In the Journals

Palliative care underused in HF despite benefits

Patients living with HF receive palliative care less often than those with cancer and other diseases despite evidence-based benefits, according to a study.

“Palliative care is an interdisciplinary approach, as well as a clinical subspecialty that focuses on improving [quality of life] and reducing suffering among patients with serious illness and their families. Core domains of palliative care interventions include expert assessment of pain and other physical symptoms, psychosocial care, identification of goals of care and support for complex treatment and decision-making,” Dio Kavalieratos, PhD, director of implementation research at the University of Pittsburgh Medical Center Palliative and Supportive Institute, and colleagues wrote. “However, most evidence for palliative care emanates from oncology; the role of palliative care in chronic, nonmalignant illnesses such as HF is underdeveloped.”

Kavalieratos and colleagues reviewed six palliative care intervention trials that included a combined 1,007 patients to understand how patients with HF can benefit from this type of care.

The researchers used studies that either exclusively enrolled people with HF or reported disease-specific outcomes.

Existing evidence

One study, which compared inpatient consultation with a palliative care team with standard of care for acute HF, found significant improvements in patient-reported outcomes, including quality of life, symptom burden and mood. There was no association found with survival or 30-day hospital readmission.

Another study evaluated the effect of inpatient palliative care consultation on hospital utilization. No associations were found between the consultation and hospitalization or patient survival.

As Cardiology Today previously reported, in the PAL-HF study, 150 high-risk patients with HF were randomly assigned to usual care or usual care plus palliative care. The palliative care arm had significant improvements in quality of life, mood and spiritual well-being, but there were no significant associations with survival or hospital readmission.

Two studies assessed home-based palliative care and found improvement in quality of life and hospital readmission. However, these studies were deemed to be high risk of bias.

Many guidelines, including those from the American College of Cardiology Foundation, the American Heart Association and the Heart Failure Society of America, have encouraged the incorporation of palliative care for people with HF, although the language varies on the appropriate role of this intervention.

“Multiple guidelines advocate for the involvement of specialty palliative care in decisions regarding high-technology interventions and end-of-life care,” the researchers wrote. “However, there is little emphasis on 1) addressing the many domains of patient and family [quality of life] aside from functional status, 2) integrating palliative care earlier in the HF trajectory or 3) providing palliative care concurrently with HF-directed therapies, particularly for patients who are ineligible for or who prefer not to receive cardiac devices.”

Future research

Kavalieratos and colleagues highlighted three areas where future research in palliative care for patients with HF should focus:

increasing palliative proficiency in all clinicians caring for patients with a serious illness, including HF;

comparing effectiveness of palliative care delivery in terms of provider specialization and delivery method; and

assessing which interventions are most effective for treating symptom burden.

“Given the growing prevalence of HF, the integration of palliative care within HF management represents an opportunity to affect the public health issue of poor [quality of life] in patients and caregivers while optimizing care delivery,” the researchers wrote.

We should not be waiting until heart failure patients are eligible for hospice care — in other words truly at the end of life — to start considering palliative options,” Kavalieratos said in a press release. “With improved education, cardiologist and primary care clinicians can integrate palliative care techniques in their everyday practice.” by Cassie Homer

Disclosures: Kavalieratos reports he received a grant from the NHLBI. Please see the study for all other authors’ relevant financial disclosures.

Patients living with HF receive palliative care less often than those with cancer and other diseases despite evidence-based benefits, according to a study.

“Palliative care is an interdisciplinary approach, as well as a clinical subspecialty that focuses on improving [quality of life] and reducing suffering among patients with serious illness and their families. Core domains of palliative care interventions include expert assessment of pain and other physical symptoms, psychosocial care, identification of goals of care and support for complex treatment and decision-making,” Dio Kavalieratos, PhD, director of implementation research at the University of Pittsburgh Medical Center Palliative and Supportive Institute, and colleagues wrote. “However, most evidence for palliative care emanates from oncology; the role of palliative care in chronic, nonmalignant illnesses such as HF is underdeveloped.”

Kavalieratos and colleagues reviewed six palliative care intervention trials that included a combined 1,007 patients to understand how patients with HF can benefit from this type of care.

The researchers used studies that either exclusively enrolled people with HF or reported disease-specific outcomes.

Existing evidence

One study, which compared inpatient consultation with a palliative care team with standard of care for acute HF, found significant improvements in patient-reported outcomes, including quality of life, symptom burden and mood. There was no association found with survival or 30-day hospital readmission.

Another study evaluated the effect of inpatient palliative care consultation on hospital utilization. No associations were found between the consultation and hospitalization or patient survival.

As Cardiology Today previously reported, in the PAL-HF study, 150 high-risk patients with HF were randomly assigned to usual care or usual care plus palliative care. The palliative care arm had significant improvements in quality of life, mood and spiritual well-being, but there were no significant associations with survival or hospital readmission.

Two studies assessed home-based palliative care and found improvement in quality of life and hospital readmission. However, these studies were deemed to be high risk of bias.

Many guidelines, including those from the American College of Cardiology Foundation, the American Heart Association and the Heart Failure Society of America, have encouraged the incorporation of palliative care for people with HF, although the language varies on the appropriate role of this intervention.

“Multiple guidelines advocate for the involvement of specialty palliative care in decisions regarding high-technology interventions and end-of-life care,” the researchers wrote. “However, there is little emphasis on 1) addressing the many domains of patient and family [quality of life] aside from functional status, 2) integrating palliative care earlier in the HF trajectory or 3) providing palliative care concurrently with HF-directed therapies, particularly for patients who are ineligible for or who prefer not to receive cardiac devices.”

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Future research

Kavalieratos and colleagues highlighted three areas where future research in palliative care for patients with HF should focus:

increasing palliative proficiency in all clinicians caring for patients with a serious illness, including HF;

comparing effectiveness of palliative care delivery in terms of provider specialization and delivery method; and

assessing which interventions are most effective for treating symptom burden.

“Given the growing prevalence of HF, the integration of palliative care within HF management represents an opportunity to affect the public health issue of poor [quality of life] in patients and caregivers while optimizing care delivery,” the researchers wrote.

We should not be waiting until heart failure patients are eligible for hospice care — in other words truly at the end of life — to start considering palliative options,” Kavalieratos said in a press release. “With improved education, cardiologist and primary care clinicians can integrate palliative care techniques in their everyday practice.” by Cassie Homer

Disclosures: Kavalieratos reports he received a grant from the NHLBI. Please see the study for all other authors’ relevant financial disclosures.