Palliative Care in Heart Failure

Abstract

BACKGROUND Advanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life. OBJECTIVES . We investigated whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes. METHODS We randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC; n =75) or UC plus a palliative care intervention (UC+PAL; n =75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy - Palliative Care scale (FACIT-Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale [HADS]), spiritual well-being (measured via the FACIT - Spiritual Well-Being scale [FACIT-Sp]), hospitalizations, and mortality. RESULTS Patients randomized to UC+PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT-Pal scores from randomization to 6 months (KCCQ difference =9.49 points, 95% CI 0.94 to 18.05, p =0.030; FACIT-Pal difference =11.77 points, 95% CI 0.84 to 22.71, p =0.035). Depression improved in UC+PAL patients (HADS-depression difference =−1.94 points; p =0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference =−1.83 points; p =0.048). Spiritual well-being was improved in UC+PAL versus UC-alone patients (FACIT-Sp difference =3.98 points; p =0.027). Randomization to UC+PAL did not affect rehospitalization or mortality. CONCLUSIONS An interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. Trial Registration ClinicalTrials.gov Identifier: NCT01589601

Palliative Care in Heart Failure

“…Two investigators independently screened and reviewed the resulting 6,158 unique records, ultimately yielding 43 trials; of these 43, five trials either only included patients with HF or presented data by disease group, and were therefore eligible for inclusion. One relevant additional trial was hand selected as it was published after our initial search (45). Each study was evaluated for risk of bias for subjective outcomes (e.g., patient-reported outcomes) and objective outcomes (e.g., survival, resource utilization) using the Cochrane Risk of Bias tool (46).…”

“…The most compelling evidence of the benefits of palliative care in HF arguably comes from the recently published PAL-HF (Palliative Care in Heart Failure) study (low risk of bias; Table 2) (45). This trial randomized 150 recently hospitalized individuals with advanced HF at high risk of re-hospitalization or six-month mortality to either usual care or usual care plus a six-month interdisciplinary palliative care intervention led by a palliative care-specialized nurse practitioner.…”

“…Nevertheless, it is clear that research regarding palliative care in HF is still developing, and due to concerns regarding risk of bias in the majority of included trials, conclusions should be interpreted cautiously. Yet, recent evidence from the high-quality PAL-HF trial provides support for the notion that longitudinal palliative care, provided concomitantly with usual HF management, is associated with improved patient-centered outcomes (45). …”

Communication Skills in the Age of COVID-19

“…We have used 5 years of experience with scaling up serious illness communication skills training-our nonprofit startup VitalTalk (www.vitaltalk.org) has reached at least 30 000 clinicians-to create a series of just-intime tips, talking maps, and video demonstrations we have made freely available (3). Our approach, which has shown positive outcomes in clinician behavior (4), patient quality of life (5), and patient trust (6), is based on 3 core principles. First, dealing with emotion is more important than giving lots of information.…”

Hospital resource utilization and presence of advance directives at the end of life for adults with congenital heart disease

“…Palliative care principles have begun to expand to other diseases, including HF, 21 although the evidence base for their application is not as robust as for cancer. The utility of palliative care for patients with ACHD is only now beginning to gain ground, and very little is known about how and when to begin palliative care or conversations about goals of care.…”