Clinicians caring for patients with advanced heart failure (HF) are encouraged not only to continue their focus on the quality of their own delivery of care as patients near the end of life, but also to advocate for changes to improve the overall care of this growing population.
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This is according to the authors of an editorial commentary accompanying the study report from Gelfman et al published in JACC: Heart Failure.
“It is incumbent upon clinicians managing this vulnerable population to champion end-of-life care, including the principles of palliation and hospice,” write the authors, who are with the Duke University Medical Center and the Division of Cardiology, Duke University School of Medicine, Durham, NC.
Heart Failure Patients Should Receive Hospice Earlier
The Gelfman finding that 45% of HF patients who entered hospice died within seven days is of particular concern to the authors. “It seems unlikely that patients and their families derive the maximal potential benefit from hospice approaches when death occurs within seven days of enrollment,” they write.
The authors acknowledge the significant contribution of the Gelfman study to the knowledge base needed to shape future policy approaches to HF end-of-life care, and identify “several urgent needs for our patients and their families” highlighted by the study.
Actions Urgently Needed to Improve HF End-of-Life Care
- The original, “one-size-fits-all” Medicare hospice framework designed to serve cancer patients must be updated and tailored to meet the needs of individuals with noncancer diseases, such as HF.
- Similarly, Medicare’s six-month prognosis restriction should be re-examined and updated to accommodate the prognostication challenges inherent in organ failure diseases, particularly HF.
- Clinicians should advocate for improved end-of-life care for HF patients.
“We need to collectively improve communication about advanced care planning, changing goals of care, symptom management and bereavement,” the authors write.
For example, evidence has shown that as chronic illnesses progress, patient goals often shift from life extension to enhancing quality of life, they note. “It is incumbent upon the HF practitioner to appreciate and anticipate these pivots in patient preference and [to] be as versed with comfort care strategies as we are with neurohormonal antagonists.”
- The optimal location for HF patients’ death needs to be better understood, rather than assuming that because most polled patients say they would prefer to die at home, this setting is desired by or appropriate for all individuals with HF.
- Payment models for hospice should be re-thought, particularly those models that form/present a barrier to hospice care for the subset of HF patients requiring interventions that hospice agencies find difficult to cover financially under the current system.
- Clinicians need to listen carefully to patients and families in order to understand their needs and desires, and to ask themselves if they are providing the most extensive care their resources allow.
“[W]e need to listen carefully to our patients and their loved ones,” write the authors. “What do they want at the end of life? Are we providing optimal care? Are we extending the full extent of our resources to assist family members? Should there be some longer- term commitment to survivor health?”
“It Is Time to Discuss Dying,” Journal of the American College of Cardiology: Heart Failure; September 2018; 6(9):790-791. Warraich HJ, Rogers JG; Department of Medicine, Division of Cardiology, Duke University Medical Center; and the Duke Clinical Research Institute, Durham, NC.