Better Access to Palliative Care Needed in Heart Failure Management

Integrating palliative care into heart failure (HF) management may benefit patients, according to a research letter published in JAMA Internal Medicine, though more definitive research is needed.

“The progressive nature of HF, coupled with high mortality rates and poor quality of life, make it suited for the incorporation of palliative care,” wrote Rabeea F. Kahn, MD, of Yale School of Medicine in New Haven, Connecticut, and colleagues. “Given that symptoms frequently drive health care use, early integration of palliative care may reduce readmissions.”

The prospective study, performed at Yale-New Haven Hospital, evaluated 91 patients between August 2013 and December 2014. The researchers questioned patients both about their symptoms—using the Edmonton Symptom Assessment Scale (ESAS), designed to appraise patients’ opinions on the severity of their symptoms— and their knowledge of palliative care services. Patients were enrolled and screened within an average of 2.5 days from hospital admission, and screened again via telephone follow-up a mean 9.9 days after discharge. Self-reported symptom severity ratings were compared between assessments, as well as patient knowledge about palliative care.

During their hospital stays, patients complained of symptoms ranging from decreased well-being, fatigue, and dyspnea to anxiety and pain. A lack of symptom improvement post-discharge was common — 58% of patients reported no improvement in fatigue (P = .86), 42% of patients reported no improvement in dyspnea (P = .03), and 41% percent reported no improvement in either pain (P = .21) or anxiety (P = .26). Only 22% of patients reported any kind of familiarity with palliative care services.

Initial survey responses regarding patients’ perceptions of palliative care indicated a range of interpretations. Many assumed that palliative care was intended to be “comfort care” meant only “for dying patients,” as a tool “useful for older people at the end of life, when they need lots of medical care,” “for cancer patients in extreme pain,” or as a recommendation “for patients who’s departure is eminent.” After a study-approved standardized explanation, 68% of patients were interested in receiving palliative care services. 

Current practices for HF symptom management typically fail to adequately address symptoms not traditionally associated with HF, the researchers noted. Patient comorbidities complicate management, and clinicians may simply not be prepared to assess and treat ailments that include pain, anxiety, depression, and fatigue.

“Fewer than 10% of patients with HF receive palliative care,” Khan and colleagues wrote. “Future studies should evaluate whether palliative care is effective in reducing symptom burden and readmission among patients who are hospitalized for HF.”

Reference

1. Khan RF, Feder S, Goldstein NE, Chaudhry SI. Symptom Burden Among Patients Who Were Hospitalized for Heart Failure. JAMA Intern Med. 2015; doi:10.1001/jamainternmed.2015.3871.