Palliative Care Issues for Patients With Heart Failure

Trends and Changes in Intensive Care Use for Patients With Heart Failure in the Last Month of Life

A good death is a human right. Unfortunately, patients with chronic heart failure (CHF) in the terminal stage still receive inappropriate life-sustaining treatment before death. There is limited understanding of the status of intensive care unit (ICU) admission, mechanical ventilation (MV), cardiopulmonary resuscitation (CPR), and even extracorporeal membrane oxygenation (ECMO) for patients with CHF before death, as well as their use of hospice-related services. This study investigated the trends and trend changes in intensive procedures and hospice-related services for patients with CHF in the last month of life. This population-based retrospective observational study included 25 375 patients with CHF from the National Health Insurance research database in Taiwan and collected information on their intensive treatments during the last month of life. We computed intensive treatment utilization rates and analyzed the trends and trend changes via joinpoint regression. The average percentage of patients with CHF admitted to ICUs was 53.27% (n = 13 516). A total of 327 (1.29%) patients with CHF received ECMO. The percentages of patients receiving MV (54.3%'41.5%) and CPR (41.5%'17%) decreased over time. Conversely, the percentage of ECMO use (0.52%'1.78%) increased. However, only 222 (0.87%) patients with CHF received hospice care in the last month of life between 2001 and 2013. The rates of ICU admission and life-sustaining treatment among patients with CHF in the month before death remain high, and hospice-related services remain inadequate. This study highlights the need for research and training in providing palliative and hospice care for patients with CHF.

Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care?

Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.

Specialized Palliative Care for Patients with Chronic Heart Failure at End of Life: Transfers, Emergency Department Visits, and Hospital Deaths

Objective: Specialized palliative care (SPC) may contribute to improved quality of life in patients with life-limiting chronic heart failure (CHF). This study examined SPC and possible differences in the care process regarding emergency department (ED) visits, transfers, and place of death for severely ill patients with CHF. Materials and Methods: This retrospective observational registry study used the health care consumption data from the Stockholm Regional Council. Logistic regression analyses of age, sex, palliative care, comorbidities, and socioeconomic status were performed. Results: Of the 4322 individuals who died of heart failure between 2015 and 2019 and did not reside in a nursing home, 24% received SPC. Receiving SPC was associated with a lower odds ratio (OR) of ED visits (OR 0.24, p < 0.0001), unplanned transfers (OR 0.39, p < 0.0001), and emergency hospital as a place of death (OR 0.10, p < 0.0001). Furthermore, a better socioeconomic situation, younger age, and fewer comorbidities were associated with a lower OR of ED visits and transfers (p < 0.0001 to p = 0.013 in different comparisons). Multiple comorbidities (p < 0.0002) and younger age (p < 0.0001) were associated with a higher OR of emergency hospitals as a place of death. Conclusion: Approximately one-quarter of patients who died of heart failure received SPC. Receipt of SPC was associated with a significantly reduced number of ED visits, transfers between health care services, and risk of dying in emergency hospitals.

Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure

Aim: To determine the association between inpatient palliative care encounter (PCE) and 30-day rehospitalization. Materials & methods: The Nationwide Readmission Database was used in a cross-sectional design study. Comorbidities and a palliative care encounter (PCE; V66.7) were defined using ICD-9 codes. Results: Overall, 21.28% of 3,534,480 index hospitalizations were readmitted. PCE occurred in 1.66% of index hospitalizations and was associated with a lower odds of 30-day rehospitalization (adjusted odds ratio, 0.38; 95% CI: 0.35-0.40). This association remained significant when assessed by discharge destination. Conclusion: PCE was associated with a lower relative odds of 30-day rehospitalization. A 73% decrease in the relative odds of 30-day rehospitalization among discharges to a facility, 64% for home with home health, and 22% for discharges to home.

The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness

CONTEXT

Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness.

OBJECTIVE

To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness.

METHODS

Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea).

RESULTS

Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness.

DISCUSSION

The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.

Telecommunication for Advance Care Planning in Heart Failure

Heart failure is a chronic illness that carries a significant burden for patients, caregivers and health systems alike. The integration of palliative care and telehealth is a growing area of interest in heart failure management to help alleviate these burdens. This review focuses on the incorporation of advance care planning for complex decision-making in heart failure in the setting of increasing virtual care and telehealth. The review will also consider the role of virtual education for advance care planning and serious illness communication. Telecommunication for clinical care and clinical education are both described as non-inferior to in-person methods. Nevertheless, more research is needed to discern best practices and the optimal integration of methods.

Patient, caregiver, and health care provider perspectives on barriers and facilitators to heart failure care in Kerala, India: A qualitative study

Background: Deficits in quality of care for patients with heart failure (HF) contribute to high mortality in this population. This qualitative study aimed to understand the barriers and facilitators to high-quality HF care in Kerala, India.

Methods: Semi-structured, in-depth interviews were conducted with a purposive sample of health care providers (n=13), patients and caregivers (n=14). Additionally, focus group discussions (n=3) were conducted with patients and their caregivers. All interviews and focus group discussions were transcribed verbatim. Textual data were analysed using thematic analysis.

Results: Patients’ motivation to change their lifestyle behaviours after HF diagnosis and active follow-up calls from health care providers to check on patients’ health status were important enablers of high-quality care. Health care providers’ advice on substance use often motivated patients to stop smoking and consuming alcohol. Although patients expected support from their family members, the level of caregiver support for patients varied, with some patients receiving strong support from caregivers and others receiving minimal support. Emotional stress and lack of structured care plans for patients hindered patients’ self-management of their condition. Further, high patient loads often limited the time health care providers had to provide advice on self-management options. Nevertheless, the availability of experienced nursing staff to support patients improved care within health care facilities. Finally, initiation of guideline-directed medical therapy was perceived as complex by health care providers due to multiple coexisting chronic conditions in HF patients.

Conclusions: Structured plans for self-management of HF and more time for patients and health care providers to interact during clinical visits may enable better clinical handover with patients and family members, and thereby improve adherence to self-care options. Quality improvement interventions should also address the stress and emotional concerns of HF patients.

Patient, caregiver, and health care provider perspectives on barriers and facilitators to heart failure care in Kerala, India: A qualitative study

Background: Deficits in quality of care for patients with heart failure (HF) contribute to high mortality in this population. This qualitative study aimed to understand the barriers and facilitators to high-quality HF care in Kerala, India. Methods: Semi-structured, in-depth interviews were conducted with a purposive sample of health care providers (n=13), patients and caregivers (n=14). Additionally, focus group discussions (n=3) were conducted with patients and their caregivers. All interviews and focus group discussions were transcribed verbatim. Textual data were analysed using thematic analysis. Results: Patients' motivation to change their lifestyle behaviours after HF diagnosis and active follow-up calls from health care providers to check on patients' health status were important enablers of high-quality care. Health care providers' advice on substance use often motivated patients to stop smoking and consuming alcohol. Although patients expected support from their family members, the level of caregiver support for patients varied, with some patients receiving strong support from caregivers and others receiving minimal support. Emotional stress and lack of structured care plans for patients hindered patients' self-management of their condition. Further, high patient loads often limited the time health care providers had to provide advice on self-management options. Nevertheless, the availability of experienced nursing staff to support patients improved care within health care facilities. Finally, initiation of guideline-directed medical therapy was perceived as complex by health care providers due to multiple coexisting chronic conditions in HF patients. Conclusions: Structured plans for self-management of HF and more time for patients and health care providers to interact during clinical visits may enable better clinical handover with patients and family members, and thereby improve adherence to self-care options. Quality improvement interventions should also address the stress and emotional concerns of HF patients.