Hospice in the U.S. remains underutilized, especially among HF patients who need it most
![Large peridevice leaks after left atrial appendage occlusion (LAAO) are incredibly rare and not associated with a greater risk of adverse outcomes, according to new research published in JACC: Clinical Electrophysiology.[1] Smaller residual links are more common, however, and associated with a risk of thromboembolic and bleeding events.](/sites/default/files/styles/top_stories/public/2018-08/olderpatient-doctor.jpg.webp?itok=Cv18wcDr)
Hospice use in the U.S. has grown to nearly 5 percent among elderly patients with heart failure (HF), according to a JAMA Cardiology study published Aug. 29, but palliative care will likely become increasingly difficult as treatment continues to improve.
The work, led by Haider J. Warraich, MD, of the division of cardiology at Duke University Medical Center in Durham, North Carolina, retrospectively analyzed 121,990 older heart failure patients in the AHA’s Get With the Guidelines-Heart Failure (GWTG-HF) registry to assess rates of discharge to hospice, readmission after hospice and survival rates in the population between 2005 and 2014.
“Studies have shown that hospice is associated with improved symptom management and overall improved satisfaction,” Shunichi Nakagawa, MD, and A. Reshad Garan, MD, both of Columbia University in New York, wrote in a JAMA editorial accompanying Warraich et al.’s research. “Dying at home with hospice—in a familiar environment, surrounded by loved ones, without burdensome symptoms—is commonly accepted as the best-case end-of-life scenario, and hospice use has increased over the last decade.”
But even now hospice care remains underused, Nakagawa and Garan said, especially in heart patients. Despite heart disease being the leading cause of death in the U.S, it makes up just 18.7 percent of the principal diagnosis for hospice admission in the country. Cancer diagnoses, on the other hand, make up 27.2 percent.
Warraich and co-authors said their analysis of the study group—which consisted largely of white patients in their 80s—found hospice care accounted for 3.8 percent of all hospital discharges during the trial period. About half were sent home for hospice, while the other half were discharged to a dedicated facility.
Hospice use did increase between 2005 and 2014, the authors said, starting at 2 percent at the study’s baseline and steadily climbing to reach 4.9 percent by 2014. Patients discharged to hospice were more likely to be white, older and have more advanced symptoms than those who remained in-hospital, and survived in the care facility for an average of 11 days. More than a third of patients discharged to hospice facilities died within three days, and only 15 percent lived for six months or more.
“This study confirmed that referral to hospice occurs very late and hospice remains underused in patients with HF,” Nakagawa and Garan commented. “Multiple barriers to hospice referral have been identified, such as lack of knowledge about hospice care, hospice admission eligibility, and ineligibility for hospice care under the Medicare Hospice Benefit. Difficulty in prognostication in HF is a major impediment to referral of the appropriate patient to hospice care.”
Nakagawa and Garan said reaching a prognosis for patients with heart failure has historically been challenging, but it “may actually become more difficult” because of the rapid and continuous evolution of cardiovascular technologies, implantable devices and treatment modalities.
“While this will contribute to improved clinical outcomes, ironically, it may further complicate efforts to accurately prognosticate for patients with heart failure,” they wrote.
They said a core solution could be initiating the conversation about end-of-life care with patients and their families earlier in the process, including discussions about care options and possible risks associated with the disease. While some doctors are apprehensive about bringing up anything negative, Nakagawa and Garan said, patients actually tend to prefer having those conversations off the bat.
“End-of-life care of patients with HF will likely continue to become more difficult as treatment improves, and provision of palliative care throughout the disease trajectory is essential,” they wrote. “Starting advance care planning at an earlier stage is one of the crucial steps in this process. While we never say never in medicine, it is never too early to start the conversation.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.