Authored by Cristina Belova*,
Abstract
Heart Failure (HF) patients have an increased burden and intricate psychosocial and decision-making needs that demand the early integration of Palliative care (PC), in order to improve the outcomes and decrease health care utilization. However, in the current era, such care occurs late in the disease course and not too often in the outpatient setting. The purpose of this review aims to understand the current state of outpatient PC in HF.
Keywords:Palliative care; Heart Failure; Outpatient
Introduction
Heart failure (HF) affects approximately 64.3 million people worldwide and its prevalence is increasing over time [1]. HF remains a progressive disease associated with high mortality rates, increased cost of care, significant symptom burden and impaired quality of life for both patients and caregivers [2-7]. A large literature calls for Palliative care (PC) for patients with HF, but there is limited experience in providing PC for these patients, especially in the outpatient/ambulatory setting [8]. The great majority of outpatient PC programs serve patients with cancer [9, 10], although patients with end-stage HF have been shown to have symptom burden comparable to that in cancer patients [11]. Therefore, we performed a literature review aiming to understand the current state of PC in the outpatient management of the HF patient. We searched on the online database “Pubmed” the MeSH terms “Palliative Care”, “Heart Failure” and “Outpatient”, and we selected 5 out of 7 papers published in the last 20 years. This research was complemented with the inclusion of other international guidelines and papers that were found relevant.
Discussion
A case series from Bekelman D, et al. [12], one of the first United States reports providing detailed characteristics in an outpatient PC program for patients with HF, concluded that palliative HF care is complementary to standard HF care at all stages of the disease process. Furthermore, advocating for PC earlier in the HF trajectory may potentially reduce suffering from both physical and psychological symptoms and lessen the distress associated with this incurable condition [13]. The Evangelista L, et al. [14] study showed that implementing a PC consultation was feasible and resulted in reduced symptom burden and depression and improved quality of life in patients with symptomatic HF, supporting consensus to initiate a PC consultation earlier rather than later in the HF trajectory, preferably at the time of diagnosis or a hospitalization for HF exacerbation. In addition, DeGroot L, et al. [15] showed that outpatient PC decreased rehospitalizations for patients with HF.
The American College of Cardiology/American Heart Association (ACC/AHA) chronic HF guidelines first recognized the utility of palliative care in 2005, giving “palliation and end-of-life care” a class I recommendation [16]. The 2013 ACC/AHA chronic HF guidelines continued to recommend palliative care and, for the first time, explicitly discussed outpatient PC, adding that access to formally trained PC specialists may be limited in ambulatory settings [17].
Despite these findings and strong recommendations that patients with HF receive PC, the referral for this type of care remains uncommon [18]. While palliative care is often available for patients hospitalized for HF, outpatient HF palliative care is rare. Unfortunately, several factors prevent outpatients with HF from receiving PC, including physician attitudes, HF’s unpredictable disease course and lack of research into PC for nononcologic patients [19]. The evidence weighs heavily in favor of developing and testing models to overcome this gap in care so that patients with HF can access PC at any stage of their illness and in any care setting [20].
Conclusion
Patients with HF have significant needs and the PC outpatient setting remains underutilized. Although PC is known to improve outcomes, HF patients rarely receive PC or its integrated late in the disease trajectory. We consider the existing literature regarding outpatient PC in HF limited and further studies are required.
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