Palliative care: Why is it so difficult for cardiologists to talk about death?

Avoidance and mixed signals have long plagued the palliative care discussion in cardiology, but that could be changing, according to research presented at the American College of Cardiology’s 67th annual meeting in Orlando, Florida.

Mary Hicks, DNP, said at the conference that palliative care—a specialized medical practice focused on providing relief and comfort for patients suffering from severe, chronic conditions—is commonly misunderstood by cardiologists. The physicians tend to be, as a whole, less comfortable talking about end-of-life than their counterparts in oncology, Hicks said, but that doesn’t change the fact that heart failure is still one of palliative care’s most frequently treated illnesses.

She said palliative care is often misunderstood by clinicians, including cardiologists, because it’s often perceived as a late-stage, last-minute treatment plan.

“I hear it all the time,” she said. “‘It’s only for the dying patient.’”

She likes to think of palliative care as a practice that can be incorporated “earlier into the living process,” she said, rather than later in the dying process.

Hicks works as part of a palliative care team at a Detroit hospital, where she guides patients with chronic diseases like cancer, stroke, Parkinson’s and renal disease through end-of-life discussions. She called the services “an extra layer of support” for both patients and their families, regardless of age or stage of an illness.

“We’re learning that palliative care is a mechanism to improve patient outcomes,” she said. “It helps with symptoms, helps with quality of life.”

A paucity of robust data on palliative care in cardiology, married with the fact that so many cardiologists misconstrue the practice as hospice care or treatment only for dying patients, has created a barrier to providing the best possible patient experience, Hicks said. Quality of life data has found that while cancer patients continue to function well until the months before death, congestive heart failure patients see increased stress and risk as their disease progresses.

As difficult as the conversation might be, Hicks said speaking with patients frankly about their end-of-life wishes is one of the most important things a palliative care team can do. Preparedness planning—asking patients what they’d prefer in the case of stroke, vasopressor dependence, organ damage or device malfunction, for example—can provide clarity for that patient’s family and lawyer if the patient ends up unresponsive and unable to make those decisions themselves. This is especially important in the context of heart failure, she said, since it’s such an unpredictable disease.

Even planning ahead for less severe complications like artificial nutrition and hydration, blood transfusion, long-term antibiotic use and nursing home placements can make a big difference, Hicks said. Coming up with a comprehensive patient plan can dramatically enhance quality of life from diagnosis to death.

On the caregiver’s part, this can be difficult, Savitri Fedson, MA, MD, said at the meeting.  Cardiologists are often invested in their cases and feel the need to do everything they possibly can to save a patient, even if the better, less painful option was death. What’s so difficult is balancing control of both cardiac and non-cardiac symptoms—almost half of heart failure patients have five or more comorbidities—aligning palliative care with a patient’s goals and preferences and determining who, if a patient is eventually unable, will take on decision-making responsibilities.

“People may die sooner,” Fedson said. “But they also feel better.”

The greatest mistakes a cardiologist can make in the case of palliative care are sending mixed signals, assuming you know what the patient wants, not including a patient in the treatment discussion, trying to “do everything” to save them and simply avoiding the end-of-life conversation.

“Our goal is the help the patient and their family, but our goal is to really help the cardiologist, who’s guiding the treatment plan,” Hicks said.