“Teach a Man to Fish”: Clinician Perspectives on Primary Palliative Care in Heart Failure

Abstract

Purpose Heart failure (HF) is a common, debilitating disease that decreases both longevity and leads to decreased quality of life. Palliative care is a clinical subspecialty, and overall approach to care, that emphasizes alleviation of suffering through symptom management, psychosocial support, and assistance with complex treatment decision-making. Despite recommendations from major cardiology societies, specialty palliative care remains underutilized in HF. Accordingly major cardiology societies have called for clinicians without specialty palliative care training to deliver basic palliative competencies (i.e., “primary” palliative care), such as symptom management and goals-of-care elicitation. It is unclear what non-palliative care specialists caring for patients with HF view as barriers and facilitators to delivering primary palliative care. Methods We conducted semi-structured phenomenological interviews with physicians, nurses, and physician assistants caring for patients with HF across the United States, recruited through a snowball convenience sample. Interview topics included: 1) a hypothetical treatment strategy for an advanced HF patient with significant unmet palliative needs; 2) knowledge and attitudes regarding the role of both primary and specialty palliative care in HF; and, 3) barriers and facilitators of primary palliative care integration in standard HF management. Two analysts independently coded data using template analysis, a hybrid inductive/deductive qualitative technique. Results We interviewed 18 clinicians: 4 physicians and 2 advanced practice providers from primary care, cardiology, and palliative care specialties. 61% were female, 89% Caucasian, average age was 43, and the median years in practice, 12. We identified several barriers to primary palliative care integration including 1) structural and organizational barriers like time constraints; 2) attitudinal barriers, such as discomfort addressing goals-of-care; and 3) educational deficits including a perceived lack of training in primary palliative care skills (e.g., symptom management, difficult communication). Clinicians of all non-palliative specialties interviewed desired training in these skills. Conclusion Many clinician-perceived barriers to the provision of primary palliative care in HF may be addressed through education regarding symptom management and advance care planning communication. Others, such as time constraints and organizational barriers, may be reduced through normalizing and integrating palliative care as a natural facet of standard HF management. While clinician respondents endorsed integrating primary palliative care into routine HF care, randomized trials are needed to establish the effectiveness of primary palliative care interventions, including HF primary palliative care curricula.