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Meehan CP, White E, CVitan A, Jiang L, Wu WC, Wice M, Stafford J, Rudolph JL. Factors Associated With Early Palliative Care Among Patients With Heart Failure. J Palliat Med 2024. [PMID: 38608234 DOI: 10.1089/jpm.2023.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.
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Affiliation(s)
- Caroline P Meehan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Emily White
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Alexander CVitan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mitchell Wice
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Jensy Stafford
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Habib MH, Tiger YKR, Dima D, Schlögl M, McDonald A, Mazzoni S, Khouri J, Williams L, Anwer F, Raza S. Role of Palliative Care in the Supportive Management of AL Amyloidosis-A Review. J Clin Med 2024; 13:1991. [PMID: 38610755 PMCID: PMC11012321 DOI: 10.3390/jcm13071991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Light chain amyloidosis is a plasma-cell disorder with a poor prognosis. It is a progressive condition, causing worsening pain, disability, and life-limiting complications involving multiple organ systems. The medical regimen can be complex, including chemotherapy or immunotherapy for the disease itself, as well as treatment for pain, gastrointestinal and cardiorespiratory symptoms, and various secondary symptoms. Patients and their families must have a realistic awareness of the illness and of the goals and limitations of treatments in making informed decisions about medical therapy, supportive management, and end-of-life planning. Palliative care services can thus improve patients' quality of life and may even reduce overall treatment costs. Light chain (AL) amyloidosis is a clonal plasma cell disorder characterized by the excessive secretion of light chains by an indolent plasma cell clone that gradually accumulates in vital organs as amyloid fibrils and leads to end-organ damage. With progressive disease, most patients develop diverse clinical symptoms and complications that negatively impact quality of life and increase mortality. Complications include cardiac problems including heart failure, hypotension, pleural effusions, renal involvement including nephrotic syndrome with peripheral edema, gastrointestinal symptoms leading to anorexia and cachexia, complex pain syndromes, and mood disorders. The prognosis of patients with advanced AL amyloidosis is dismal. With such a complex presentation, and high morbidity and mortality rates, there is a critical need for the establishment of a palliative care program in clinical management. This paper provides an evidence-based overview of the integration of palliative care in the clinical management of AL amyloidosis as a means of reducing ER visits, rehospitalizations, and in-hospital mortality. We also discuss potential future collaborative directions in various aspects of clinical care related to AL amyloidosis.
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Affiliation(s)
- Muhammad Hamza Habib
- Department of Palliative Care, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ 08901, USA
| | - Yun Kyoung Ryu Tiger
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
| | - Danai Dima
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
| | - Mathias Schlögl
- Department of Geriatric Medicine, Clinic Barmelweid, 5017 Barmelweid, Switzerland;
| | - Alexandra McDonald
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
| | - Sandra Mazzoni
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
| | - Jack Khouri
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
| | - Louis Williams
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
| | - Faiz Anwer
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
| | - Shahzad Raza
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.D.); (A.M.); (S.M.); (J.K.); (L.W.); (F.A.); (S.R.)
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3
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Belur AD, Mehta A, Bansal M, Wieruszewski PM, Kataria R, Saad M, Clancy A, Levine DJ, Sodha NR, Burtt DM, Rachu GS, Abbott JD, Vallabhajosyula S. Palliative care in the cardiovascular intensive care unit: A systematic review of current literature. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00112-X. [PMID: 38531709 DOI: 10.1016/j.carrev.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
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.
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Affiliation(s)
- Agastya D Belur
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, United States of America
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Mridul Bansal
- Department of Medicine, East Carolina University Brody School of Medicine, Greenville, NC, United States of America
| | - Patrick M Wieruszewski
- Departments of Pharmacy and Anesthesiology, Mayo Clinic, Rochester, MN, United States of America
| | - Rachna Kataria
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Marwan Saad
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Annaliese Clancy
- Department of Pharmacy, Lifespan Health System, Providence, RI, United States of America
| | - Daniel J Levine
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Neel R Sodha
- Lifespan Cardiovascular Institute, Providence, RI, United States of America; Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Douglas M Burtt
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Gregory S Rachu
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - J Dawn Abbott
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America.
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4
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Bharani A, Mehta A, Hiensch K, Zeng L, Lala A, Pinney S, Goldstein N, Chai E, Gelfman LP. Referral Versus Embedded Palliative Care Consultation Among People Hospitalized With Heart Failure: A Report From a Single Center Pilot Program. J Pain Symptom Manage 2024; 67:241-249. [PMID: 38040389 DOI: 10.1016/j.jpainsymman.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023]
Abstract
CONTEXT Despite calls for integration into routine heart failure (HF) care, optimal palliative care delivery for people living with HF remains unclear. OBJECTIVES Describe an innovative model of an embedded palliative care nurse practitioner (NP) within a HF team. Compare demographics and utilization among people hospitalized with HF receiving referral or embedded consultation. METHODS Using an electronic health record-based palliative care registry, we conducted descriptive analyses and t-tests and χ2 tests, as appropriate, to examine bivariate associations between sociodemographic, clinical and utilization data of hospitalized people with HF receiving a traditional, referral-based palliative care consultation generated exclusively by the primary team vs. a novel, embedded-based consultation generated by collaboration between a palliative care NP and the advanced HF team at an urban, quaternary care academic medical center in New York City. RESULTS During the study period from January 1, 2019-December 31, 2021, consultation volume nearly doubled with 363 consults from traditional referrals and an additional 317 consults from the newly embedded NP. People in the embedded group, as compared to referral, were younger (mean age: 60.1 vs. 71.9 years (2019); 59.2 vs. 70.4 (2020); 61.3 vs. 69.6 (2021), p-value < 0.001), more functional (median Karnofsky Performance Status: 40% vs. 30%, p-value = 0.01 (2019); 40% vs 20%, p-value < 0.0001 (2020); 40% vs. 20%, p-value = 0.02 (2021)), more likely had capacity to designate a medical decision maker (56.4% vs. 20.6%, p-value < 0.001 (2020); 76.3% vs. 49.5%, p-value < 0.001 (2021)), received earlier consultation (median days before discharge: 9.5 vs. 4 (2019); 11 vs. 5 (2020); 7 vs. 3 (2021), p-value ≤ 0.001), and more likely to discharge home (60% vs. 26%, p-value ≤ 0.001 (2019); 62.7% vs 20.6%, p-value ≤ 0.001 (2020); 42.3% vs. 28%, p-value = 0.03 (2021)). CONCLUSION Hospitalized people living with advanced HF who received an embedded palliative care consult were younger, had higher functional status and less illness severity compared to those served by a traditional, referral-based consult.
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Affiliation(s)
- Anup Bharani
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Ankita Mehta
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karen Hiensch
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anuradha Lala
- The Zena and Michael A. Wiener Cardiovascular Institute (A.L., S.P.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.L.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Pinney
- The Zena and Michael A. Wiener Cardiovascular Institute (A.L., S.P.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Geriatric Research Education and Clinical Center (L.P.G.), James J. Peters VA Medical Center, Bronx, New York, USA
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Fraser M, Barnes SG, Barsness C, Beavers C, Bither CJ, Boettger S, Hallman C, Keleman A, Leckliter L, McIlvennan CK, Ozemek C, Patel A, Pierson NW, Shakowski C, Thomas SC, Whitmire T, Anderson KM. Nursing care of the patient hospitalized with heart failure: A scientific statement from the American Association of Heart Failure Nurses. Heart Lung 2024; 64:e1-e16. [PMID: 38355358 DOI: 10.1016/j.hrtlng.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Meg Fraser
- University of Minnesota MHealth Physicians, Minneapolis, MN, USA.
| | | | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | | | | | - Anne Keleman
- MedStar Washington Section of Palliative Care, Washington, DC, USA
| | | | | | - Cemal Ozemek
- University of Illinois at Chicago, Cardiac Rehabilitation, College of Applied Health Sciences, Chicago, IL, USA
| | - Amit Patel
- Ascension St. Vincent Medical Group Cardiology, Indianapolis, IN, USA
| | - Natalie W Pierson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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6
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Johnson K, Vaughan L, Dulin J, Higgins E, Southard A. A Single-Center Analysis of Palliative-Care Clinician Contact Following Declination of Advanced Heart Failure Therapy. J Card Fail 2024:S1071-9164(24)00012-5. [PMID: 38280411 DOI: 10.1016/j.cardfail.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 12/07/2023] [Accepted: 12/21/2023] [Indexed: 01/29/2024]
Affiliation(s)
- Kolby Johnson
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Leigh Vaughan
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer Dulin
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Higgins
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Abigail Southard
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
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7
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McClung JA, Frishman WH, Aronow WS. The Role of Palliative Care in Cardiovascular Disease. Cardiol Rev 2024:00045415-990000000-00182. [PMID: 38169299 DOI: 10.1097/crd.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.
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Affiliation(s)
- John Arthur McClung
- From the Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
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8
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Kittleson MM. Management of Heart Failure in Hospitalized Patients. Ann Intern Med 2023; 176:ITC177-ITC192. [PMID: 38079639 DOI: 10.7326/aitc202312190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Heart failure affects more than 6 million people in the United States, and hospitalizations for decompensated heart failure confer a heavy toll in morbidity, mortality, and health care costs. Clinical trials have demonstrated effective interventions; however, hospitalization and mortality rates remain high. Key components of effective hospital care include appropriate diagnostic evaluation, triage and risk stratification, early implementation of guideline-directed medical therapy, adequate diuresis, and appropriate discharge planning.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California (M.M.K.)
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9
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Godfrey S, Kirkpatrick JN, Kramer DB, Sulistio MS. Expanding the Paradigm for Cardiovascular Palliative Care. Circulation 2023; 148:1039-1052. [PMID: 37747951 PMCID: PMC10539017 DOI: 10.1161/circulationaha.123.063193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/13/2023] [Indexed: 09/27/2023]
Abstract
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.
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Affiliation(s)
- Sarah Godfrey
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, TX, USA
| | | | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melanie S. Sulistio
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, TX, USA
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10
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Taj J, Taylor EP. End-Stage/Advanced Heart Failure: Geriatric Palliative Care Considerations. Clin Geriatr Med 2023; 39:369-378. [PMID: 37385689 DOI: 10.1016/j.cger.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Heart failure remains a condition with high morbidity and mortality affecting 23 million people globally with a cost burden equivalent to 5.4% of the total health care budget in the United States. These costs include repeated hospitalizations as the disease advances and care that may not align with individual wishes and values. The coincidence of comorbid conditions with advanced heart failure poses significant challenges in the geriatric population. Advance care planning, medication education, and minimizing polypharmacy are primary palliative opportunities leading to specialist palliative care such as symptom management at end of life and timing of referral to hospice.
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Affiliation(s)
- Jabeen Taj
- Division of Hospice and Palliative Medicine, Department of Family Medicine, Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road, Atlanta, GA 30322, USA.
| | - Emily Pinto Taylor
- Division of General Internal Medicine, Department of Family Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Drive Southeast, Atlanta, GA 30303, USA; Division of Hospice and Palliative Medicine, Department of Family Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Drive Southeast, Atlanta, GA 30303, USA
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11
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DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Dy SM, Davidson PM, Szanton SL, Saylor MA. Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure. J Pain Symptom Manage 2023; 65:500-509. [PMID: 36736499 PMCID: PMC10192105 DOI: 10.1016/j.jpainsymman.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023]
Abstract
CONTEXT Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described. OBJECTIVES This study describes the PC needs of community dwelling, physically frail persons with HF. METHODS We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs. RESULTS Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001). CONCLUSION Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.
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Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA.
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Johns Hopkins University School of Medicine (N.A.G), Baltimore, Maryland, USA
| | - Sydney M Dy
- Johns Hopkins University School of Public Health (S.M.D), Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Martha Abshire Saylor
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
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Gruen J, Gandhi P, Gillespie-Heyman S, Shamas T, Adelman S, Ruskin A, Bauer M, Merchant N. Hospitalisations for heart failure: increased palliative care referrals - a veterans affairs hospital initiative. BMJ Support Palliat Care 2023:spcare-2022-004118. [PMID: 36609533 DOI: 10.1136/spcare-2022-004118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Heart failure (HF) portends significant morbidity and mortality. Integrating palliative care (PC) with HF management improves quality of life and preparedness planning. At a Veterans Affairs hospital, PC was used in 6.5% of patients admitted for HF from October 2019 to September 2020. We sought to increase the percentage of referrals to PC to 20%. METHODS PC referral guidelines were developed and used to screen all HF admissions between October 2020 and May 2021. Point-of-care education on the benefits of PC was delivered to teams caring for patients who met PC referral criteria. Changes were tested using Plan-Do-Study-Act (PDSA) cycles. Results were analysed using run charts. RESULTS During the study period, there were 109 HF admissions in patients who were not already followed by PC. Thirty-one (28%) received a new PC consult. The mean age was 81±9.5 years, median B-type natriuretic peptide was 1202 pg/mL, and mean length of stay was 8±5 days. After our intervention, there was an upward shift in the percentage of new referrals to PC with 6 values above the baseline median, which represents a significant change. CONCLUSIONS Through multiple PDSA cycles, referrals to PC for patients admitted with HF increased from 6.5% to 28%. Point-of-care education was an effective tool to teach medical teams about the benefits of PC. Inpatient teams more consistently and independently considered PC for patients with HF, representing a cultural shift. This quality improvement model may serve as a paradigm to improve the care of HF patients.
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Affiliation(s)
- Jadry Gruen
- Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Parul Gandhi
- Cardiovascular Disease, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Cardiovascular Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarah Gillespie-Heyman
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Tracy Shamas
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Samuel Adelman
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Andrea Ruskin
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Margaret Bauer
- Mental Health, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Naseema Merchant
- Hospital Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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13
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Rohlfing AB, Bischoff KE, Kolaitis NA, Kronmal RA, Kime NA, Gray MP, Bartolome S, Chakinala MM, Frantz RP, Ventetuolo CE, Mathai SC, De Marco T. Palliative care referrals in patients with pulmonary arterial hypertension: The Pulmonary Hypertension Association Registry. Respir Med 2023; 206:107066. [PMID: 36470050 DOI: 10.1016/j.rmed.2022.107066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/07/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a life limiting disease with substantial symptom burden and healthcare utilization. Palliative care alleviates physical and emotional symptoms for patients with serious illness, and has been underutilized for these patients. OBJECTIVE To characterize patients with PAH referred to palliative care and identify predictors of referral. METHODS We conducted an observational study of adult patients enrolled in the Pulmonary Hypertension Association Registry from January 2015 through June 2021, performing descriptive statistics on patient characteristics at baseline for all patients and the subset referred to palliative care. These characteristics were modeled in a backwards elimination Cox regression with time to referral to palliative care as the primary outcome. RESULTS 92 of 1,578 patients were referred to palliative care (5.8%); 43% were referred at their last visit prior to death. Referrals were associated with increasing age per decade (hazard ratio 1.35 [95% confidence interval 1.16-1.58]), lower body mass index (hazard ratio 0.97 [95% confidence interval 0.94-0.998]), supplemental oxygen use (hazard ratio 2.01 [95% confidence interval 1.28-3.16]), parenteral prostanoid use (hazard ratio 2.88 [95% confidence interval 1.84-4.51]), and worse quality of life, measured via lower physical (hazard ratio 0.97 [95% confidence interval 0.95-0.99]) and mental (hazard ratio 0.98 [95% confidence interval 0.96-0.995]) scores on the 12-item Short Form Health Survey. CONCLUSION Patients with PAH are infrequently referred to palliative care, even at centers of excellence. Referrals occur in sicker patients with lower quality of life scores, often close to the end of life.
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Affiliation(s)
- Anne B Rohlfing
- Extended Care & Palliative Medicine Service, VA Palo Alto Health Care System, Palo Alto, CA, United States; Division of Primary Care & Population Health, Stanford Medicine, Stanford, CA, United States.
| | - Kara E Bischoff
- Division of Palliative Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Nicholas A Kolaitis
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Richard A Kronmal
- Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Noah A Kime
- Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Michael P Gray
- Faculty of Medicine & Health, Division of Cardiology, University of Sydney Royal North Shore Hospital, Sydney, NSW, Australia.
| | - Sonja Bartolome
- Division of Pulmonary & Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Murali M Chakinala
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, St Louis, MO, United States.
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care & Sleep Medicine, Brown University, Providence, RI, United States.
| | - Stephen C Mathai
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco, San Francisco, CA, United States.
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14
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Fürst P, Schultz T, Strang P. Specialized Palliative Care for Patients with Chronic Heart Failure at End of Life: Transfers, Emergency Department Visits, and Hospital Deaths. J Palliat Med 2022. [PMID: 36576786 DOI: 10.1089/jpm.2022.0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Specialized palliative care (SPC) may contribute to improved quality of life in patients with life-limiting chronic heart failure (CHF). This study examined SPC and possible differences in the care process regarding emergency department (ED) visits, transfers, and place of death for severely ill patients with CHF. Materials and Methods: This retrospective observational registry study used the health care consumption data from the Stockholm Regional Council. Logistic regression analyses of age, sex, palliative care, comorbidities, and socioeconomic status were performed. Results: Of the 4322 individuals who died of heart failure between 2015 and 2019 and did not reside in a nursing home, 24% received SPC. Receiving SPC was associated with a lower odds ratio (OR) of ED visits (OR 0.24, p < 0.0001), unplanned transfers (OR 0.39, p < 0.0001), and emergency hospital as a place of death (OR 0.10, p < 0.0001). Furthermore, a better socioeconomic situation, younger age, and fewer comorbidities were associated with a lower OR of ED visits and transfers (p < 0.0001 to p = 0.013 in different comparisons). Multiple comorbidities (p < 0.0002) and younger age (p < 0.0001) were associated with a higher OR of emergency hospitals as a place of death. Conclusion: Approximately one-quarter of patients who died of heart failure received SPC. Receipt of SPC was associated with a significantly reduced number of ED visits, transfers between health care services, and risk of dying in emergency hospitals.
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Affiliation(s)
- Per Fürst
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Torbjörn Schultz
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Peter Strang
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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15
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Yazdanyar A, Guthier D, Maitz T, Singh S, Parfianowicz D, Li S, Jarjous S. Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure. Future Cardiol 2022; 18:809-816. [PMID: 36052818 DOI: 10.2217/fca-2022-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Ali Yazdanyar
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Desire Guthier
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18013, USA
| | - Theresa Maitz
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18013, USA
| | - Satinder Singh
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA
| | - Dominic Parfianowicz
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18013, USA
| | - Shuisen Li
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Shadi Jarjous
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
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16
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Graham C, Schonnop R, Killackey T, Kavalieratos D, Bush SH, Steinberg L, Mak S, Quinn K, Isenberg SR. Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study. J Am Heart Assoc 2022; 11:e024628. [PMID: 35730640 PMCID: PMC9333360 DOI: 10.1161/jaha.121.024628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home-based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home. Methods and Results We conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi-structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on-going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours). Conclusions Our results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.
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Affiliation(s)
- Cassandra Graham
- Division of Palliative Medicine, Department of Medicine University of Toronto Toronto Canada.,Division of Palliative Care University Health Network Toronto Canada
| | - Rebecca Schonnop
- Department of Emergency Medicine University of Alberta Edmonton Canada.,Department of Emergency Medicine Royal Alexandra Hospital Edmonton Canada
| | - Tieghan Killackey
- Child Health Evaluative Sciences The Hospital for Sick Children Toronto Canada
| | - Dio Kavalieratos
- Division of Palliative Medicine Emory University Atlanta Georgia
| | - Shirley H Bush
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Canada.,Bruyere Continuing Care Ottawa Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada.,Division of Palliative Care SinaiHealth Toronto Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine University of Toronto Toronto Canada.,Division of Cardiology Department of Medicine SinaiHealth Toronto Canada
| | - Kieran Quinn
- Department of Medicine University of Toronto Toronto Canada.,ICES Toronto and Ottawa Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada.,Department of Medicine SinaiHealth Toronto Canada
| | - Sarina R Isenberg
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada
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17
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Ament SMC, van den Broek LM, van den Beuken-van Everdingen MHJ, Boyne JJJ, Maessen JMC, Bekkers SCAM, Bellersen L, Rocca HPBL, Engels Y, Janssen DJA. What to consider when implementing a tool for timely recognition of palliative care needs in heart failure: a context-based qualitative study. Palliat Care 2022; 21:1. [PMID: 34980105 PMCID: PMC8723899 DOI: 10.1186/s12904-021-00896-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Needs assessment tools can facilitate healthcare professionals in timely recognition of palliative care needs. Despite the increased attention for implementation of such tools, most studies provide little or no attention to the context of implementation. The aim of this study was to explore factors that contribute positively and negatively to timely screening of palliative care needs in advanced chronic heart failure. METHODS Qualitative study using individual interviews and focus groups with healthcare professionals. The data were analysed using a deductive approach. The Consolidated Framework for Implementation Research was used to conceptualise the contextual factors. RESULTS Twenty nine healthcare professionals with different backgrounds and working in heart failure care in the Southern and Eastern parts of the Netherlands participated. Several factors were perceived to play a role, such as perception and knowledge about palliative care, awareness of palliative care needs in advanced chronic heart failure, perceived difficulty when and how to start palliative care, limited acceptance to treatment boundaries in cardiology, limited communication and collaboration between healthcare professionals, and need for education and increased attention for palliative care in advanced chronic heart failure guidelines. CONCLUSIONS This study clarified critical factors targeting patients, healthcare professionals, organisations to implement a needs assessment tool for timely recognition of palliative care needs in the context of advanced chronic heart failure. A multifaceted implementation strategy is needed which has attention for education, patient empowerment, interdisciplinary collaboration, identification of local champions, chronic heart failure specific guidelines and culture.
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Affiliation(s)
- Stephanie M C Ament
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | | | | | - Josiane J J Boyne
- Department of Patient and Care, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - José M C Maessen
- Department of Patient and Care, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Sebastiaan C A M Bekkers
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands. .,Department of Research and Development, Ciro Horn, P.O. Box 4009, Haelen, 6080 AA, the Netherlands.
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18
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Arenas Ochoa LF, González-Jaramillo V, Saldarriaga C, Lemos M, Krikorian A, Vargas JJ, Gómez-Batiste X, Gonzalez-Jaramillo N, Eychmüller S. Prevalence and characteristics of patients with heart failure needing palliative care. BMC Palliat Care 2021; 20:184. [PMID: 34856953 PMCID: PMC8638101 DOI: 10.1186/s12904-021-00850-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/16/2021] [Indexed: 12/28/2022] Open
Abstract
Background Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems. Methods This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (–NECPAL). Results Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to –NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems. Conclusion The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00850-y.
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Affiliation(s)
- Luisa Fernanda Arenas Ochoa
- Pain and Palliative Care Group, School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia.,Department of Palliative Care, Clínica Cardio VID, Medellín, Colombia
| | - Valentina González-Jaramillo
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. .,Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Clara Saldarriaga
- Department of Cardiology, Clínica Cardio VID, Medellín, Colombia.,Cardiology Department, Universidad de Antioquia, Medellín, Colombia
| | - Mariantonia Lemos
- Department of Psychology, School of Humanities, Universidad EAFIT, Medellín, Colombia
| | - Alicia Krikorian
- Pain and Palliative Care Group, School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - John Jairo Vargas
- Pain and Palliative Care Group, School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia.,Institute of Cancerology, Clínica Las Américas, Medellin, Colombia
| | - Xavier Gómez-Batiste
- Chair Qualy Palliative Care, Faculty Medicine, University of Vic/Central of Catalonia, Barcelona, Spain
| | - Nathalia Gonzalez-Jaramillo
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
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19
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Elkaryoni A, Sperry BW, Royce A, Walsh K, Bruno E, Shah S, Darki A, Elgendy IY. Hospitalization Rates Before and After Palliative Care Utilization for Heart Failure Patients (from a Nationwide Sample). Am J Cardiol 2021; 145:169-170. [PMID: 33561424 DOI: 10.1016/j.amjcard.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
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20
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Sobanski PZ, Krajnik M, Goodlin SJ. Palliative Care for People Living With Heart Disease-Does Sex Make a Difference? Front Cardiovasc Med 2021; 8:629752. [PMID: 33634172 PMCID: PMC7901984 DOI: 10.3389/fcvm.2021.629752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Center, Department of Internal Medicine, Spital Schwyz, Schwyz, Switzerland
| | - Malgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Sarah J Goodlin
- Geriatrics and Palliative Medicine, Veterans Affairs Portland Health Care System, Department of Medicine, Oregon Health and Sciences University, Patient-Centered Education and Research, Portland, OR, United States
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21
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Diop MS, Bowen GS, Jiang L, Wu WC, Cornell PY, Gozalo P, Rudolph JL. Palliative Care Consultation Reduces Heart Failure Transitions: A Matched Analysis. J Am Heart Assoc 2020; 9:e013989. [PMID: 32456514 PMCID: PMC7428983 DOI: 10.1161/jaha.119.013989] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Palliative care supports quality of life, symptom control, and goal setting in heart failure (HF) patients. Unlike hospice, palliative care does not restrict life‐prolonging therapy. This study examined the association between palliative care during hospitalization for HF on the subsequent transitions and procedures. Methods and Results Veterans admitted to hospitals with HF from 2010 to 2015 were randomly selected for the Veterans Administration External Peer Review Program. Variables pertaining to demographic, clinical, laboratory, and usage were captured from Veterans Administration electronic records. Patients receiving hospice services before admission were excluded. Patients who received palliative care were propensity matched to those who did not. The primary outcomes were whether the patient experienced transitions or procedures in the 6 months after admission. Transitions included multiple readmissions (≥2) or intensive care admissions and procedures included mechanical ventilation, pacemaker implantation, or defibrillator implantation. Among 57 182 hospitalized HF patients, 1431 received palliative care, and were well matched to 1431 without (standardized mean differences ≤ ±0.05 on all matched variables). Palliative care was associated with significantly fewer multiple rehospitalizations (30.9% versus 40.3%, P<0.001), mechanical ventilation (2.8% versus 5.4%, P=0.004), and defibrillator implantation (2.1% versus 3.6%, P=0.01). After adjustment for facility fixed effects, palliative care consultation was associated with a significantly reduced hazard of multiple readmissions (adjusted hazard ratio=0.73, 95% CI, 0.64–0.84) and mechanical ventilation (adjusted hazard ratio=0.76, 95% CI, 0.67–0.87). Conclusions Palliative care during HF admissions was associated with fewer readmissions and less mechanical ventilation. When available, engagement of HF patients and caregivers in palliative care for symptom control, quality of life, and goals of care discussions may be associated with reduced rehospitalizations and mechanical ventilation.
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Affiliation(s)
- Michelle S Diop
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI.,Primary Care and Population Medicine Program Warren Alpert Medical School of Brown University Providence RI
| | - Garrett S Bowen
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI.,Primary Care and Population Medicine Program Warren Alpert Medical School of Brown University Providence RI
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI
| | - Wen-Chih Wu
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI.,Department of Medicine Warren Alpert Medical School of Brown University Providence RI
| | - Portia Y Cornell
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI.,Center for Gerontology and Healthcare Research Brown University School of Public Health Providence RI
| | - Pedro Gozalo
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI.,Center for Gerontology and Healthcare Research Brown University School of Public Health Providence RI
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports Providence VA Medical Center Providence RI.,Department of Medicine Warren Alpert Medical School of Brown University Providence RI.,Center for Gerontology and Healthcare Research Brown University School of Public Health Providence RI
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