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Heart, Lung and Circulation

The Palliative Approach and Terminal Heart Failure Admissions – Are We Getting it Right?

Published:February 11, 2022DOI:https://doi.org/10.1016/j.hlc.2022.01.002

      Background

      Chronic heart failure has a high mortality and early provision of palliative care supports complex decision-making and improves quality of life.

      Aim

      To explore whether and when a palliative approach was adopted during the last 12 months of life in patients who experienced an in-hospital death from heart failure.

      Design

      Retrospective medical record review of all deaths from chronic heart failure (January 2010 to December 2019).

      Participants

      Admissions with chronic heart failure resulting in death were analysed from an Australian tertiary referral centre.

      Results

      The cohort (n=517) were elderly (median age 83.8 years IQR=77.6–88.7) and male (55.1%). Common comorbidities were ischaemic heart disease (n=293 56.7%) and atrial fibrillation (n=289 55.9%). Life sustaining interventions occurred in 97 (18.8%) patients. In 31 (6.0%) patients referral to specialist palliative care occurred prior to, and in 263 (50.9%) during, the terminal admission. Opioids were prescribed to 440 (85.1%) patients. Comfort care was the documented goal in 158 patients (30.6%). A palliative approach was significantly associated with prior admission in the preceding 12 months (OR=1.5 95% CI=1.0–2.1 p<0.043), receiving outpatient care (OR=2.6 95% CI=1.6–4.1 p<0.01), and admissions in the latter half of the decade (OR=1.5 95% CI=1.0–2.0 p<0.038).

      Conclusion

      Despite greater adoption of a palliative approach in the terminal admission over the last decade, a significant proportion of patients receive palliative care late, just prior to death.

      Keywords

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      References

        • Groenewegen A.
        • Rutten F.H.
        • Mosterd A.
        • Hoes A.W.
        Epidemiology of heart failure.
        Eur J Heart Fail. 2020; 22: 1342-1356
        • Labrosciano C.
        • Air T.
        • Tavella R.
        • Beltrame J.F.
        • Ranasinghe I.
        Readmissions following hospitalisations for cardiovascular disease: a scoping review of the Australian literature.
        Aust Health Rev. 2020; 44: 93-103
        • O'Connor C.M.
        High heart failure readmission rates: is it the health system's fault?.
        JACC Heart Fail. 2017; 5: 393
        • Wideqvist M.
        • Cui X.
        • Magnusson C.
        • Schaufelberger M.
        • Fu M.
        Hospital readmissions of patients with heart failure from real world: timing and associated risk factors.
        ESC Heart Fail. 2021; 8: 1388-1397
        • Cui X.
        • Thunstrom E.
        • Dahlstrom U.
        • Zhou J.
        • Ge J.
        • Fu M.
        Trends in cause-specific readmissions in heart failure with preserved vs. reduced and mid-range ejection fraction.
        ESC Heart Fail. 2020; 7: 2894-2903
        • Rogers J.G.
        • Patel C.B.
        • Mentz R.J.
        • Granger B.B.
        • Steinhauser K.E.
        • Fiuzat M.
        • et al.
        Palliative care in heart failure: the PAL-HF randomized, controlled clinical trial.
        J Am Coll Cardiol. 2017; 70: 331-341
        • Retrum J.H.
        • Boggs J.
        • Hersh A.
        • Wright L.
        • Main D.S.
        • Magid D.J.
        • et al.
        Patient-identified factors related to heart failure readmissions.
        Circ Cardiovasc Qual Outcomes. 2013; 6: 171-177
        • World Health Organization
        Palliative Care World Health Organization 2020.
        (Available from:)
        • Atherton J.J.
        • Sindone A.
        • De Pasquale C.G.
        • Driscoll A.
        • MacDonald P.S.
        • Hopper I.
        • et al.
        National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.
        Heart Lung Circ. 2018; 27: 1123-1208
        • Jaarsma T.
        • Beattie J.M.
        • Ryder M.
        • Rutten F.H.
        • McDonagh T.
        • Mohacsi P.
        • et al.
        Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology.
        Eur J Heart Fail. 2009; 11: 433-443
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • Butler J.
        • Casey Jr., D.E.
        • Drazner M.H.
        • et al.
        2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 62: 147-239
        • Janssen D.J.
        • Boyne J.
        • Currow D.C.
        • Schols J.M.
        • Johnson M.J.
        • La Rocca H.B.
        Timely recognition of palliative care needs of patients with advanced chronic heart failure: a pilot study of a Dutch translation of the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF).
        Eur J Cardiovasc Nurs. 2019; 18: 375-388
        • Ament S.M.
        • Couwenberg I.M.
        • Boyne J.J.
        • Kleijnen J.
        • Stoffers H.E.
        • van den Beuken M.H.
        • et al.
        Tools to help healthcare professionals recognize palliative care needs in patients with advanced heart failure: A systematic review.
        Palliat Med. 2021; 35: 45-58
        • Kavalieratos D.
        • Gelfman L.P.
        • Tycon L.E.
        • Riegel B.
        • Bekelman D.B.
        • Ikejiani D.Z.
        • et al.
        Palliative care in heart failure: rationale, evidence, and future priorities.
        J Am Coll Cardiol. 2017; 70: 1919-1930
        • Maciver J.
        • Ross H.J.
        A palliative approach for heart failure end-of-life care.
        Curr Opin Cardiol. 2018; 33: 202-207
        • Chang Y.K.
        • Kaplan H.
        • Geng Y.
        • Mo L.
        • Philip J.
        • Collins A.
        • et al.
        Referral criteria to palliative care for patients with heart failure: a systematic review.
        Circ Heart Fail. 2020; 13e006881
        • Arestedt K.
        • Alvariza A.
        • Boman K.
        • Ohlen J.
        • Goliath I.
        • Hakanson C.
        • et al.
        Symptom relief and palliative care during the last week of life among patients with heart failure: a national register study.
        J Palliat Med. 2018; 21: 361-367
        • Gadoud A.
        • Kane E.
        • Macleod U.
        • Ansell P.
        • Oliver S.
        • Johnson M.
        Palliative care among heart failure patients in primary care: a comparison to cancer patients using English family practice data.
        PLoS One. 2014; 9e113188
        • Smallwood N.
        • Moran T.
        • Thompson M.
        • Eastman P.
        • Le B.
        • Philip J.
        Integrated respiratory and palliative care leads to high levels of satisfaction: a survey of patients and carers.
        BMC Palliat Care. 2019; 18: 7
        • Smallwood N.
        • Thompson M.
        • Warrender-Sparkes M.
        • Eastman P.
        • Le B.
        • Irving L.
        • et al.
        Integrated respiratory and palliative care may improve outcomes in advanced lung disease.
        ERJ Open Res. 2018; 4
        • Datla S.
        • Verberkt C.A.
        • Hoye A.
        • Janssen D.J.A.
        • Johnson M.J.
        Multi-disciplinary palliative care is effective in people with symptomatic heart failure: A systematic review and narrative synthesis.
        Palliat Med. 2019; 33: 1003-1016
        • Ponikowski P.
        • Voors A.A.
        • Anker S.D.
        • Bueno H.
        • Cleland J.G.F.
        • Coats A.J.S.
        • et al.
        2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
        Eur Heart J. 2016; 37: 2129-2200
        • Singh G.K.
        • Ferguson C.
        • Davidson P.M.
        • Newton P.J.
        Attitudes and practices towards palliative care in chronic heart failure: a survey of cardiovascular nurses and physicians.
        Contemp Nurse. 2021; 57: 113-127
        • Rosenwax L.
        • Spilsbury K.
        • McNamara B.A.
        • Semmens J.B.
        A retrospective population based cohort study of access to specialist palliative care in the last year of life: who is still missing out a decade on?.
        BMC Palliat Care. 2016; 15: 46
        • Nazim A.
        • Demers C.
        • Berbenetz N.
        • You J.J.
        Patterns of care during the terminal hospital admission for patients with advanced heart failure: a retrospective cohort study.
        Can J Cardiol. 2018; 34: 1215-1218
        • Campbell R.T.
        • Petrie M.C.
        • Jackson C.E.
        • Jhund P.S.
        • Wright A.
        • Gardner R.S.
        • et al.
        Which patients with heart failure should receive specialist palliative care?.
        Eur J Heart Fail. 2018; 20: 1338-1347
        • Madelaire C.
        • Gustafsson F.
        • Kristensen S.L.
        • D'Souza M.
        • Stevenson L.W.
        • Kober L.
        • et al.
        Burden and causes of hospital admissions in heart failure during the last year of life.
        JACC Heart Fail. 2019; 7: 561-570
        • Kaneko H.
        • Itoh H.
        • Yotsumoto H.
        • Kiriyama H.
        • Kamon T.
        • Fujiu K.
        • et al.
        Association between the number of hospital admissions and in-hospital outcomes in patients with heart failure.
        Hypertens Res. 2020; 43: 1385-1391
      1. Organization WH. ICD-10: international statistical classification of diseases and related health problems: tenth revision World Health Organisation 2004 [2nd]. Available from: https://apps.who.int/iris/handle/10665/42980.

        • Young K.A.
        • Redfield M.M.
        • Strand J.J.
        • Dunlay S.M.
        End-of-life discussions in patients with heart failure.
        J Card Fail. 2017; 23: 821-825
        • Strachan P.H.
        • Ross H.
        • Rocker G.M.
        • Dodek P.M.
        • Heyland D.K.
        Canadian researchers at the end of life n. mind the gap: opportunities for improving end-of-life care for patients with advanced heart failure.
        Can J Cardiol. 2009; 25: 635-640
        • El-Jawahri A.
        • Paasche-Orlow M.K.
        • Matlock D.
        • Stevenson L.W.
        • Lewis E.F.
        • Stewart G.
        • et al.
        Randomized, controlled trial of an advance care planning video decision support tool for patients with advanced heart failure.
        Circulation. 2016; 134: 52-60
        • Schallmo M.K.
        • Dudley-Brown S.
        • Davidson P.M.
        Healthcare providers' perceived communication barriers to offering palliative care to patients with heart failure: an integrative review.
        J Cardiovasc Nurs. 2019; 34: E9-E18
        • Singh G.K.
        • Davidson P.M.
        • Macdonald P.S.
        • Newton P.J.
        The perspectives of health care professionals on providing end of life care and palliative care for patients with chronic heart failure: an integrative review.
        Heart Lung Circ. 2019; 28: 539-552

      Linked Article

      • Integrating Heart Failure Palliative Care Delivery in an Uncertain Disease Trajectory
        Heart, Lung and CirculationVol. 31Issue 6
        • Preview
          Dying with end stage heart failure can be like a roller-coaster: a process punctuated by unpredictable episodes of acute deterioration, recovery, and often seemingly unexpected decline [1–3]. This not-so-predictable disease trajectory often results in referral to palliative care in only the terminal, or ‘end of life’ phase. Yet, late engagement with palliative care can result in increased hospitalisations, length of stays, depression [4], poor symptom management, and decreased quality of life, and most importantly, fewer days for patients and family members in their preferred place of care before they die [5–7].
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