Patients with advanced heart failure may not receive the palliative care they need

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Patients with advanced heart failure (HF) are less likely to receive palliative care than are patients with advanced cancer, even though both groups have similar needs, new research shows.

While new ACC/AHA guidelines stress the potential benefit of palliative care for HF patients, they may not receive it because providers misperceive palliative care as a service reserved for people near death, the researchers reported online January 2 in Journal of the American Heart Association.

But "optimistically, when providers in our study were informed of what palliative care is and what it can offer patients, caregivers and providers, they were enthusiastic about exploring how to collaborate with palliative care specialists," wrote lead author Dr. Dio Kavalieratos of the University of Pittsburgh School of Medicine, in email to Reuters Health.

"Providers should be aware that specialist palliative care is a clinical service that provides an extra layer of support to patients and their families - including patients with heart failure. Palliative care specialists work alongside patients' existing care teams to optimize quality-of-life, alleviate physical symptoms and emotional distress, and help create a healthcare experience that respects patients' goals of care," he wrote.

"Importantly, unlike hospice, palliative care can be initiated at any time. Providers needn't wait until their patients are imminently dying" to improve their survival and quality-of-life, he added.

Dr. Kavalieratos and his colleagues found that providers either didn't know that palliative care exists as an actual clinical service or they equated palliative care with hospice.

"This is particularly regrettable, since palliative care eligibility does not require an expectation that a patient will likely die within six months (as does the Medicare Hospice Benefit). This means that patients living with heart failure-related burdens and their caregivers could benefit from supportive, whole-person care earlier in their illness, but they do not, partly because of providers' misperceptions of what palliative care is," he wrote.

In the first U.S. study to explore the perceived factors that prevent cardiology, primary care, and palliative care providers from referring their HF patients for palliative care, Dr. Kavalieratos and his research team conducted semistructured interviews exploring how providers perceived the needs of patients with advanced HF.

Eligible participants were physicians, nurse practitioners and physician assistants who practiced in cardiology, primary care and palliative care in North Carolina and had cared for three or more HF patients in the preceding six months. They were given a $50 honorarium.

Of 22 people contacted, they interviewed 18. Within each specialty, four were physicians and two were nonphysicians drawn from two academic medical centers, the Veterans Affairs Medical Center, and community-based non-academic practices.

By phone or in in-person interviews over roughly six months, participants were asked 10 questions covering the needs of HF patients; their knowledge and perceptions of palliative care; the indications for, and optimal timing of, palliative care referral in HF; and the barriers to palliative care referral in HF. Data were examined using template analysis.

Even though most cardiology and primary care providers practiced near specialist palliative care services, they knew little about what nonhospice palliative care is and how it differs from hospice care; what it offers patients, their families and providers; when it is indicated; and how to access it.

All of the primary care and cardiology providers reported that they could define palliative care, but almost none of them knew that palliative care is not prognosis dependent and can be provided concurrently with life-prolonging therapy. Many cardiology and primary care providers did not know that specialist palliative care is a tangible clinical service.

Potential barriers included the unpredictable course of HF and the lack of clear referral triggers across the HF trajectory. Providers were interested in integrating palliative care into traditional HF care, but were not sure how to begin.

"I was surprised that we found such limited or complete lack of knowledge of what palliative is," Dr. Kavalieratos said. He called for more research on integrating palliative care into advanced HF patients' standard care to improve the quality of life for them and their families.

Dr. Deborah Waldrop of the School of Social Work at the University at Buffalo, State University of New York, commented in an email that "this study provides important information about significant structural and process barriers to the use of palliative care in HF patients that can be addressed through education and collaboration."

"Palliative care is slowly becoming more widely known and utilized, but comfort with and reliance on palliative care really requires that physicians are first comfortable with a shift from a cure-focused to care-focused approach. This shift is sometimes difficult and can be experienced as contradictory to expected practice," she added. Dr. Waldrop was not involved in the study.

SOURCE: http://bit.ly/1jbNJn8

J Am Heart Assoc 2014.

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