Advertisement

Role of Palliative Care in the Outpatient Management of the Chronic Heart Failure Patient

  • Sarah Chuzi
  • Esther S. Pak
  • Akshay S. Desai
  • Kristen G. Schaefer
  • Haider J. WarraichEmail author
Nonpharmacologic Therapy: Surgery, Ventricular Assist Devices, Biventricular Pacing, and Exercise (A Hasan, Section Editor)
  • 31 Downloads
Part of the following topical collections:
  1. Topical Collection on Nonpharmacologic Therapy: Surgery, Ventricular Assist Devices, Biventricular Pacing, and Exercise

Abstract

Purpose of Review

Patients with heart failure (HF) have an increased symptom burden and complex psychosocial and decision-making needs that necessitate the integration of palliative care. However, in the current era, palliative care is frequently evoked for these patients only at the end-of-life or in the inpatient setting; rarely is palliative care proactively utilized in outpatients with HF. The purpose of this review is to evaluate the current state of palliative care and heart failure and to provide a roadmap for the integration of palliative care into outpatient HF care.

Recent Findings

Recent studies, including PAL-HF, CASA, and SWAP-HF, have demonstrated that structured palliative care interventions may improve quality of life, depression, anxiety, understanding of prognosis, and well-being in HF.

Summary

HF is associated with high mortality risk, significant symptom burden, and impaired quality of life. Palliative care can meet many of these needs; however, in the current era, palliative care consultations in HF occur late in the disease course and too often in the inpatient setting. Primary palliative care should be provided to all outpatients with heart failure based on their needs, with referral to secondary palliative care provided based on certain triggers and milestones.

Keywords

Heart failure Palliative care Outpatient Clinic Symptoms 

Notes

Compliance with Ethical Standards

Conflicts of Interest

Dr. Desai reports personal fees from Abbott, grants and personal fees from Alnylam, grants and personal fees from AstraZeneca, personal fees from Boston Scientific, personal fees from Boehringer Ingelheim, grants and personal fees from Biofourmis, personal fees from DalCor Pharma, grants and personal fees from Novartis, personal fees from Relypsa, and personal fees from Regeneron, outside the submitted work.

Human and Animal rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139:e56–e528.PubMedCrossRefGoogle Scholar
  2. 2.
    Curtis LH, Greiner MA, Hammill BG, et al. Early and long-term outcomes of heart failure in elderly persons, 2001-2005. JAMA Intern Med. 2008;168:2481–8.CrossRefGoogle Scholar
  3. 3.
    Jong P, Vowinckel E, Liu PP, Gong Y, Tu JV. Prognosis and determinants of survival in patients newly hospitalized for heart failure: a population-based study. JAMA Intern Med. 2002;162:1689–94.CrossRefGoogle Scholar
  4. 4.
    van Diepen S, Tran DT, Ezekowitz JA, et al. Incremental costs of high intensive care utilisation in patients hospitalised with heart failure. Eur Heart J Acute Cardiovasc Care 8(7),660–666.  https://doi.org/10.1177/2048872619845282.PubMedGoogle Scholar
  5. 5.
    Bekelman DB, Havranek EP, Becker DM, et al. Symptoms, depression, and quality of life in patients with heart failure. J Card Fail. 2007;13:643–8.PubMedCrossRefGoogle Scholar
  6. 6.
    McCarthy M, Lay M, Addington-Hall J. Dying from heart disease. J R Coll Physicians Lond. 1996;30:325–8.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Chung ML, Lennie TA, Mudd-Martin G, Dunbar SB, Pressler SJ, Moser DK. Depressive symptoms in patients with heart failure negatively affect family caregiver outcomes and quality of life. Eur J Cardiovasc Nurs. 2016;15:30–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative Care: The World Health Organization’s global perspective. J Pain Symptom Manag. 2002;24:91–6.CrossRefGoogle Scholar
  9. 9.
    Allen LA, Stevenson LW, Grady KL, et al. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2012;125:1928–52.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Braun Lynne T, Grady Kathleen L, Kutner Jean S, et al. Palliative care and cardiovascular disease and stroke: a policy statement from the American Heart Association/American Stroke Association. Circulation. 2016;134:e198–225.PubMedCrossRefGoogle Scholar
  11. 11.
    Jaarsma T, Beattie JM, Ryder M, 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;11:433–43.PubMedCrossRefGoogle Scholar
  12. 12.
    Yancy Clyde W, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137–61.PubMedGoogle Scholar
  13. 13.
    Warraich HJ, Hernandez AF, Allen LA. How medicine has changed the end of life for patients with cardiovascular disease. J Am Coll Cardiol. 2017;70:1276–89.PubMedCrossRefGoogle Scholar
  14. 14.
    Warraich HJ, Mentz RJ, Hernandez AF. Paving a better path for patients dying of heart disease. Circulation. 2018;137:1216–7.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Bakitas M, MacMartin M, Trzepkowski K, et al. Palliative care consultations for heart failure patients: how many, when, and why? J Card Fail. 2013;19:193–201.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Alsalem AB, Zheng Z, Huang Y, et al. Palliative care consultations for advanced heart failure patients: experience from a safety-net hospital. J Card Fail. 2018;24:S94.CrossRefGoogle Scholar
  17. 17.
    Warraich HJ, Wolf SP, Mentz RJ, Rogers JG, Samsa G, Kamal AH. Characteristics and trends among patients with cardiovascular disease referred to palliative carecharacteristics and trends among patients with cardiovascular disease referred to palliative carecharacteristics and trends among patients with cardiovascular disease referred to palliative care. JAMA Netw Open. 2019;2:e192375–5.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care. 2013;12:7.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Weitzen S, Teno JM, Fennell M, Mor V. Factors associated with site of death: a national study of where people die. Med Care. 2003;41:323–35.PubMedGoogle Scholar
  20. 20.
    Services CfMaM. Proposed decision memo for ventricular assist devices for bridge-to-transplant and destination therapy (CAG-00432R).Google Scholar
  21. 21.
    Bekelman DB, Hutt E, Masoudi FA, Kutner JS, Rumsfeld JS. Defining the role of palliative care in older adults with heart failure. Int J Cardiol. 2008;125:183–90.PubMedCrossRefGoogle Scholar
  22. 22.
    Quill TE, Abernethy AP. Generalist plus specialist palliative care — creating a more sustainable model. N Engl J Med. 2013;368:1173–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Kavalieratos D, Gelfman LP, Tycon LE, et al. Palliative care in heart failure. rationale, evidence, and future priorities. 2017;70:1919–1930.  https://doi.org/10.1016/j.jacc.2017.08.036.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Fendler TJ, Swetz KM, Allen LA. Team-based palliative and end-of-life care for heart failure. Heart Fail Clin. 2015;11:479–98.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Nakagawa S, Garan AR. Hospice use and palliative care for patients with heart failure: never say never in medicine, but it is never too early to start the conversationpalliative care and hospice for patients with heart failure research. JAMA Cardiol. 2018;3:926–8.PubMedCrossRefGoogle Scholar
  26. 26.
    • Warraich HJ, Xu H, DeVore AD, et al. Trends in hospice discharge and relative outcomes among medicare patients in the get with the guidelines–Heart Failure Registry Trends in Hospice Discharge and Outcomes Among Medicare Patients in the GWTG-HF Registry Trends in Hospice Discharge and Outcomes Among Medicare Patients in the GWTG-HF Registry. JAMA Cardiol. 2018;3:917–26 This registry review of Medicare-linked claims data of HF patients showed infrequent hospice utilization among HF patients. When referred, patients were often referred too late with brief hospice enrollment. PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Xu J, Nolan MT, Heinze K, et al. Symptom frequency, severity, and quality of life among persons with three disease trajectories: cancer, ALS, and CHF. Appl Nurs Res. 2015;28:311–5.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Bekelman DB, Rumsfeld JS, Havranek EP, et al. Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients. J Gen Intern Med. 2009;24:592–8.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Rumsfeld JS, Alexander KP, Goff DC, et al. Cardiovascular health: the importance of measuring patient-reported health status. Circulation. 2013;127:2233–49.PubMedCrossRefGoogle Scholar
  30. 30.
    Heo S, Doering LV, Widener J, Moser DK. Predictors and effect of physical symptom status on health-related quality of life in patients with heart failure. Am J Crit Care. 2008;17:124–32.PubMedGoogle Scholar
  31. 31.
    Walke LM, Gallo WT, Tinetti ME, Fried TR. The burden of symptoms among community-dwelling older persons with advanced chronic disease. JAMA Intern Med. 2004;164:2321–4.CrossRefGoogle Scholar
  32. 32.
    Rumsfeld JS, Havranek E, Masoudi FA, et al. Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol. 2003;42:1811–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48:1527–37.PubMedCrossRefGoogle Scholar
  34. 34.
    Warraich HJ, Kitzman DW, Whellan DJ, et al. Physical function, frailty, cognition, depression, and quality of life in hospitalized adults ≥60 years with acute decompensated heart failure with preserved versus reduced ejection fraction. Circ Heart Fail. 2018;11:e005254.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Levenson JW, McCarthy EP, Lynn J, Davis RB, Phillips RS. The last six months of life for patients with congestive heart failure. J Am Geriatr Soc. 2000;48:S101–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32:157–87.PubMedCrossRefGoogle Scholar
  37. 37.
    Solomon SD, Dobson J, Pocock S, et al. Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation. 2007;116:1482–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Pulignano G, Del Sindaco D, Tavazzi L, et al. Clinical features and outcomes of elderly outpatients with heart failure followed up in hospital cardiology units: data from a large nationwide cardiology database (IN-CHF Registry). Am Heart J. 2002;143:45–55.PubMedCrossRefGoogle Scholar
  39. 39.
    Levy Wayne C, Mozaffarian D, Linker David T, et al. The Seattle Heart Failure Model. Circulation. 2006;113:1424–33.PubMedCrossRefGoogle Scholar
  40. 40.
    Pocock SJ, Ariti CA, McMurray JJV, et al. Predicting survival in heart failure: a risk score based on 39 372 patients from 30 studies. Eur Heart J. 2012;34:1404–13.PubMedCrossRefGoogle Scholar
  41. 41.
    Allen LA, Matlock DD, Shetterly SM, et al. Use of risk models to predict death in the next year among individual ambulatory patients with heart failurepredicting death among ambulatory patients with heart failurepredicting death among ambulatory patients with heart failure. JAMA Cardiol. 2017;2:435–41.PubMedCrossRefGoogle Scholar
  42. 42.
    Straw S, Byrom R, Gierula J, et al. Predicting one-year mortality in heart failure using the ‘Surprise Question’: a prospective pilot study. Eur J Heart Fail. 2019;21:227–34.PubMedCrossRefGoogle Scholar
  43. 43.
    Allen LA, Yager JE, Funk MJ, et al. Discordance between patient-predicted and model-predicted life expectancy among ambulatory patients with heart failure. JAMA. 2008;299:2533–42.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Dunlay Shannon M, Swetz Keith M, Mueller Paul S, Roger VL. Advance directives in community patients with heart failure. Circulation. 2012;5:283–9.PubMedGoogle Scholar
  45. 45.
    Butler J, Binney Z, Kalogeropoulos A, et al. Advance directives among hospitalized patients with heart failure. JACC: Heart Fail. 2015;3:112–21.Google Scholar
  46. 46.
    Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol. 2003;21:1133–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Hoyer T. A History of the Medicare hospice benefit. Hosp J. 1998;13:61–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Janssen DJA, Spruit MA, Wouters EFM, Schols JMGA. Family caregiving in advanced chronic organ failure. J Am Med Dir Assoc. 2012;13:394–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Hooley PJD, Butler G, Howlett JG. The relationship of quality of life, depression, and caregiver burden in outpatients with congestive heart failure. Congest Heart Fail. 2005;11:303–10.PubMedCrossRefGoogle Scholar
  50. 50.
    Bidwell JT, Lyons KS, Lee CS. Caregiver well-being and patient outcomes in heart failure: a meta-analysis. J Cardiovasc Nurs. 2017;32:372–82.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Garlo K, O’Leary JR, Van Ness PH, Fried TR. Burden in caregivers of older adults with advanced illness. J Am Geriatr Soc. 2010;58:2315–22.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Dunbar Sandra B, Khavjou Olga A, Bakas T, et al. Projected costs of informal caregiving for cardiovascular disease: 2015 to 2035: A Policy Statement From the American Heart Association. Circulation. 2018;137:e558–77.PubMedGoogle Scholar
  53. 53.
    •• Rogers JG, Patel CB, Mentz RJ, et al. Palliative care in heart failure. The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol. 2017;70:331–41 The PAL-HF studied and demonstrated that palliative care involvement in patients in addition to usual care led to improvement in HF-related quality of life, depression, and spiritual wellbeing. PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    •• O’Donnell AE, Schaefer KG, Stevenson LW, et al. Social worker–Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): a pilot randomized clinical trial. JAMA Cardiol. 2018;3:516–9 This study showed that intervention led by social work resulted in increased documentation of patient preferences and increased concordance between physician and patient assessment of prognosis. PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Gandesbery B, Dobbie K, Gorodeski EZ. Outpatient palliative cardiology service embedded within a heart failure clinic: experiences with an emerging model of care. Am J Hosp Palliat Med. 2017;35:635–9.CrossRefGoogle Scholar
  56. 56.
    Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733–42.PubMedCrossRefGoogle Scholar
  57. 57.
    Koser KD, Ball LS, Homa JK, Mehta V. An outpatient heart failure clinic reduces 30-day readmission and mortality rates for discharged patients: process and preliminary outcomes. J Nurs Res. 2018;26:393–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Ezekowitz JA, Thai V, Hodnefield TS, Sanderson L, Cujec B. The correlation of standard heart failure assessment and palliative care questionnaires in a multidisciplinary heart failure clinic. J Pain Symptom Manag. 2011;42:379–87.CrossRefGoogle Scholar
  59. 59.
    Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs. 2005;4:198–206.PubMedCrossRefGoogle Scholar
  60. 60.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Setoguchi S, Stevenson LW, Schneeweiss S. Repeated hospitalizations predict mortality in the community population with heart failure. Am Heart J. 2007;154:260–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Dabbouseh NM, Kaushal S, Peltier W, Johnston FM. Palliative care training in cardiology fellowship: a national survey of the fellows. Am J Hosp Palliat Med. 2017;35:284–92.CrossRefGoogle Scholar
  63. 63.
    Back AL, Arnold RM, Baile WF, et al. Faculty development to change the paradigm of communication skills teaching in oncology. J Clin Oncol. 2009;27:1137–41.PubMedPubMedCentralCrossRefGoogle Scholar
  64. 64.
    •• Bekelman DB, Allen LA, et al. Effect of a collaborative care intervention vs usual care on health status of patients with chronic heart failure: the CASA Randomized Clinical Trial. JAMA Intern Med. 2018;178(4):511–9 This study showed that though focused symptom and psychosocial intervention did not result in difference in health status, secondary outcomes including depression and fatigue improved. PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2019

Authors and Affiliations

  • Sarah Chuzi
    • 1
  • Esther S. Pak
    • 2
  • Akshay S. Desai
    • 3
    • 4
  • Kristen G. Schaefer
    • 4
    • 5
    • 6
  • Haider J. Warraich
    • 3
    • 4
    • 7
    Email author
  1. 1.Division of Cardiology, Department of MedicineNorthwestern University at Feinberg School of MedicineChicagoUSA
  2. 2.Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaUSA
  3. 3.Center for Advanced Heart Disease, Division of Cardiovascular Medicine, Department of MedicineBrigham and Women’s HospitalBostonUSA
  4. 4.Harvard Medical SchoolBostonUSA
  5. 5.Department of Psychosocial Oncology and Palliative CareDana Farber Cancer InstituteBostonUSA
  6. 6.Division of Palliative MedicineBrigham and Women’s HospitalBostonUSA
  7. 7.Cardiology Section, Department of MedicineBoston VA Healthcare SystemBostonUSA

Personalised recommendations