When should heart failure patients be referred for palliative care?
Patients with heart failure (HF) should be referred for palliative care if they fulfill certain needs-based or disease-based criteria, in view of the evidence for its benefits in advanced stages of the disease.
“Palliative care is a supportive approach to care that is complementary to standard medical therapies. The prospective, randomized PAL-HF trial showed that palliative care in addition to usual care improved quality of life, anxiety and depression in patients with advanced HF as compared with usual care alone,” said Dr Joseph Rogers of Duke University, Durham, North Carolina, US. [J Am Coll Cardiol 2017;70:331-341] “However, palliative care is currently underutilized in HF patients.”
“A recent systematic review has identified seven needs-based and 10 disease-based criteria that should prompt palliative care consultation for patients with HF,” he continued. [Circ Heart Fail 2020, doi: 10.1161/CIRCHEARTFAILURE.120.006881]
The needs-based criteria were physical or emotional symptoms, functional decline, decision support needs, psychosocial needs, caregiver distress, cardiac cachexia, and the patient’s request for palliative care referral. The disease-based criteria were cardiac stage, hospital utilization, prognosis, use of advanced cardiac therapies, disease progression, medical complications of HF, end-of-life stage, comorbidities, new HF diagnosis, and high-risk procedures.
However, the systematic review also showed a lack of consensus on criteria that should trigger palliative care referral.
While physical or emotional symptoms (50 percent) and cardiac stage (45 percent) were the most commonly discussed criteria, the advice was discordant in terms of the New York Heart Association (NYHA) functional class cut-off for referral (class ≥III, 30 percent; class ≥IV, 12 percent).
About one-third of articles included in the review recommended hospital utilization (37 percent), prognosis (36 percent), and advanced cardiac therapies (35 percent) as referral criteria, while 21 percent of the articles suggested prognosis of ≤1 year as a potential trigger.