Heart failure is one of the most common diagnoses encountered in the acute care setting. It afflicts an estimated 5.1 million American adults in 2013 with attendant health care expenditures of $32 billion, and is projected by 2030 to affect 6.4 million Americans at an annual cost of $70 billion. Advances in treatment have extended the lives of patients with HF, yet the 5-year mortality remains around 50% (Circulation 2013:127:e6-e245).
Patients with heart failure (HF) are frequently readmitted within 30 days of hospital discharge, leading the Centers for Medicare and Medicaid Services to include this diagnosis in public reporting and incentive payment programs.
Prognostication can be challenging, with the incidence of sudden death reported as high as 60%. Harbingers of poor prognosis include: inability to achieve euvolemia without symptomatic hypotension or increasing renal insufficiency (GFR less than 20mL/min), need for inotropic support to maintain clinical stability, hospitalization longer than 30 days, and need to reduce angiotensin-converting enzyme inhibitor (ACEI) or beta-blocker therapy due to patient intolerance. HF is often one of several comorbid illnesses, with 45% of decedents in the TIME-CHF study dying of other causes (Am. Heart J. 2010;160:308-14). This prognostic uncertainty generates underinformed patients who are less likely to be involved in shared decision making about their care.
The ACCF/AHA Guideline for the Management of Heart Failure recommend incorporating palliative care into the treatment of patients with HF, but do not provide more specific parameters.
As part of a community-wide effort to standardize and improve the care of patients with HF, we are considering how best to integrate palliation into the continuum of care for this illness. HF patients carry a significant symptom burden. Dyspnea, fatigue, edema, and decreased exercise tolerance are generally well recognized and treated, but patients also experience myalgias, nausea, anorexia, constipation, loss of function, and psychological distress. Systematic assessment and treatment of these symptoms improve quality of life, and may improve survival.
Hospitalists typically encounter HF patients in the chronic disease management phase, receiving guideline directed medical therapy. When symptoms worsen despite optimal management or the patient is diagnosed with a new comorbid illness, consider a palliative care consult. The team will assist the patient and family reassess goals of care, manage symptoms, and construct a preparedness plan. A preparedness plan is a disease-specific advance directive as well as a management plan for expected complications. Preparedness planning begins with assessment of the understanding of the disease process and further education where needed, followed by establishment of goals of care. Goals of care may include prolongation of life, symptom management, improved quality of life, and improved support to family caregivers. Patients identify a surrogate decision maker in the event of incapacity, and complete other advance directives as appropriate. Preferences for CPR are assessed and documented, and a symptom management plan is constructed with input from the cardiology team. This plan is reassessed and updated at times of transition or unanticipated clinical events. HF patients need an outpatient management plan that includes access to a clinician after hours (to forestall avoidable ED visits and readmissions).
At present, palliative care consultations are predominantly available in the acute care hospital setting. Disease education, goals of care and preparedness planning conversations are ideally held in an outpatient setting with a trusted health care provider. True integration of palliative care into the continuum of care for HF will necessitate a combination of collocated palliative care clinicians, primary palliative care education for cardiology clinicians, and realignment of payment incentives. Health care reform efforts such as Accountable Care Organizations and value-based purchasing are intended (in part) to drive this clinical redesign. It remains to be seen whether or not these efforts will succeed.
Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the UT Southwestern Residency Programs in Austin, Tex. Their respective backgrounds are internal medicine and family medicine. Between the two of them they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.