Patients with advanced heart failure (HF) who receive ongoing, coordinated palliative care in the outpatient setting following hospital discharge show significantly greater improvement in quality of life, spiritual well-being and symptoms of depression and anxiety compared with patients receiving usual cardiology care only, according to a report of the results of a rare, randomized trial published in the Journal of the American College of Cardiology.
“HF progression is a frightening and uncomfortable experience for patients, with both physical and psychological sequelae,” write the authors. “The addition of palliative care principles in this vulnerable population improved physical, psychosocial (anxiety/depression) and spiritual quality-of-life measures—the key domains of patient experience in serious illness.”
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6-Month Palliative Intervention
Investigators analyzed results of a trial in which 150 patients with advanced HF who were at high risk for rehospitalization and six-month mortality (mean age 71 years; female 47%; black race 41%) were randomized to usual care (UC), i.e., evidence based HF management, or usual care plus a palliative care intervention (UC + PAL). The interdisciplinary palliative care intervention, the Palliative Care in Heart Failure (PAL-HF) trial, enrolled patients between August 2012 and June 2015. The intervention phase of the trial was six months, but patients were supported afterward via contact every three months until death or the study’s end.
Palliative was coordinated by a certified palliative care nurse practitioner in conjunction with a physician specialist in hospice and palliative medicine. Each patient’s clinical cardiology team collaborated in the shared goal setting of combining HF symptom control with palliative care.
HF and General Quality of Life
Quality of life was assessed using two measurements, one for HF-specific quality of life and the other for general and palliative-care-specific quality of life.
- The Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary is scored from 0-100. Higher scores represent better health; a 5-point change is considered clinically meaningful.
- The Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal) is self-reported quality-of-life assessment with a range of 0-184. Higher scores indicate better quality of life; a 10-point change is considered clinically meaningful.
Assessments of depression, anxiety and spiritual well-being were measured using the Hospital Anxiety and Depression Scale (HADS) and the FACIT-Spiritual Well-Being scale (FACIT-Sp).
- HADS has a range of 0-42, with depression and anxiety subscores ranging from 0-21. Higher scores indicate worse symptoms.
- FACIT-Sp scores range from 0-48. Higher scores indicate more spirituality.
Benefits Observed after 3 Months
Patients in the UC + PAL group had greater improvement in all endpoint scores at six months than did those in the UC-only group, with the real benefit of the palliative care intervention becoming observable after three months. “We posit that this finding may be related to the sustained involvement of palliative care and the relationships that develop between patients, their families and care teams,” the authors suggest.
Mean differences in assessment scores at six months, UC + PAL vs UC-only:
- KCCQ (HF-specific) difference, 9.49 points; 95% confidence interval (CI), 0.94 to 18.05; P = 0.03
- FACIT-Pal (palliative-care-specific) difference, 11.77 points; 95% CI, 0.84 to 22.71; P = 0.035
- HADS-depression difference, -1.94 points; 95% CI, 3.57 to -0.31; P = 0.02
- HADS-anxiety difference, -1.83 points; 95% CI, -3.64 to -0.02; P = 0.48
- FACIT-Sp (spiritual) difference, 3.98 points; 95% CI, 0.46 to 7.50; P = 0.027
Care That Reaches Beyond the Health System
“The findings support the patient-reported benefits of a care delivery model that transitions and changes, much like symptoms do, beyond the walls of the health system to the community and home settings,” write the authors. “PAL-HF is the first randomized, controlled trial of a longitudinal palliative care intervention to show the significant clinical benefit of embedding such an interdisciplinary intervention in the overall management of patients with advanced HF.”
The authors suggest that larger, multicenter studies are needed to confirm the results of their study, which is limited by being a single-center trial. Study strengths include the “diverse and high-risk HF cohort that mirrors the broader population commonly admitted to the hospital,” they note.
The quality-of-life outcomes were derived from patient reports rather than “hard endpoints,” which are often of less importance to patients. “Many of these patients have a strong desire for relief of suffering and assistance with end-of-life planning,” note the authors. “PAL-HF provides empirical evidence that palliative care improves health-related quality of life in end-stage HF patients.”
Source: “Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial,” Journal of the American College of Cardiology; July 18, 2017; 70(3):331-341. Rogers JG, Patel CB, Tulsky JA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; and Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, both in Boston.