Palliative Care Ups Quality of Life, Mental Health for HF Patients

Palliative care can enable patients with advanced heart failure (HF) to reap gains in quality of life as well as better mental and spiritual health, according to findings from the single-center but randomized PAL-HF trial.

Lead author Joseph G. Rogers, MD (Duke University School of Medicine, Durham, NC), told TCTMD that data are lacking on the best approach to palliative care in the heart failure setting. “Typically, these kinds of approaches have been applied mostly in malignant diseases, but I think one might reasonably argue that the prognosis of advanced heart failure is not dissimilar to that of advanced cancer, it’s just that cardiologists lack the data to utilize some of these interventions,” he commented.

The researchers’ goal in conducting PAL-HF, Rogers said, was to begin gathering evidence “that would inform cardiologists about how to integrate palliative care principles into the practice of heart failure.”

The exact ingredients may vary, but the overall approach is holistic, Rogers explained. What’s needed is better understanding of how to effectively meet the needs of patients getting palliative care. “You wouldn’t give the same pill to everybody,” he explained. “You need to know who needs the pill. You need to know how often you should give it and what the dosage should be.”

While “intuitively,” palliative care makes sense, there’s much to figure out in terms of what interventions help the most, how long they last, and who will benefit from them, he said.

Results from the PAL-HF trial were published in the July 18, 2017 issue of the Journal of the American College of Cardiology.

Positive Shifts by 6 Months

To tease out how palliative care can best be done, Rogers and colleagues randomized 150 patients with advanced HF being treated between August 15, 2012, and June 25, 2015, at Duke University Medical Center (Durham, NC). By design, they enrolled patients at high risk for dying within the next 6 months; the mean age was 71 years, 47% were women, and 41% were African-American. Mean HF duration was around 5.5 years and, on average, patients had been hospitalized 2.2 times within the previous year. Most (82%) were sedentary for more than half of the time, with a similar proportion describing their overall health as poor/fair.

“In that population that had no opportunities for other kinds of advanced heart failure therapies—so they weren’t candidates for [ventricular assist devices] and they weren’t candidates for transplant—their goals of care shift,” Rogers said. “They really are much more interested in saying to their physicians, ‘I’d like to live as long as I can, but I’d really like to be comfortable. And I have all of these other issues that I need to take care of.’ These people have spirituality issues, they have relationship issues—all these things that we don’t learn about when we’re training in cardiovascular medicine.”

[What’s key is] someone sitting there spending time with people, trying to make sure we have addressed the things that are really important to them. Joseph G. Rogers

Patients were randomized to usual care with or without palliative care, which was coordinated by a certified palliative care nurse practitioner in collaboration with a hospice and palliative medicine board-certified physician. Each patient’s clinical cardiology team took part, and the added layer of care focused on symptom relief as well as other bigger-picture goals.

Between randomization and 6 months, patients showed significant gains in the primary outcome of quality of life as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) scale. Measures of depression and spiritual well-being also significantly improved.

Importantly, the intervention continued after hospital discharge into the outpatient setting, Rogers said. “If you look at the primary outcome curves, they don’t separate out right away. You’d think if it was all the inpatient piece, that the quality of life would’ve gotten better right away. But [these measures] don’t—they don’t get better for a couple of months.”

This may be because, over time, a relationship grows, with the palliative care specialist not only providing symptom relief but also other forms of support, he explained.

However, PAL-HF did not demonstrate any difference in mortality or readmission rates between the palliative care and usual care groups.

‘Spending Time With People’

Cardiologists interested in offering palliative care to their patients can be advocates, Rogers said, noting that the PAL-HF intervention at Duke could be done elsewhere. “It’s something that’s widely amenable to implementation. There are a lot of palliative care specialists in a lot of institutions now,” he said, specifying that the added care could also be given by physicians with an interest in the area or advanced practice providers.

Yet Eric D. Adler, MD, and Nicholas Wettersten, MD (University of California, San Diego), assert in an accompanying editorial that “this amount of resource utilization is unlikely to be broadly available, as there are not enough practitioners available for the 5.7 million HF patients [currently diagnosed in the United States].”

As a result, they say, the burden “falls on the cardiologist primarily taking care of the HF patient to regularly incorporate [palliative] modalities into his or her usual care of all HF patients” and to identify those who are progressing and might need more intensive interventions. To provide the right care requires “learning what is in the palliative care syringe,” the editorialists conclude, pointing out that it’s not yet known whether providing palliative care earlier can alter the HF trajectory.

What exactly is included in palliative care is hard to define, Rogers acknowledged. Much of it, like symptom relief, is already being done. “[We] do that all the time anyway. It may not be our primary focus, and we may not actually be asking the questions correctly or spending the time with patients so we’re getting that kind of information and acting on it appropriately,” he said.

What’s key is “someone sitting there spending time with people, trying to make sure we have addressed the things that are really important to them.” Also, palliative care specialists are often linked with experts in spiritual care and advanced directives, for example.

An ongoing part of PAL-HF, Rogers said, involves “bereavement interviews,” in which surviving family members were asked what the experience was like for them. “It’s a devastating, horrible disease,” he said. “So, we can’t lose sight of the fact that oftentimes the caregiver is someone who’s spent decades with the patient. They’re also trying to deal with all the issues surrounding advanced illness . . . and people who they care deeply about are uncomfortable.”