Abstract and Introduction
Abstract
Heart failure is a common hospital admission diagnosis and a progressive terminal disease. Prognosis is difficult to predict, and patients are often unaware of their poor prognosis. The Seattle Heart Failure Model is a tool that predicts life expectancy for heart failure patients. The aim of this study was to determine if this tool could identify heart failure inpatients who would benefit from palliative care referrals. The tool was applied retrospectively to 214 patients with a discharge diagnosis of heart failure. Cases were divided for data analysis into three groups of predicted baseline life expectancy: those with prognosis of less than or equal to 1.5 years, more than 1.5 years to less than 5 years, and 5 years or more. Of those with life expectancy equal to or less than 1.5 years, 63% of these patients (n = 17) would have received timely palliative care consultation had the Seattle Heart Failure Model been used as a screening tool. More research is needed to explore the use of this tool and others for inpatients with heart failure. Such tools can be helpful in ensuring that patients receive the information they need to make end-of-life decisions.
Introduction
Heart failure (HF) places stress on the healthcare system and causes considerable morbidity and mortality each year. It is a leading cause of hospitalizations, readmissions, and ambulatory visits in the Medicare population and affects 5.7 million people in the United States with associated health expenditures estimated at $33.7 billion. Prognosis with HF is poor, with one in five patients dying within 1 year of diagnosis and half within 5 years. One-year mortality rates in population-based studies have been reported to be 25% to 40%. Previous studies in outpatient HF patients have identified a number of variables that are associated with increased mortality, including etiology, patient age, clinical assessment at the time of hospitalization, left ventricular ejection fraction (EF), serum sodium concentration, serum creatinine concentration, and B-type natriuretic peptide concentration. Despite research that has led to improved survival with medical therapy, HF is still a progressive terminal disease with few tools to help estimate prognosis, thereby lessening patient access to palliative care.
The needs of patients with HF are as complex as those of patients with other terminal diseases, who traditionally have greater access to palliative care. Patients with HF not only have a prognosis worse than many cancers, but also share symptoms with patients dying of malignant disease. Patients with HF are frequently unaware of their poor prognosis. In a study by Allen et al, ambulatory patients with HF substantially overestimated their life expectancy compared with model-based predictions using the Seattle Heart Failure Model (SHFM). Differences in patients' perception of survival as compared with actual survival could affect their decision making regarding end-of-life (EOL) planning. The National Service Framework for Coronary Heart Disease suggests that when symptom control is the underlying aim of HF treatment, palliative care may improve a patient's quality of life.
Given the progressive nature of HF and the associated high mortality rate, discussions about medical management of symptoms and possible altered health states should be included in initial patient education.At present, healthcare professionals tend to focus on maintaining or improving patients' cardiac function. This results in many HF patients having a slow progression to death while having distressing symptoms during their final days. There is a growing acknowledgement that palliative care can play an important role in improving quality of life for this group of patients and their families. Use of palliative care, however, is relatively uncommon in the HF population.
Reasons for lack of palliative care among HF patients are multifactorial. Common reasons include poor patient and family education regarding the progressive terminal nature of HF, lack of willingness by physicians to discuss EOL planning with their patients and families, and difficulty predicting prognosis in HF patients. In addition, high levels of comorbidity may result in increased difficulty recognizing HF patients who are approaching the end of life.
A retrospective study of random UK deaths based on family interviews, Regional Study for Care of the Dying, explored EOL decisions. One quarter of the patients in this study died of heart disease. Patients with HF and their families believed that their involvement in decision making was inadequate and that they received little community support. Half of the families of patients who died of HF would have preferred comfort measures, but 40% received invasive life-sustaining treatments in the final days of life.
Recent guidelines and summary statements have supported the idea of offering palliative care as part of the optimal medical management for patients with advanced HF. It is difficult, however, to determine when a patient reaches the end stages of HF. Palliative care and hospice referrals are underutilized, and aggressive care often continues until the last days of life. A scientifically based, objective method of identifying end-stage HF patients could result in targeted symptom relief, less aggressive futile care, and increased EOL support during a patient's last days. In addition, an objective tool would provide a data-driven measurement for physicians who might be reluctant to discuss EOL issues with patients and families.
Discussing prognosis is a challenging task for physicians, both because the news of poor prognosis is emotionally difficult and because considerable prognostic uncertainty exists. Previous studies suggest that 90% of physicians are reluctant to provide specific prognostic information, 75% shade their prognostic estimates to be more optimistic, and 44% of these physicians wait to be asked before discussing prognosis. Most families of ill patients do not view withholding prognostic information as an acceptable way to maintain hope, because honest information about prognosis can help family members begin to prepare emotionally for the possibility that the patient may die.