Ten Questions and Some Reflections about Palliative Care in Advanced Heart Failure Patients

Abstract

Heart failure is a clinical syndrome with increasing prevalence, high morbidity and mortality. It is characterized by high symptom burden, poor quality of life and high economic costs. This implies that the heart failure (HF) patients who receive palliative care (PC) have needs similar to cancer patients, but which are often unmet. This paper analyzes the main unresolved issues regarding the relationship between HF patients and the referral to an early PC program. These issues are presented as ten questions related to which patients should be admitted to PC and at what stage of their disease. Furthermore, the barriers opposing to referral to PC, the role of cardiologists and PC physicians within the care team, the gap between the scientific societies’ suggestions and the real world, the right time to promote patients’ awareness and shared decision making, regarding prognosis, end of life wishes and choices, with reference also to cardiac implantable devices’ deactivation, are discussed. These unresolved questions support the need to reevaluate programs and specific models in achieving equal access to palliative care interventions for HF patients, which is still mainly offered to patients with cancer.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

“…A routine and early palliative care initiation to deal with the burden of physical and psychological symptoms of patients with malignant disease has become the standard of care [23]. Furthermore, the importance of palliative care intervention for patients with end-stage organ dysfunction, such as kidney injury [24,25], advanced heart failure [26], and chronic obstructive pulmonary disease [27], has been increasingly addressed. Discussions of EOL care preferences and modalities of life-sustaining treatments are challenging [28].…”

A Qualitative Study of the Limits and Possibilities of Integrating Palliative Care in Heart Failure

“…Although there is no consensus in clinical guidelines on the timing of starting palliative care in HF, in line with the American Heart Association and the Global Atlas of Palliative Care, we advocate that starting palliative care as early as possible, in line with expectations and needs of each person with HF, integrated with the clinical care in HF, gradually increasing its approaches, respecting the will of the person and in response to the worsening of the signs and symptoms of HF, and evolution of its phases. 11 - 13 …”

“…10 Although there is no consensus in clinical guidelines on the timing of starting palliative care in HF, in line with the American Heart Association and the Global Atlas of Palliative Care, we advocate that starting palliative care as early as possible, in line with expectations and needs of each person with HF, integrated with the clinical care in HF, gradually increasing its approaches, respecting the will of the person and in response to the worsening of the signs and symptoms of HF, and evolution of its phases. [11][12][13] However, integrating palliative care with clinical care in HF is difficult, even in advanced HF. The lack of clarity about the trajectory of the disease, professionals' insufficient knowledge about the specialty competence of palliative care in the control of symptoms and signs, as well as the lack of resources to structure and maintain outpatient palliative care programs and home care, are many of the obstacles that contribute to the person with HF not having access to palliative care.…”

“…14 Despite scientific evidence reinforcing the importance of integrating palliative care to improve the overall quality of life and to reduce negative economic pressure on the publicprivate health system, barriers to this integrated care persist in practice, which still varies widely between geographic regions, in addition to the serious access difficulties, when compared, for example, to the context of oncology. 11,15 Given this evidence, we aimed to discuss the limits and possibilities of integrating palliative care in HF.…”