Palliative Care’s Sobering Question: Quality vs. Quantity of Life for Heart Failure Patients

As a growing body of evidence links palliative care to improved quality of life and better healthcare utilization for patients with heart failure, some in the medical community are advocating a shift from the traditionalist, acute care model to one more in tune with the psychological and physical needs of people with advanced cardiovascular disease.

Explaining to a patient with end-stage heart failure why palliative care may be a better option than curative or life-prolonging treatment is a conversation that even the most experienced cardiologists may dread. As a result, in many cases, that discomfiting discussion never takes place, and aggressive treatment continues for a disease that can only worsen, with no chance of recovery.

Indeed, a survey of International Society of Heart Failure and Transplant members found that only 17 percent of clinicians felt they were “really well trained” to discuss the complexities of palliative care with their heart failure patients, according to Deborah Meyers, MD, associate professor of medicine in the advanced heart failure and transplant division at Baylor College of Medicine, who conducted the unpublished survey. “These are time-consuming and confronting conversations that doctors aren’t comfortable with or well trained for, and which typically occur in the middle of a busy day when the impetus is on billing and keeping your practice going,” says Meyers. “And that’s why the default for most patients in the U.S. who die from heart failure is to do so in the [intensive care unit], where everything is being done on their behalf.”

Another part of palliative care’s challenge is that both physicians and patients often confuse it with hospice. There is a difference. For one thing, palliative care (unlike hospice) doesn’t necessarily mean the patient is dying. Palliative treatment is designed to relieve the symptom burden and provide the best possible quality of life for patients with chronic illnesses such as heart failure, where the prognosis is uncertain or may be measured in years, rather than in months as it may be with cancer. Moreover, while hospice employs palliative techniques, palliative care is broader. It’s a multidisciplinary and holistic approach that addresses not just the physical but the emotional, spiritual and logistical needs of both patients and caregivers.

“Palliative care says we’re going for quality of life first, but we’re not giving up on keeping you alive longer, if we can,” says Daniel Hoefer, MD, chief medical officer for Outpatient Palliative Medicine at Sharp HealthCare, a San Diego-based, regional, not-for-profit system that runs a palliative care program known as Transitions. “We’re not taking care away, but trying to stop those exacerbations that end up with the patient in the hospital.”

[[{"fid":"22739","view_mode":"media_original","type":"media","attributes":{"height":342,"width":416,"style":"font-size: 13.008px; width: 416px; height: 342px; margin: 5px; float: left;","alt":" - palliative-care-service-penetration","class":"media-element file-media-original"}}]]

Signs of progress

There are signs that palliative care is making inroads in the cardiovascular world, as acknowledged in an American Heart Association/American Stroke Association policy statement published last year. “[T]he inclusion of palliative care teams in the provision of care for patients with advanced [heart failure] is slowly gaining acceptance,” wrote Lynne Braun, PhD, professor in the College of Nursing and the College of Medicine at Rush University Medical Center in Chicago, and co-authors. As signs of progress, they noted that the Joint Commission now requires a palliative care

specialist to be included on a hospital’s mechanical circulatory support (MCS) team in order to earn ventricular assist device certification and that, in 2016, Medicare began reimbursing physicians for advance care planning discussions with patients as part of the palliative care process. At the same time, though, the associations listed multiple barriers that continue to make it difficult for patients to get effective palliative care, including a lack of knowledge by providers about the benefits or the availability of palliative care services as well as limitations on payment for services by insurers (Circulation 2016;134[11]:e198-225).

A small but growing body of clinical evidence may help clear the way. A study that evaluated Sharp HealthCare’s Transitions program between 2007 and 2014, for example, found that a proactive, home-based palliative care program for individuals with advanced chronic illnesses can help to avoid the escalation in hospital use and costs commonly seen in the final months of life. In the case of heart failure, Transitions participants’ costs increased only slightly from $1,550 four months before death to $3,711 in the final month, compared to $2,631 and $17,006, respectively, for control group participants. Moreover, 21.8 percent of Transitions’ heart failure patients were admitted to the hospital in their last month of life, compared to 74.7 percent for the control group, and 10.9 percent of Transitions’ patients died in the hospital compared to 58.5 percent of the control group (J Am Geriatr Soc 2016;64[11]:2288-95).

“The most beneficial thing is that we kept our patients from suffering,” maintains Hoefer, who is board-certified in palliative medicine and a co-author of the study. “And if you’re in a capitated arrangement, you can see the financial advantage of practicing healthcare in this manner. If you’re still doing fee-for-service, though, it can be very scary because you’re not going to have as many ‘heads-on-beds’ as you used to.”

The prospective, controlled, unblinded, single-center Palliative Care in Heart Failure Trial (PAL-HF), performed at Duke University Medical Center in Durham, N.C., showed quality-of-life improvements in a cohort of 150 very sick patients who received palliative care focused on relieving physical and psychosocial symptoms, addressing spiritual concerns and advanced care planning (Am Heart J 2014;168[5]:645-51).

“The general physician population needs to be thinking critically about the most effective interventions to be used, when and how to use them, and the timing of transition from a palliative care to a hospice approach,” says Joseph Rogers, MD, principal investigator of PAL-HF and medical director of the Duke Mechanical Circulatory Support Program.

[[{"fid":"22740","view_mode":"media_original","type":"media","attributes":{"height":427,"width":400,"style":"font-size: 13.008px; width: 400px; height: 427px; float: left; margin: 5px;","alt":" - referring-physician-specialties-sites","class":"media-element file-media-original"}}]]

Legislative course of action

In their policy statement, the American Heart Association and American Stroke Association called palliative care “an essential health benefit that is central to high-quality overall care,” particularly in the case of heart failure, which impacts an estimated 5.7 million Americans.

The groups advocate a list of legislative recommendations designed to create an environment more open to palliative care. They say federal and state agencies should reimburse for palliative care services; strong payer-provider collaborations should be established based on sharing and reviewing data to identify patients most likely to benefit from palliative care; and educational institutions and professional societies should provide training in palliative care throughout clinicians’ careers.

Braun points to the contribution palliative care intervention can make to better healthcare utilization. “We spend a lot of healthcare dollars saving lives, which is not always cost-efficient or what the patient wants,” she says. “By having these conversations with patients through palliative care, we can better tailor our resources to what the patient truly values. And in most cases, that will be the best possible quality of life in the final stages.”