“Not the ‘Grim Reaper Service’”: An Assessment of Provider Knowledge, Attitudes, and Perceptions Regarding Palliative Care Referral Barriers in Heart Failure

Abstract

BackgroundAlthough similar to cancer patients regarding symptom burden and prognosis, patients with heart failure (HF) tend to receive palliative care far less frequently. We sought to explore factors perceived by cardiology, primary care, and palliative care providers to impede palliative care referral for HF patients.Methods and ResultsWe conducted semistructured interviews regarding (1) perceived needs of patients with advanced HF; (2) knowledge, attitudes, and experiences with specialist palliative care; (3) perceived indications for and optimal timing of palliative care referral in HF; and (4) perceived barriers to palliative care referral. Two investigators analyzed data using template analysis, a qualitative technique. We interviewed 18 physician, nurse practitioner, and physician assistant providers from 3 specialties: cardiology, primary care, and palliative care. Providers had limited knowledge regarding what palliative care is, and how it can complement traditional HF therapy to decrease HF‐related suffering. Interviews identified several potential barriers: the unpredictable course of HF; lack of clear referral triggers across the HF trajectory; and ambiguity regarding what differentiates standard HF therapy from palliative care. Nevertheless, providers expressed interest for integrating palliative care into traditional HF care, but were unsure of how to initiate collaboration.ConclusionsPalliative care referral for HF patients may be suboptimal due to limited provider knowledge and misperceptions of palliative care as a service reserved for those near death. These factors represent potentially modifiable targets for provider education, which may help to improve palliative care referral for HF patients with unresolved disease‐related burden.

A palliative care approach in heart failure: knowledge and attitudes of cardiac nurses

“…One of the most common misconceptions relating to palliative care within HF is the belief that the philosophy of palliative care is incompatible with that of aggressive management and this is perhaps the greatest challenge to ensuring the integration of a palliative care approach into HF management (Gott et al, 2011;Kavalieratos et al, 2014). This study confirmed this misconception with over three quarters of respondents believing, incorrectly, that the philosophy of palliative care was incompatible with that of aggressive treatment.…”

“…This study confirmed this misconception with over three quarters of respondents believing, incorrectly, that the philosophy of palliative care was incompatible with that of aggressive treatment. Kavalieratos et al (2014) also found that clinicians on the whole do not recognise that palliative care need not be prognosis dependent but can be provided alongside life prolonging treatment. There is no conflict between palliative care and active management approaches; one does not commence where the other ends.…”

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

“…When multidisciplinary HF providers were interviewed to assess knowledge, attitudes, and perceptions about palliative care, they reported limited palliative care knowledge, confused palliative and hospice care, and were uncertain about differences between standard HF therapy and palliative care. 285 A survey of HF nurses found that 67% felt it was a physician's role to initiate discussions about end-of-life care with patients, and 91% reported a need for more palliative training. 286 Additional barriers to the provision of palliative care services identified by healthcare providers included uncertainty about end of life because of its unpredictable trajectory, lack of need for end-of-life discussions in patients in New York Heart Association class II to III HF, and lack of time and resources to initiate discussions.…”

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association

“…111 By determining patient and caregiver goals of care through skilled communication, treating distressing symptoms while coordinating care, providing practical support for patients and caregivers, and mobilizing community support and resources to ensure a secure and safe living environment, palliative care teams help meet patient and caregiver needs so that they can avoid unwanted and expensive crisis care. [112][113][114] Many large US hospitals now have palliative care services, but availability across settings is highly variable by region and by state. Only a small fraction of the patients and families who could benefit receive it.…”