Palliative Care Across the HF Spectrum: Key Points

Gelfman LP, Blum M, Ogunniyi MO, McIlvennan CK, Kavalieratos D, Allen LA.
Palliative Care Across the Spectrum of Heart Failure. JACC Heart Fail 2024;Mar 6:[Epub ahead of print].

The following are key points to remember from a state-of-the-art review on palliative care across the spectrum of heart failure (HF):

  1. Patients with HF may be affected by a high symptom burden, poor functional status and quality of life (QoL), frequent hospitalizations, and high mortality rates. In addition, uncertainty about prognosis and potential treatment options, psychosocial and spiritual distress, and caregiver burden may impact overall care. Palliative care may help with addressing many of these issues.
  2. All clinicians caring for patients with HF should be able to address foundational palliative care needs (basic symptom management, identifying surrogate decision makers, discussing goals of care and preferences, helping with advanced directives), also referred to as primary palliative care. Specialty palliative care by those with specific training may provide additional benefit when symptoms become intractable or if complex medical decision-making and care for advanced disease management is required.
  3. In the ambulatory setting, specialty palliative care clinicians can help collaborate with the care team to manage symptoms, provide support and education to patients and caregivers, assist with advance care planning, and coordinate additional resources.
  4. In the hospitalized setting, which often represents a key clinical worsening in a patient’s overall trajectory, focus should remain on improving QoL, providing optimal HF guideline-directed medical therapies (GDMTs), assessing goals of care, and planning for effective transitions of care. In situations where HF treatment options are limited and prognosis is poor, the general focus of care is the same, though de-prescribing medications that do not provide symptom relief and using palliative inotropes can be considered.
  5. In patients with advanced HF, specialty palliative care may help patients to understand the potential benefits/risks/burdens with specific therapies (heart transplantation, durable left ventricular assist device) and the psychosocial impact (lifestyle changes, caregiver support, etc.). For patients who are ineligible for life-prolonging advanced therapy options, specialty palliative care can help patients and families adjust to new plans of care and potentially engage with hospice services.
  6. Home-based palliative and hospice care is an alternative to hospital-based programs for appropriate patients living with HF. Models for home-based care are still being developed, though they have the potential to serve the needs of many patients.
  7. Appropriate consideration needs to be given to caregivers and families, as they are key members of the care team and assume significant responsibilities (direct patient care, transportation, psychosocial support, etc.). Palliative care can assist with engaging caregivers and families in the decision-making and planning process.
  8. The evidence base for palliative care for patients with HF generally shows positive associations with outcomes. However, the studies are limited by small sample sizes, variable quality, and heterogeneous interventions and outcome measures. Future opportunities to enhance the palliative care evidence base include standardizing what a palliative care intervention should include and what outcomes are most appropriate and clinically relevant.
  9. The future vision of palliative care in HF includes being able to equitably provide access to care and to provide this care at the right level at the right time. Considering the shortage of trained specialty palliative care clinicians, new models of care and initiatives are needed. This may include providing more basic palliative care training to care team members (community health workers, primary care physicians, general cardiologist, etc.) and utilizing virtual care visits.
  10. To reduce disparities in palliative care utilization and referrals, it is recommended that systems be put in place to identify patients early in the disease course who may have unmet needs and to engage with community health workers to build trust in communities and remove barriers to care.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure, Cardiovascular Care Team

Keywords: Heart Failure, Geriatrics, Palliative Care

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