Failing the failing heart: a review of palliative care in heart failure.

Heart failure (HF) is the most common reason for hospital admission for patients older than 65 years. With an aging population and improving survival in heart failure patients, the number of people living with HF continues to grow. As this population increases, the importance of treating symptoms of fatigue, dyspnea, pain, and depression that diminish the quality of life in HF patients becomes increasingly important. Palliative care has been shown to help alleviate these symptoms and improve patients' satisfaction with the care they receive. Despite this growing body of evidence, palliative care consultation remains underutilized and is not standard practice in the management of HF. With an emphasis on communication, symptom management, and coordinated care, palliative care provides an integrated approach to support patients and families with chronic illnesses. Early communication with patients and families regarding the unpredictable nature of HF and the increased risk of sudden cardiac death enables discussions around advanced care directives, health care proxies, and deactivation of permanent pacemakers or implantable cardioverter defibrillators. Cardiologists and primary care physicians who are comfortable initiating these discussions are encouraged to do so; however, many fear destroying hope and are uncertain how to discuss end-of-life issues. Thus, in order to facilitate these discussions and establish an appropriate relationship, we recommend that patients and families be introduced to a palliative care team at the earliest appropriate time after diagnosis.

An evaluation of the prevalence and severity of pain and other symptoms in acute decompensated heart failure.

BACKGROUND: Heart failure is characterized by recurrent decompensations and persistent symptoms that decrease quality of life. Shortness of breath and fatigue are commonly identified symptoms but there is limited data on pain in heart failure patients. The Edmonton Symptom Assessment System (ESAS) was used to identify the prevalence and severity of pain and other symptoms experienced by patients with acute decompensated heart failure. METHODS: This is a cross-sectional study that evaluated patients with a history of chronic heart failure admitted to the hospital with acute decompensated heart failure. A standardized questionnaire (ESAS) was administered to patients within 24 hours of hospital admission. Exclusion criteria included patients <18 years of age, admission for a noncardiac reason, active malignancy, history of chronic pain, outpatient chronic pain medication use, and those actively followed by the palliative care service. RESULTS: One hundred patients, 67 males, with a mean age of 58 ± 17 years were recruited. The mean ejection fraction (EF) was 37%± 18%. Sixty patients (60%) reported pain of any degree. Patients with lower EF (≤ 40%, n=61) reported significantly higher pain scores (4.1 ± 3.6) compared to patients with higher EF (>40%, n=36, 2.7 ± 3.4, p<0.05). Tiredness, shortness of breath, and decreased well-being were the most severe symptoms with mean scores of 6.3 ± 2.8, 6.1 ± 3.1, and 5.7 ± 2.6, respectively. CONCLUSION: Pain is a common, underrecognized symptom in patients with chronic but acute decompensated heart failure. Decreased well-being, shortness of breath, and tiredness are the most common and severe symptoms in patients with chronic heart failure, regardless of ejection fraction.

Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation.

BACKGROUND: Heart failure (HF) in its chronic form is an irreversible and progressive disease. Palliative care (PC) interventions have traditionally been focused on patients with advanced cancer. We performed a pilot study to assess the feasibility of implementing the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for early PC intervention in patients with advanced HF who were seeking or received potentially curative therapies. METHODS: Twenty consecutive patients with advanced HF referred to PC from the heart transplant service with stage D, New York Heart Association (NYHA) class III-IV symptoms were analyzed retrospectively in a tertiary care setting. Data were reviewed to assess the clinical impact of PC intervention. Feedback was obtained to assess satisfaction of the patients, their families, and the health care professionals. An independent assessment of the impact of the PC service in the care of each patient was performed by a cardiologist and PC physician by use of a scoring system. RESULTS: Twenty consecutive patients with HF were analyzed. PC consult was obtained for a variety of reasons. All patients complained of a high symptom burden. PC consultation resulted in a decrease in the use of opioids and increased patient satisfaction. Patients and their family members generally reported improved holistic care, continuity of care, more focused goals of care, and improved planning of treatment courses. The nonstandardized scoring system used to determine the impact of the PC service showed an average of moderate to significant impact when assessed by both a cardiologist and a PC physician. CONCLUSION: PC consultation appears to be beneficial in the treatment and quality of life of advanced HF patients, independent of their prognosis. This pilot study demonstrated feasibility and sufficient evidence of clinical benefit to warrant a larger randomized clinical trial assessing the benefit of standard involvement by PC in patients with advanced HF, independent of the patient's prognosis or treatment goals.