of death and patterns of care

AIMS

Although life expectancy in adults with congenital heart diseases (CHD) has increased dramatically over the past five decades, still a substantial number of patients dies prematurely. To gain understanding in the trajectories of dying in adults with CHD, the last year of life warrants further investigation. Therefore, our study aimed to (i) define the causes of death and (ii) describe the patterns of healthcare utilization in the last year of life of adults with CHD.

METHODS AND RESULTS

This retrospective mortality follow-back study used healthcare claims and clinical data from BELCODAC, which includes patients with CHD from Belgium. Healthcare utilization comprises cardiovascular procedures, CHD physician contacts, general practitioner visits, hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, and specialist palliative care, and was identified using nomenclature codes. Of the 390 included patients, almost half of the study population (45%) died from a cardiovascular cause. In the last year of life, 87% of patients were hospitalized, 78% of patients had an ED visit, and 19% of patients had an ICU admission. Specialist palliative care was provided to 17% of patients, and to only 4% when looking at the patients with cardiovascular causes of death.

CONCLUSIONS

There is a high use of intensive and potentially avoidable care at the end of life. This may imply that end-of-life care provision can be improved. Future studies should further examine end-of-life care provision in the light of patient's needs and preferences, and how the healthcare system can adequately respond.

State of the science and future research directions in palliative and end-of-life care in paediatric cardiology: a report from the Harvard Radcliffe Accelerator Workshop

Workshop proceedings, priorities, and recommendations from the "State of the Science and Future Directions in Palliative and End-of-Life Care in Pediatric Cardiology," a Harvard Radcliffe Accelerator Workshop, are detailed. Eight priorities for research were identified, including patient and family decision making, communication, patient and family experience, patient symptom measurement and management, training and curriculum development, teamwork, family hardships and bereavement, and ethical considerations. Barriers to research in this area were also identified: lack of outcome/measurement tools, lack of research funding, small population sizes, lack of effort/protected time for research, undervalued research topic by field and colleagues, and heterogeneous research participant diversity. Priorities and barriers were mostly consistent with those reported by the field of paediatric palliative care at large. These collective, consensus-based findings from diverse, multidisciplinary leaders in the field, as well as parent representatives, provide a catalyst for scientific advancement specific to paediatric and end-of-life care in paediatric cardiology.

Advance Care Directives Among a Population-Based Sample of Young Adults with Congenital Heart Defects, CH STRONG, 2016-2019

Little is known about advance care planning among young adults with congenital heart defects (CHD). Congenital Heart Survey to Recognize Outcomes, Needs, and well-beinG (CH STRONG) participants were born with CHD between 1980 and 1997, identified using active, population-based birth defects surveillance systems in Arkansas, Arizona and Atlanta, and Georgia, and surveyed during 2016-2019. We estimated the percent having an advance care directive standardized to the site, year of birth, sex, maternal race, and CHD severity of the 9312 CH STRONG-eligible individuals. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for characteristics associated with having advance care directives. Of 1541 respondents, 34.1% had severe CHD, 54.1% were female, and 69.6% were non-Hispanic white. After standardization, 7.3% had an advance care directive (range: 2.5% among non-Hispanic blacks to 17.4% among individuals with "poor" perceived health). Individuals with severe CHD (10.5%, aOR = 1.6, 95% CI: 1.1-2.3), with public insurance (13.1%, aOR = 1.7, 95% CI: 1.1-2.7), with non-cardiac congenital anomalies (11.1%, aOR = 1.9, 95% CI: 1.3-2.7), and who were hospitalized in the past year (13.3%, aOR = 1.8, 95% CI: 1.1-2.8) were more likely than their counterparts to have advance care directives. Individuals aged 19-24 years (6.6%, aOR = 0.4, 95% CI: 0.3-0.7) and 25-30 years (7.6%, aOR = 0.5, 95% CI: 0.3-0.8), compared to 31-38 years (14.3%), and non-Hispanic blacks (2.5%), compared to non-Hispanic whites (9.5%, aOR = 0.2, 95% CI: 0.1-0.6), were less likely to have advance care directives. Few young adults with CHD had advance care directives. Disparities in advance care planning may exist.

Outcomes and healthcare resource utilization in adult congenital heart disease patients with heart failure

AIMS

While heart failure (HF) is a leading cause of death in adults with congenital heart disease (ACHD), few studies report contemporary outcomes after the first HF hospitalization. We examined outcomes of ACHD patients newly admitted for HF compared with ACHD patients without HF and the general HF population without ACHD.

METHODS AND RESULTS

Using population databases from a single-payer health system from 1994 to 2018, ACHD patients newly admitted for HF were matched 1:1 to ACHD patients without HF (n = 4030 matched pairs). Similarly, ACHD patients newly admitted for HF were matched 1:1 to HF patients without ACHD (n = 4336 matched pairs). Patients with ACHD and HF (median age 68 years, 45% women) experienced higher mortality in short-term [30 day adjusted hazard ratio (HR) 4.68, 95% confidence interval (CI) 4.06, 5.43, P < 0.001], near-term (1 year HR 3.87, 95% CI 3.77, 4.92, P < 0.001), and long-term (24 year HR 1.59, 95% CI 1.13, 2.36, P = 0.008) follow-up. Patients with ACHD and HF had fewer baseline cardiovascular comorbidities than non-ACHD HF but demonstrated higher 30 day (HR 1.56, 95% CI 1.41, 1.73, P < 0.001), 1 year (HR 1.30, 95% CI 1.20, 1.40, P < 0.001), and 24 year (HR 2.40, 95% CI 1.73, 3.38, P < 0.001) mortality. Those with ACHD and HF also exhibited higher cardiovascular readmission rates at 30 days with HRs 9.15 (95% CI; 8.00, 10.48, P < 0.001) vs. ACHD without HF, and 1.71 (95% CI; 1.54, 1.85, P < 0.001) vs. HF without ACHD, and the higher readmission risk extended to 10 year follow-up.

CONCLUSIONS

Adults with congenital heart disease patients with new HF have high risks of death and cardiovascular hospitalization, and preventative strategies to improve outcomes are urgently needed.

Social Media in Heart Failure: A Mixed-Methods Systematic Review

BACKGROUND

Among social media (SoMe) platforms, Twitter and YouTube have gained popularity, facilitating communication between cardiovascular professionals and patients.

OBJECTIVE

This mixed-methods systematic review aimed to assess the source profile and content of Twitter and YouTube posts about heart failure (HF).

METHODS

We searched PubMed, Embase and Medline using the terms "cardiology," "social media," and "heart failure". We included full-text manuscripts published between January 1, 1999, and April 14, 2019. We searched Twitter and YouTube for posts using the hashtags "#heartfailure", "#HF", or "#CHF" on May 15, 2019 and July 6, 2019. We performed a descriptive analysis of the data.

RESULTS

Three publications met inclusion criteria, providing 677 tweets for source profile analysis; institutions (54.8%), health professionals (26.6%), and patients (19.4%) were the most common source profiles. The publications provided 1,194 tweets for content analysis: 83.3% were on education for professionals; 33.7% were on patient empowerment; and 22.3% were on research promotion. Our search on Twitter and YouTube generated 2,252 tweets and > 400 videos, of which we analyzed 260 tweets and 260 videos. Sources included institutions (53.5% Twitter, 64.2% You- Tube), health professionals (42.3%, 28.5%), and patients (4.2%, 7.3%). Content included education for professionals (39.2% Twitter, 62.3% YouTube), patient empowerment (20.4%, 21.9%), research promotion (28.8%, 13.1%), professional advocacy (5.8%, 2.7%), and research collaboration (5.8%, 0%).

CONCLUSION

Twitter and YouTube are platforms for knowledge translation in HF, with contributions from institutions, health professionals, and less commonly, from patients. Both focus largely on education for professionals and less commonly on patient empowerment. Twitter includes more research promotion, research collaboration, and professional advocacy than YouTube.

Palliative care in pulmonary hypertension associated with congenital heart disease: systematic review and expert opinion

AIMS

Pulmonary arterial hypertension (PAH) is common amongst patients with congenital heart disease (CHD). It is a severe and complex condition that adversely affects quality of life and prognosis. While quality of life questionnaires are routinely used in clinical pulmonary hypertension practice, little is known on how to interpret their results and manage PAH-CHD patients with evidence of impaired health-related quality of life, especially those with advanced disease and palliative care needs.

METHODS AND RESULTS

We performed a systematic review of studies concerning palliative care for people with PAH-CHD, also reviewing the health-related quality of life literature pertaining to these patients. Of 330 papers identified through initial screening, 17 were selected for inclusion. Underutilization of advance care planning and palliative care resources was common. Where palliative care input was sought, this was frequently late in the course of the disease. No studies provided evidence-based clinical criteria for triggering referral to palliative care, a framework for providing tailored care in this patient group, or how to manage the risk of sudden cardiac death and implantable cardioverter defibrillators in advanced PAH-CHD. We synthesize this information into eight important areas, including the impact of PAH-CHD on quality of life, barriers to and benefits of palliative care involvement, advance care planning discussions, and end-of-life care issues in this complex patient group, and provide expert consensus on best practice in this field.

CONCLUSIONS

This paper presents the results of a systematic review and expert statements on the preferred palliative care strategy for patients with PAH-CHD.

Greater admissions, mortality and cost of heart failure in adults with congenital heart disease

OBJECTIVE

Limited contemporary data exist regarding outcomes and resource use among adults with congenital heart disease and heart failure (ACHD-HF). This study compared outcomes, emergency department (ED) and hospital resource use, and advanced heart failure (HF) therapies in ACHD-HF versus non-ACHD with HF (HF-non-ACHD).

METHODS

The Nationwide Emergency Department Sample and Nationwide Inpatient Sample were used to analyse outcomes and resource use among ACHD-HF ED visits and hospitalisations from 2006 to 2016. ACHD-HF was stratified by single-ventricle (SV) and two-ventricle (2V) disease.

RESULTS

A total of 76 557 ACHD-HF visits (3.6% SV physiology) and 31 137 414 HF-non-ACHD visits were analysed. ACHD-HFs were younger (SV 33 years (IQR 25-44), 2V 62 years (IQR 45-76); HF-non-ACHD 74 years (IQR 63-83); p<0.001). ACHD-HFs had higher ED admissions (78% vs 70%, p<0.001), longer hospital length of stay (5 days (IQR 2-8) vs 4 days (IQR 2-7), p<0.001) and greater hospital costs ($49K (IQR 2K-121K) vs $32K (17K-66K), p<0.001). Mortality was significantly higher among ACHD-HFs with SV physiology (6.6%; OR 1.6, 95% CI 1.1 to 2.3) or 2V physiology (6.3%; OR 1.4, 95% CI 1.3 to 1.5) versus HF-non-ACHD (5.5%). ACHF-HF hospitalisations increased more (46% vs 6% HF-non-ACHD) over a 10-year period, but the proportion receiving ventricular assist device (VAD) (ACHD-HF -2% vs HF-non-ACHD 294%) or transplant (ACHD-HF -37% vs HF-non-ACHD 73%) decreased.

CONCLUSION

ACHD-HFs have significant ED and hospital resource use that has increased over the past 10 years. However, advanced HF therapies (VAD and transplantation) are less commonly used compared with those without adult congenital heart disease.

Barriers and Facilitators of Palliative Care and Advance Care Planning in Adults With Congenital Heart Disease

Palliative care has potential to improve quality of life and goal-concordant care for patients with adult congenital heart disease (ACHD). However, it is rarely employed prior to critical illness because the best methods for implementation are not well-defined. We qualitatively evaluated ACHD patients' understanding of and opinions regarding palliative care and advance care planning (ACP) to better define the needs of this population. We conducted a thematic analysis of 25 semistructured interviews with patients with ACHD in which we assessed participants' perspectives on the need for, and barriers and facilitators to, the use of palliative care and ACP. In a group of participants with ACHD (mean age 38, 48% male) classified as simple (24%), moderate (32%), or complex (44%), we identified 4 major themes: (1) using knowledge to combat future uncertainties; (2) unfamiliarity with and limited exposure to palliative care and ACP; (3) facilitators and barriers to engaging in palliative care and ACP; and (4) importance of timing and presentation of ACP discussions. In conclusion, participants expressed a desire for knowledge about ACHD progression and treatment. They supported routine incorporation of palliative care and ACP and identified related facilitators and barriers to doing so. Importantly, timing and format of these discussions must be individualized using shared decision-making between clinicians, patients, and their families.

Value of Advance Care Directives for Patients With Serious Illness in the Era of COVID Pandemic: A Review of Challenges and Solutions

Advance care directives (ACDs) are instructions regarding what types of medical treatments a patient desires and/or who they would like to designate as a healthcare surrogate to make important healthcare decisions when the patient is mentally incapacitated. At end-of-life, when faced with poor prognosis for a meaningful health-related quality of life, most patients indicate their preference to abstain from aggressive, life-sustaining treatments. Patients whose wishes are left unsaid often receive burdensome life sustain therapy by default, prolonging patient suffering. The CoVID pandemic has strained our healthcare resources and raised the need for prioritization of life-sustaining therapy. This highlights the urgency of ACDs more than ever. Despite ACDs' potential to provide patients with care that aligns with their values and preferences and reduce resource competition, there has been relatively little conversation regarding the overlap of ACDs and CoVID-19. There is low uptake among patients, lack of training for healthcare professionals, and inequitable adoption in vulnerable populations. However, solutions are forthcoming and may include electronic medical record completion, patient outreach efforts, healthcare worker programs to increase awareness of at-risk minority patients, and restructuring of incentives and reimbursement policies. This review carefully describes the above challenges and unique opportunities to address them in the CoVID-19 era. If solutions are leveraged appropriately, ACDs have the potential to address the described challenges and ethically resolve resource conflicts during the current crisis and beyond.

Palliative Care Opportunities Among Adults With Congenital Heart Disease-A Systematic Review

CONTEXT

Little is known about advance care planning (ACP) and palliative care needs among adults with congenital heart disease (ACHD).

OBJECTIVES

The objective of this study was to identify and synthesize studies concerning palliative care among ACHD patients.

METHODS

We searched five electronic databases (PubMed, Embase, SCOPUS, Web of Science, and CINAHL) using the keywords palliative care and congenital heart disease. Inclusion criteria were adults (age > 18 years) with congenital heart disease and publications in English through March 3, 2019.

RESULTS

Our search yielded 2872 studies, and after removal of duplicates, we screened 2319 abstracts and identified seven for inclusion. Study findings were grouped into three domains: ACP, symptomatology, and end-of-life care. Among the five cross-sectional studies, only 1%-28% of ACHD patients recalled participating in ACP discussions with their doctors but 69%-78% reported a strong interest and desire to participate in ACP. In one study, 46% (n = 67) of patients had elevated anxiety symptoms (Hospital Anxiety and Depression Scale [HADS-A] ≥ 8) and 11% (n = 15) had elevated depressive symptoms (HADS-A ≥ 8). ACHD patients who had a documented goals of care conversation before cardiac decompensation had a lower incidence of resuscitation and aggressive treatments at end of life (12% [n = 3] vs. 100% [n = 12], P < 0.001).

CONCLUSION

While few ACHD patients complete advance directives, our findings support that many ACHD patients recognize the value of initiating end-of-life and goals of care conversations early on in the course of illness. Future studies investigating communication and implementation strategies of ACP as well as the symptom experience of patients with ACHD are needed.