Author + information
- Published online August 27, 2018.
- Haider J. Warraich, MD and
- Joseph G. Rogers, MD∗ ()
- Department of Medicine, Division of Cardiology, Duke University Medical Center; and the Duke Clinical Research Institute, Durham, North Carolina
- ↵∗Address for correspondence:
Dr. Joseph G. Rogers, Division of Cardiology, Duke University School of Medicine, Duke University Medical Center, Box 3034 DUMC, Durham, North Carolina 27710.
The prevalence of heart failure (HF) is increasing, particularly among those aged 85 years and older (Figure 1). Advances in medical management have altered the natural history of HF and have extended quality years of life. However, the median survival of hospitalized HF patients aged 65 years or older is only 2.1 years (1). Evidence also shows that progression of chronic illnesses is linked to a shift in patient preferences from life extension to enhancing quality (2). It is incumbent upon the HF practitioner to appreciate and anticipate these pivots in patient preference and be as versed with comfort care strategies as we are with neurohormonal antagonists.
Hospice is a component of palliative care intended for patients with an estimated survival of <6 months. Although hospice use remains limited in patients with cardiovascular disease, the number of Americans with heart disease using hospice is rising (3). Thus, it is important to critically evaluate the care received by HF patients in hospice, to assess their outcomes, and to use those findings to shape future research and policy.
In this issue of JACC: Heart Failure, Gelfman et al. (4) reported on predictors of hospice enrollment and subsequent health care use in a Medicare population with ≥2 HF hospitalizations within 6 months, a functional assessment following hospital discharge, and death within 6 months of enrollment. Counterintuitively, the only predictor of hospice enrollment was fewer emergency room visits. Enrollees spent an average of 22 days in hospice, with nearly one-half dying in the first week. Hospice patients had lower use of emergency rooms, hospitals, and intensive care units at 30 and 180 days following enrollment compared with nonhospice patients. Perhaps more importantly, the hospice cohort was less likely to die in a hospital or a skilled nursing facility, and were more likely to die at home, which is an important finding because most patients in the United States desire to die at home rather than in a health care facility (5).
Finally, patients who chose hospice lived longer than those who did not (80 days vs. 71 days; p < 0.01). Similar observations were noted in other studies that assessed palliative care in HF patients (6). Although these findings should be interpreted cautiously, the present data challenges the notion that hospice necessarily shortens lifespan in critically ill patients, including those with HF.
This study is a significant contribution to the growing literature that addresses care at the end of life for HF patients and highlights several urgent needs for our patients and their families. First, it is time to move away from the one-size-fits-all framework of hospice care originally designed to support cancer patients. Recent years have seen modest but meaningful increases in hospice patients with noncancer diagnoses. However, significant opportunities exist to optimize and tailor hospice care for HF. Second, hospice is intended for patients with an estimated survival of <6 months. However, prognostication in HF is often more challenging and inaccurate than cancer, and may ultimately be a barrier to hospice enrollment (7). Third, it is incumbent upon clinicians managing this vulnerable population to champion end-of-life care, including the principles of palliation and hospice. We need to collectively improve communication about advanced care planning, changing goals of care, symptom management, and bereavement. It seems unlikely that patients and their families derive the maximal potential benefit from hospice approaches when death occurs within 7 days of enrollment. Fourth, we need a better understanding of the optimal location for our patients to die. There is a push for our patients to die in their homes, but this is inappropriate in many circumstances. Fifth, current payment models for hospice can be prohibitive for a subset of HF patients. For example, some HF patients derive benefit from inotropes and intravenous or subcutaneous diuretics, which are difficult for hospice agencies to financially cover under current per-diem payments. Finally, we need to listen carefully to our patients and their loved ones. What do they want at the end of life? Are we providing optimal care? Are we extending the full extent of our resources to assist family members? Should there be some longer term commitment to survivor health?
The current study represents a substantive advance in enhancing the understanding of factors that determine hospice enrollment for HF patients and subsequent outcomes experienced by these patients. However, research on end-of-life care for patients with HF remains in its nascent phase and represents the beginning of scientific contributions that we hope will lead to changes in policy and provider training to optimize the care of this growing population.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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