Resultados de un programa de Cuidados Paliativos en pacientes con insuficiencia cardíaca avanzada en etapa final de vida

Abstract

Introduction: The prevalence of heart failure is on the rise. In its advanced stage (AHF) the condition manifests with incapacitating symptoms. Exacerbations, frequent admissions, and high morbidity and mortality represent conditions amenable to palliative care. A cardiology palliative care (CPC) program was designed to monitor symptoms, deepen communication, establish advanced directives, and adjust therapeutic efforts. The goal of the study was to compare the care of patients who died from AHF before and after CPC program implementation. Material and methods: This was an observational, comparative study. CPC was offered to patients with AHF, and these subjects were compared to a control group without CPC because of unavailability (preCPC). In the statistical analysis categorical variables were evaluated using non-parametric tests. Continuous variables were compared using the Mann-Whithey U-test. Results: Seventy-seven patients were included in the preCPC group, and 65 in the CPC group. They all had similar demographic characteristics: age (median), 75 years; male gender, 70 %. A decrease in duration (27.3 vs. 7.2; p < 0.001) and in number of hospital admissions (2.64 vs. 1.51; p < 0.001) was found in the CPC group as compared to the control group. Invasive procedures within the final 5 days of life predominated in the preCPC group; assisted mechanical ventilation (52.7 % vs. 7.8 %; p < 0.001), hemodialysis (41 % vs. 5.5 %; p < 0.001), cardiopulmonary resuscitation (88.2 % vs. 11 %; p < 0.001), central vascular access (75.7 % vs. 26.5 %, p < 0.01), and use of inotropics (70.5 % vs. 20 %; p < 0.001). Non-invasive, comfort interventions predominated in the CPC group: palliative sedation (3 % vs. 25 %), opioid use (35 % vs. 58.3 %), deactivation of implantable cardiac defibrillator (0 vs. 37,5 %), and do-not-resuscitate orders (3 % vs. 77 %; p < 0.001). Mortality in critical care settings predominated in the preCPC group (51 % vs. 26 %; p < 0.005). Discussion: CPC improves quality of care for patients with AHF, and ensures adequacy of therapeutic efforts, thus preventing disproportionate, unnecessary interventions.