A Practical Guide to Palliative Care for Heart Failure Patients

With a few practical steps, cardiology practices can meet the palliative care needs of heart failure patients.     

Despite new treatment options for cardiac patients, heart failure is a progressive and deadly disease with a heavy symptom burden and a complex and unpredictable trajectory. Living with heart failure places enormous demands on patients, caregivers, doctors and healthcare systems. The American Heart Association recommends that palliative care should be integrated into the care of all patients with advanced cardiovascular disease to help relieve symptoms, improve patient satisfaction, reduce avoidable utilization and costs, and extend survival (Circulation 2016;134[11]: e198-225).

While much of the evidence base for palliative care interventions has developed around care for patients with cancer, evidence is building that palliative care is associated with significant improvements in outcomes for heart failure patients (Heart Fail Rev, online Feb. 13, 2017). Cardiology practices can implement the following practical steps to meet their patients’ palliative care needs.

Understand & communicate the goals of palliative care

Palliative care is interdisciplinary medical care aimed at improving quality of life for patients living with serious illness and their families. It adds a layer of support for pain and symptom control, coordination of care and transitions, and skilled communication to elicit patients’ goals of care and support shared decision making. Palliative care can be provided from the point of diagnosis and together with curative and disease-directed treatment.

One critical objective of a palliative care consultation is to help patients and families understand the trajectory of the disease, so they can clarify, plan for and periodically revisit their goals. Palliative care providers are trained to have these difficult conversations to support and empower patients to make complex medical decisions.

A second important objective is to support the primary cardiologist in symptom control at all times, so as to improve and maintain the patient’s quality of life—according to their goals and values—until either advance therapy is appropriate or the end of the patient’s life. Heart failure patients not only suffer from shortness of breath and fatigue as a result of their disease but also experience pain, nausea, anxiety and depression, which may lead to distress for both patients and their caregivers.

Know when to refer patients to palliative care

Cardiology programs around the country have begun to integrate routine palliative care consultations for high-risk patients receiving ventricular assist devices or transplant, but cardiologists can incorporate other triggers to reach patients earlier. Patients with heart failure should be considered for a palliative care referral if they meet any of the following criteria: multiple hospital admissions, uncontrolled symptoms despite maximal treatment of their disease, a complex home or social situation that makes discharge unsafe or when the patient or family doesn’t seem to fully understand the illness. For those with advanced illness, cardiologists also can identify patients suitable for palliative care by asking themselves the “surprise question”: Would you be surprised if this patient died in the next 12 months?

Find palliative care teams & develop your palliative care skills

Most large hospitals now have inpatient palliative care teams, while access to community-based palliative care is more limited but growing. Cardiologists can access palliative care expertise through their health system or by contacting their patients’ health plans and case managers. Cardiologists also can expand their palliative care skills in symptom management and communication by taking online courses with the Center to Advance Palliative Care, a nonprofit membership organization that provides training and technical assistance.

Nathan E. Goldstein, MD, is a professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, chief of the Division of Palliative Care at Mount Sinai Beth Israel, and a clinician researcher at the James J. Peters Veterans Affairs Medical Center, all in New York. His research examines patient–physician communication about deactivating implantable cardioverter defibrillators.

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