Cardiologist and Hospitalist Decision-Making in Palliative Care Referral for Hospitalized Patients with Heart Failure: A Multi-Institutional Survey (GP700)

Abstract

•Identify several subjective and system-level factors that are influential in hospitalist and cardiologist decision-making regarding the timing and appropriateness of palliative care referral in hospitalized advanced heart failure patients.•Recognize the low uptake of guidelines among hospitalists and cardiologists regarding palliative care delivery to heart failure patients and be able to name opportunities to improve awareness of these guidelines. Despite frequent hospitalizations, end-stage heart failure patients rarely receive palliative care during admissions. To evaluate factors influencing provider decisions about palliative care referral in hospitalized heart failure patients. We conducted a multi-institutional, randomized, vignette-based survey of cardiologists and hospitalists. Participants reported their likelihood of referring a standardized patient with an acute heart failure exacerbation with multiple prior hospital admissions and acute renal failure to palliative care (scale of 0-100%) after the initial stem and again after being cued with three randomized vignette modifiers, including (a) presence versus absence of continuity with an outpatient cardiologist; (b) presence versus absence of documented advance care planning in the medical record; and (c) the patient voicing that he is accepting of his severe illness versus wanting everything done. Adjusted generalized linear models and predictive margins were used to evaluate the impact of each randomized modifier on likelihood of palliative care referral. Response rate was 28.2% (n=188). The mean likelihood of referring the heart failure patient described in the initial vignette to palliative care was similar for cardiologists and hospitalists (59.2% versus 58.5%, P=0.56). Predictive margins from generalized linear models demonstrated (a) lack of continuity with an outpatient cardiologist; (b) documentation of advance care planning in the chart; and (c) patient acceptance of serious illness were associated with higher likelihood of palliative care referral. No interaction effect was noted based on provider specialty. The majority of hospitalists and cardiologists were unaware of palliative care guidelines for patients with heart failure (74.3% versus 70.3%, P=0.71). Factors like patient understanding of disease, provider continuity, and advance care planning documentation may be more impactful in palliative care referral for hospitalized heart failure patients than objective clinical data alone.