Using the Evidence for Palliative Care to Improve Outcomes for Patients With Heart Failure

Heart failure is a complex, progressive life-limiting condition affecting 6 million Americans. By 2030, it is projected to affect 8 million people (3% of our population), consuming $69.8 billion in direct medical cost.1,2 With a 5-year mortality of 43%,2,3 many patients with heart failure experience poor quality of life (QOL) and endure signs and symptoms such as dyspnea, pain, gastrointestinal disorders, thirst, and anxiety. As the stage of illness advances, so do intensive care unit (ICU) admissions, especially at the end of life. These admissions account for 20% of US deaths and consume approximately 20% of hospital expenses.4 As a result, hospitals are reducing the numbers of acute care beds and increasing the numbers of ICU beds to accommodate current and projected increases in ICU admissions.5Mortality associated with heart failure increases with each hospitalization. Rising costs and system strain have prompted health care systems and national organizations to develop programs and standards that improve outcomes for this population. Medicare’s Hospital Readmission Reduction Program6 and the American College of Cardiology (ACC)/ American Heart Association (AHA) heart failure management guidelines7 are examples. The AHA recommends that providers review prognosis annually,8 yet only 12% of providers implement this guideline and 4% have never discussed prognosis.9 Despite these guidelines, hospital 30-day readmission rates remain at 20%10 and the 1-year mortality rate is 20% to 25% for patients with heart failure.3,6Another strategy endorsed by the ACC/AHA and World Health Organization is the initiation of palliative care.11–13 Palliative care is an approach that improves QOL for patients facing problems with life-limiting illnesses. In palliative care, subspecialists integrate interventions to prevent or relieve suffering and treat physical, psychosocial, or spiritual problems.14Palliative care is not new to the health care arena. Since 1990, laws have mandated elements of palliative care for hospitalized patients, for example, advance directives, which outline information regarding shared decision-making and establish goals of care.15 As part of the multiprofessional team, palliative care specialists provide support with assessments, education, communication, and future care planning.12,16 Palliative care specialists work synergistically within the multiprofessional team to support goals of care, including life-prolonging and advanced heart failure therapies. Despite supporting evidence, palliative care as an intervention is underused,17 with only 6% of patients admitted for heart failure receiving a palliative care consultation.18 Cardiology consultations to palliative care often happen within the final 3 days of life, and 27% of patients admitted to the ICU die without any conversation regarding goals of care.19,20 Given the endorsement of palliative care and its suboptimal use, the following PICO (patient/population/problem, intervention, comparison, outcome) question is generated:Do patients with heart failure have improved outcomes (QOL, advance care planning, symptom management, and reduced hospital readmissions) when palliative care interventions are implemented compared with patients who receive usual care?The strategy included searching CINAHL and PubMed. Key words included heart failure, intensive care palliative care, palliative care interventions, quality of life, and outcomes. Bibliographies of the articles found were searched by hand. The search was limited to the past 10 years.Seven studies are presented in Table 1. Five studies were randomized controlled trials (RCT) and 2 were systematic reviews. Two of the 5 RCTs were conducted outside of the United States and examined palliative care provided at home versus usual care, whereas US studies investigated palliative care interventions integrated in the interdisciplinary team.The majority of studies show that palliative care interventions are associated with significant improvement in QOL and symptom burden, including depression and anxiety. Other outcomes include reduced primary care and hospital utilization (ie, shorter stay, fewer emergency department visits, and fewer readmissions) and higher levels of advanced care planning and satisfaction with care. In 1 study, palliative care consultations did not affect patients’ likelihood of choosing comfort care (hospice or do-not-resuscitate status). In 2 studies, palliative care had no impact on mortality.The current level A and B evidence28 supports implementation of palliative care interventions. Palliative care improves QOL and symptom management, reduces hospital readmissions and health care utilization, and increases advance care planning, all of which influence the quadruple aims of cost, quality, and patient and provider satisfaction.29Many barriers to implementing palliative care have been identified. These barriers can be categorized as training/education, consult timing and coordination, general misconceptions, and prognostic uncertainty about heart failure.16,17,30–33 Health care providers have limited knowledge or misunderstandings about palliative care, often confusing it with hospice care,33 which reduces use of palliative care.34 Providers who lack communication skills and confidence to discuss illness trajectory or end-of-life preferences foster poor planning of future care.9 Without adequate patient and family education about their heart failure, an environment is cultivated for discrepant goals of care and inadequate advanced care planning.35 The evidence tells us, however, that adding palliative care to the services provided by the interdisciplinary team promotes advance care planning.21,26Clinicians are confused about which discipline should provide palliative care and when in the illness continuum palliative care should be considered.17 Venues such as heart failure and palliative care collaborative clinics have been addressed as a means for meeting the needs of patients and targeting early interventions to define best outcomes.36 With early integration of palliative care by skilled clinicians who are confident and willing to discuss heart failure prognosis and goals of care, patients can experience reduced hospitalizations, improved symptom management, and better QOL.12,18Benefits of palliative care are not new to nurses. For years, nurses have cared for patients who are often admitted to the ICU without advanced care planning and with discrepant patient and family goals of care. Barriers exist to considering palliative care, a model of care that may use a different approach than the approach used in an already established plan of care.32,33 This leaves nurses caught between an existing plan of care, which may be suboptimal, and what is known to be best practice. Such discrepancies can result in moral distress. When the patient’s illness trajectory and goals of care conflict with the current plan of care, nurses are challenged to find a means to break down barriers and implement best practice. With the evidence behind palliative care interventions, the responsibility to advocate for patients becomes clear, and nurses are empowered to explore avenues and options to provide optimal care for patients even if the culture is not well established.Addressing barriers improves outcomes for patients (symptom burden, QOL) and the system (readmission, health care utilization). Provider education, early discussions about prognosis and advance care planning, and a thought-out multidisciplinary approach to improve the use of palliative care support have been addressed as avenues to reduce barriers.30,31,35More recent opinions to mitigate barriers include implementation of triggers (or criteria) to assist nurses in partnering with providers to request palliative care consultations.16,37 Automatic triggers improve numbers of palliative care consultations, decrease anxiety about discussions for providers and nurses, and reduce 30-day readmissions.16,38 Although triggers for automatic palliative care consultations have been tried out for patients with heart failure, no clear consensus has been reached.16,37,39,40 Given the benefits and outcomes associated with palliative care interventions, considering the initial diagnosis of heart failure a principal trigger could mitigate many existing barriers.Many triggers warrant a palliative care consultation (Table 2).12,16,37,39 These triggers could be laboratory values, signs or symptoms, disease progression, and social determinants related to heart failure. The cultures of the patient, the nursing unit, and the hospital system play an integral part in the selection of triggers. Thus, triggers should be engineered by site-specific committees. Nurses must have a seat at these tables, along with stakeholders and interdisciplinary team members to foster shared decision-making.38 Nurses can also promote crucial conversations and skilled communication among members of the team to heighten the readiness of the culture for palliative care with patients with heart failure.In summary, the following recommendations are offered for integrating palliative care triggers into practice: More studies are needed to support adoption of palliative care at the onset of heart failure to mitigate barriers around prognostication, discrepant goals of care, and consultation timing. Meanwhile, nurses are poised to apply available evidence to nursing practice and improve outcomes for patients with heart failure.The author acknowledges Margo Halm for her inspiration, contribution to evidence-based practice, and editorial support.