Too Few Patients With Heart Failure Get Palliative Care

Abstract

Few patients with heart failure receive palliative care, although their condition often warrants it and evidence suggests it’s helpful, a specialist in geriatrics and palliative medicine told an audience at the 2018 annual meeting of the American Geriatrics Society. “The classic paradigm of palliative care is to think of cancer,” Laura P. Gelfman, MD, MPH, of the Icahn School of Medicine at Mount Sinai and James J. Peters Veterans Affairs Medical Center, told Caring. “But patients with heart failure are also facing a tremendous burden in terms of the symptoms and stress of the illness of itself, and there are burdens on caregivers as well.” The prognosis for heart failure is similar to that of many malignancies as far as life expectancy and progressive functional decline. According to the Centers for Disease Control and Prevention, about 5.7 million Americans have heart failure, and the condition contributed to an estimated one in nine deaths in 2009 (“Heart Failure Fact Sheet,” June 16, 2016; http://bit.ly/2IZTBze). Between 20% to 37% of the residents in skilled nursing facilities are estimated to be patients with heart failure (Circ Heart Fail 2015;8:655–687). “These patients are seriously ill for a long time,” Dr. Gelfman said. “They’re navigating complicated medication regimens and transitions between home and the hospital.” But in contrast to patients with cancer, who more commonly get palliative care, patients with heart failure have a less predictable trajectory, Dr. Gelfman said. In cancer, for instance, it’s often clear that patients are reaching the end of their lives and no longer benefit from treatments like chemotherapy, she said. But patients with heart failure may go through cycles of disease worsening and recovery. “As the pump function of the heart fails, it’s hard to predict when that last exacerbation will occur,” she said. And, in another contrast to cancer, treatments can become available at the later stages of heart failure such as cardiac transplants and ventricular assist devices. So, if the course of heart failure is so different from cancer, why should patients with the condition get palliative care? Because research has confirmed its value, Dr. Gelfman said. She pointed to a 2017 randomized, controlled, single-center clinical trial of palliative care in patients with heart failure. The study, in which 150 patients were evenly divided between the usual care and the usual care plus palliative care, “showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being” compared with usual care, although it found no evidence that palliative care affected rehospitalization or mortality (J Am Coll Cardiol 2017;70:331–341). When bringing up the idea of palliative care in the context of heart failure, Dr. Gelfman advised caregivers to continually talk with patients about their wishes. “Understand that those goals and values may change over time,” she said. The words that caregivers use to bring up the topic of palliative care are important too, said Dr. Gelfman. She suggested reviewing the guidance provided by the Center to Advance Palliative Care (www.capc.org). “Often the way I introduce myself to patients is to say, ‘Your doctor asked us to come by and help you live as best as possible,’” she said. Going forward, “one of the questions will be about how to tailor palliative care for patients with heart failure,” Dr. Gelfman said. “That’s going to require real thoughtfulness. The number of patients with heart failure is fairly vast, and the number of palliative care providers is relatively small.” Randy Dotinga is a San Diego-based freelance writer.