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Palliative Care and End-Stage Heart Failure
Study Questions:
What is the role of home-based transitional palliative care in patients with end-stage heart failure post-discharge?
Methods:
This was a randomized controlled trial that took place in three hospitals in Hong Kong between May 2013 and December 2014. Patients all had end-stage heart failure and were referred to palliative care after discharge randomized to an intervention arm that included weekly home visits/telephone calls in the first 4 weeks and then monthly for the first 12 months. The primary outcome was readmissions (from 4 weeks to 12 weeks post-discharge). Secondary outcome was symptom intensity (measured by the Edmonton Symptom Assessment Scale [ESAS]), functional status (measured by the Palliative Performance Scale [PPS]), quality of life (measured by the McGill Quality of Life questionnaire-Hong Kong [MQOL-HK] and the chronic heart failure questionnaire-Chinese [CHQ]), and satisfaction with care measured by an 11-item questionnaire. Both groups received palliative care consultation in clinic and heart failure education with appropriate referrals.
Results:
A total of 389 patients were screened and 84 were eligible. The mean age was 78.3 years, with males making up 52.4% of the study population. The demographic background of the two groups was very similar. The intervention group had a lower 4-week readmission rate (intervention 20.9% vs. control 29.3%, χ2 = 4.41, p = 0.79) and a mean number of readmissions (intervention 0.21 [standard error 0.07] vs. control 0.41 [standard error 0.10] p = 0.097), but was not significant. At 12 weeks, the readmission rate (intervention 33.6% vs. control 61.0%, χ2 = 6.8, p = 0.009) and mean number of readmissions was significantly lower for the intervention group (intervention 0.42 [standard error 0.10] vs. control 1.10 [standard error 0.16], p = 0.001). The results of secondary endpoints showed no difference in functional status and some improvement, as measured by depression and anxiety in the intervention group. There were no significant differences between the two groups in changes over time for quality of life measured by MQOL-HK (p < 0.05) and CHQ (p < 0.01) questionnaires. The interventional group had significantly higher satisfaction with care than the control group (p < 0.001).
Conclusions:
A post-discharge home-based palliative care program can reduce end-stage heart failure readmissions and improve quality of life and symptom control.
Perspective:
When approaching patients with end-stage heart failure, a multidisciplinary team is needed to co-manage these patients. This model should include a member from the palliative care team. The effectiveness of early discussion of goals of care, communication on quality of life, and collaboration can provide the necessary support and coordinated care that these patients often find lacking. I encourage more programs to incorporate these discussions and system-based practices in patients with end-stage heart failure.
Keywords: Anxiety, Cardiomyopathies, Depression, Heart Failure, Palliative Care, Patient Care Planning, Patient Care Team, Patient Discharge, Patient Readmission, Personal Satisfaction, Quality of Life, Symptom Assessment
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