Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care

Analysis of palliative care needs in hospitalized patients

AIM

To determine the prevalence of palliative care needs in patients in an acute care hospital and to analyze the profile of these patients.

DESIGN

We conducted a prospective cross-sectional study in an acute care hospital, in April 2018. The study population consisted of all patients over 18 years of age admitted to hospital wards and intensive care units. Variables were collected on a single day by six micro-teams using the NECPAL CCOMS-ICO© instrument. The descriptive analysis, on patient mortality and length of stay, was performed at a one-month follow-up.

RESULTS

We assessed 153 patients, of whom 65 (42.5%) were female, with a mean age of 68.17±17.03 years. A total of 45 patients (29.4%) were found to be SQ+, of which 42 were NECPAL+ (27.5%), with a mean age of 76.64±12.70 years. According to the disease indicators, 33.35% had cancer, 28.6% had heart disease, and 19% had COPD, resulting in a ratio of 1:3 between patients with cancer and non-cancer disease. Half of the inpatients in need of palliative care were in the Internal Medicine Unit.

CONCLUSIONS

Almost 28% of patients were identified as NECPAL+, most of them not identified as under palliative care in clinical records. Greater awareness and knowledge from healthcare professionals would facilitate the early identification of these patients and avoid overlooking palliative care needs.

Chronic Obstructive Pulmonary Disease in Elderly Patients with Acute and Advanced Heart Failure: Palliative Care Needs-Analysis of the EPICTER Study

Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study (“Epidemiological survey of advanced heart failure”) is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan−Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 ± 0.98 vs. 0.51 ± 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies.

Cancer Impacts Prognosis on Mortality in Patients with Acute Heart Failure: Analysis of the EPICTER Study

Introduction: Heart failure (HF) and cancer are currently the leading causes of death worldwide, with an increasing incidence with age. Little is known about the treatment received and the prognosis of patients with acute HF and a prior cancer diagnosis. Objective: to determine the clinical characteristics, palliative treatment received, and prognostic impact of patients with acute HF and a history of solid tumor. Methods: The EPICTER study (“Epidemiological survey of advanced heart failure”) is a cross-sectional, multicenter project that consecutively collected patients admitted for acute HF in 74 Spanish hospitals. Patients were classified into two groups according to whether they met criteria for acute HF with and without solid cancer, and the groups were subsequently compared. A multivariable logistic regression analysis was conducted, using the forward stepwise method. A Kaplan–Meier survival analysis was performed to evaluate the impact of solid tumor on prognosis in patients with acute HF. Results: A total of 3127 patients were included, of which 394 patients (13%) had a prior diagnosis of some type of solid cancer. Patients with a history of cancer presented a greater frequency of weight loss at admission: 18% vs. 12% (p = 0.030). In the cancer group, functional impairment was noted more frequently: 43% vs. 35%, p = 0.039). Patients with a history of solid cancer more frequently presented with acute HF with preserved ejection fraction (65% vs. 58%, p = 0.048) than reduced or mildly reduced. In-hospital and 6-month follow-up mortality was 31% (110/357) in patients with solid cancer vs. 26% (637/2466), p = 0.046. Conclusion: Our investigation demonstrates that in-hospital mortality and mortality during 6-month follow-up in patients with acute HF were higher in those subjects with a history of concomitant solid tumor cancer diagnosis.

Palliative Care in Heart Failure: Challenging Prognostication

Heart failure (HF) is a chronic progressive disease with high morbimortality and poor quality of life (QoL). Palliative care significantly improves clinical outcomes but few patients receive it, in part due to challenging decisions about prognosis. This retrospective study, included all patients consecutively discharged from an Acute Heart Failure Unit over a period of one year, aiming to assess the accuracy of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in predicting mortality. Additionally, predictors of death at one and three years were explored using a multivariate regression model. The MAGGIC score was useful in predicting mortality, without significant difference between mortality observed at three-years follow-up compared with a mortality given by the score (p=0.115). Selected variables were statistically compared showing that poor functional status, high New York Heart Association (NYHA) at discharge, psychopharmacs use, and high creatininemia were associated with higher mortality (p<0.05). The multivariate regression model identified three predictors of one-year mortality: psychopharmacs baseline use (OR=4.110; p=0.014), angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) medication at discharge (OR=0.297; p=0.033), and higher admission's creatinine (OR=2.473; p=0.028). For three-year mortality outcome, two variables were strong independent predictors: psychopharmacs (OR=3.330; p=0.022) and medication with ACEI/ARB at discharge (OR=0.285; p=0.018). Models' adjustment was assessed through the receiver operating characteristic (ROC) curve. The best model was the one-year mortality (area under the curve, AUC 81%), corresponding to a good discrimination power. Despite prognostication, when setting goals of care an individualised patient-centred approach is imperative, based on the patient's objectives and needs. Risk factors related to poorer outcomes should be considered, in particular, higher NYHA at discharge which also represents symptom burden. Hospitalisation is an opportunity to optimize global care for heart failure patients including palliative care.