Overcoming the Barriers to Palliative Care Referral for Patients With Advanced Heart Failure

In the care of seriously ill patients, cardiologists and other physicians must have many skills to effectively help the patient and family manage the symptoms from the illness, cope with and understand the likely illness trajectory, and navigate complex medical decision making. Cardiologists routinely use these skills to effectively maximize the patient’s quality of life. However, for those patients who have a severe symptom burden or more difficulty coping with the complexities of a serious illness, consultation by a palliative care clinician can be a valuable resource. The Center to Advance Palliative Care defines subspecialty palliative care as follows: “Specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis or prognosis. The goal is to improve quality of life for both the patient and the family. Palliative care is delivered by a team of doctors, nurses, and other specialists who work with the patient’s doctors to provide an extra layer of support.” This differs from hospice, which is a type of medical care that is limited to patients who have a prognosis of less than 6 months and who have agreed to forgo any further curative treatment. Unlike hospice, palliative care is appropriate at any stage in a serious illness and can be provided together with curative treatment. Until recently, most palliative care research has focused on patients with metastatic cancer. Randomized, controlled trials have shown a multitude of benefits, including improved quality of life and prolonged survival. 1,2 Patients receiving palliative care report lower rates of depression in the context of increased illness understanding, and prognostic awareness and they tend to elect less aggressive medical care at the end of life with longer enrollment in hospice and even longer survival. Interestingly, these benefits become apparent when palliative care consultation is provided alongside standard oncology care early in the disease process. Palliative care is less established for heart failure patients, but studies show that this patient population may benefi ta s much from palliative care as cancer patients. 3–5 Heart failure causes many different symptoms that adversely affect a patient’s quality of life, such as fatigue, shortness of breath, anxiety, and depression. 6 The illness trajectory is less predictable than for cancer, often making it more difficult for patients to navigate the illness and plan for the future. However, because life expectancy is unpredictably shortened after a heart failure diagnosis, identifying a patient’s, goals and values are as important. For example, a consequence of end-stage heart failure is increasingly frequent hospitalizations, which can become burdensome to patients and their families. Palliative care can help make sure that burden is balanced with the patient’s overall goals. Despite the potential benefits, palliative care specialists do not frequently participate in the care of patients with heart failure. The study by Kavalieratos et al. 7 in this issue of the Journal of the American Heart Association explores barriers to palliative care referrals in heart failure. They conducted semistructured interviews with primary care, cardiology, and palliative care providers to assess their knowledge, attitudes, and perceptions of palliative care. All participating clinicians endorsed palliative care involvement in the care of patients with heart failure. However, it was not clear that the providers had an accurate understanding of the domains of palliative care and how it differs from a hospice. In the study, nearly all primary care and cardiology providers were unable to distinguish palliative care from hospice or end-of-life care. Subjects also did not recognize that palliative care is not prognosis dependent and can be provided alongside life-prolonging therapy. Consequently, cardiology providers frequently identified the indication for palliative care referral as the “point at which you are unable to do more.” The study also identified more basic referral The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.