Defining the role of palliative care in older adults with heart failure

https://doi.org/10.1016/j.ijcard.2007.10.005Get rights and content

Abstract

While palliative care is often thought of as only being applicable to dying patients, its focus on symptom alleviation, patient function, and quality of life has much to offer older adults with chronic heart failure. Heart failure worsens patients' health status through patients' symptom burden, functional limitations, and reduced health-related quality of life. Moreover, older adults with heart failure have multiple other comorbidities and polypharmacy that further contribute to poor health status. Comorbid depression is a particularly important issue. In this patient population, prognosis is limited and often uncertain. Spouses and caregivers of patients report significant distress and depression. Through symptom management, depression and psychosocial care, assistance with defining goals of care and planning for the future, and caregiver support, palliative care has the potential to improve patient health status and reduce costs and hospitalizations. This care is complementary to contemporary heart failure care and can be provided concurrently at any point during the illness based on patient and caregiver needs.

Introduction

Older adults shoulder the population burden of heart failure. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older [1] and as many as 6–10% of people in developed countries over the age of 65 have heart failure [2]. Heart failure is the leading cause of hospital admissions in people aged 65 years and older [2] and heart failure admissions are increasing in all industrialized countries [3].

Heart failure causes worsened health status, shortened survival, and a high risk of hospitalization among older adults. Despite therapeutic advances, population-based outcomes for heart failure have not improved substantially over the past decade [4], possibly reflecting an increasing complexity of the population of older adults with heart failure.

Older adults with heart failure differ substantially from those enrolled in randomized clinical trials of heart failure therapy [5]. Half of all older Medicare patients in the United States discharged from an acute care hospital with a principal diagnosis of HF have preserved left ventricular ejection fractions, one-third have chronic obstructive pulmonary disease, and 40% have diabetes [6]. Polypharmacy is the rule rather than the exception in older patients with heart failure; on average, elderly Medicare beneficiaries hospitalized with heart failure are discharged on more than 11 chronic medications [7]. These characteristics of the older population challenge clinicians, patients, and their families to formulate effective strategies of care to improve both longevity as well as the quality of life.

While palliative care is often thought of as only being applicable to dying patients, its focus on symptom alleviation, patient function, and quality of life has much to offer older adults with chronic heart failure. The primary aim of this article is to discuss how palliative care strategies may be implemented to meet the needs of older persons with heart failure. We define the need for palliative care and use a case example to illustrate how this type of care might benefit a heart failure patient. We conclude with a research agenda for palliative care in heart failure. Our objective is to help define the role of palliative care in the treatment of older adults with heart failure, providing clinicians with strategies that acknowledge the complexity of older persons with heart failure and have the potential to improve outcomes for these patients.

Section snippets

Case: Mrs. J

Mrs. J is a 73 year-old retired administrative assistant with coronary artery disease, diabetes, gastroesophageal reflux disease, hypertension, urinary incontinence, and ischemic cardiomyopathy with an ejection fraction of 0.25. She has persistent NYHA Class III heart failure on maximally tolerated doses of ACE-inhibitor, beta-blocker, and diuretic therapy. She takes 12 medications and has an implanted cardioverter-defibrillator/biventricular pacemaker. She visits her cardiologist monthly and

What is palliative care?

Palliative care is “patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy” [43]. Thus, palliative care expands the traditional medical goals of curing illness and prolonging life to emphasize the patient-centered goals of reducing symptom burden, enhancing function,

Case: Mrs. J, continued

The palliative care specialist targeted her depression and symptoms. Her symptoms could have been related to heart failure, side effects of heart failure or other medicines, or her depression/anxiety. Her shortness of breath was treated with opiates, constipation with bowel stimulants, dry mouth with oral rinses and sugarless hard candy, neck pain (thought to be muscular in origin) with heat and muscle relaxation techniques. Her anxiety and fears were addressed with supportive communication,

Research agenda for palliative care in heart failure

We have reviewed evidence for palliative and supportive care needs in patients with heart failure, described a conceptual framework that depicts measurable outcomes for palliative care programs and interventions, and suggested how palliative care might benefit patients with heart failure and their families. Important unanswered questions remain [51].

First, what are the critical elements of a palliative care intervention, and can the intervention be standardized so that it is replicable across

Conclusion

The health status burden of heart failure in older patients will require increasing attention from heart failure care providers over the next 20 years as the number of older adults grows and the oldest old (those over 85) become an ever greater proportion of the population. Failure to integrate a palliative care approach for these patients, whose disease in ultimately incurable and whose health status is poor, would be a profound disservice. By integrating pharmaceutical and behavioral

References (77)

  • K. Dracup et al.

    Emotional well-being in spouses of patients with advanced heart failure

    Heart Lung

    (2004)
  • J. Martensson et al.

    Living with heart failure: depression and quality of life in patients and spouses

    J Heart Lung Transplant

    (2003)
  • L.S. Evangelista et al.

    Emotional well-being of heart failure patients and their caregivers

    J Card Fail

    (2002)
  • I.J. Higginson et al.

    Do hospital-based palliative teams improve care for patients or families at the end of life?

    J Pain Symptom Manage

    (2002)
  • I.G. Finlay et al.

    Palliative care in hospital, hospice, at home: results from a systematic review

    Ann Oncol

    (2002)
  • S.J. Goodlin et al.

    Consensus statement: palliative and supportive care in advanced heart failure

    J Card Fail

    (2004)
  • F.A. Masoudi et al.

    The burden of chronic congestive heart failure in older persons: magnitude and implications for policy and research

    Heart Fail Rev

    (2002)
  • J.J. McMurray et al.

    Epidemiology, aetiology, and prognosis of heart failure

    Heart

    (2000)
  • M. Kosiborod et al.

    National trends in outcomes among elderly patients with heart failure

    Am J Med

    (2006)
  • F.A. Masoudi et al.

    The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998–2001

    Arch Intern Med

    (2005)
  • J. Juenger et al.

    Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables

    Heart

    (2002)
  • A. Steptoe et al.

    Health related quality of life and psychological wellbeing in patients with dilated cardiomyopathy

    Heart

    (2000)
  • P. Johansson et al.

    Measurement of health-related quality of life in chronic heart failure, from a nursing perspective — a review of the literature

    Eur J Cardiovasc Nurs

    (2004)
  • A.L. Stewart et al.

    Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study

    JAMA

    (1989)
  • G.E. Soto et al.

    Prognostic value of health status in patients with heart failure after acute myocardial infarction

    Circulation

    (2004)
  • C.H. Zambroski et al.

    Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure

    Eur J Cardiovasc Nurs

    (2005)
  • Bekelman DB, Havranek EP, Becker DM, et al. Symptoms, depression, and quality of life in patients with heart failure. J...
  • M.R. Bristow et al.

    Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure

    N Engl J Med

    (2004)
  • J.G. Cleland et al.

    The effect of cardiac resynchronization on morbidity and mortality in heart failure

    N Engl J Med

    (2005)
  • W. Jiang et al.

    Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure

    Arch Intern Med

    (2001)
  • M. Sullivan et al.

    Depression-related costs in heart failure care

    Arch Intern Med

    (2002)
  • S.B. Dunbar et al.

    Association of mood disturbance and arrhythmia events in patients after cardioverter defibrillator implantation

    Depress Anxiety

    (1999)
  • K. Kroenke et al.

    The PHQ-9: validity of a brief depression severity measure

    J Gen Intern Med

    (2001)
  • A.S. Zigmond et al.

    The hospital anxiety and depression scale

    Acta Psychiatr Scand

    (1983)
  • A. Arthur et al.

    Using an annual over-75 health check to screen for depression: validation of the short Geriatric Depression Scale (GDS15) within general practice

    Int J Geriatr Psychiatry

    (1999)
  • K. MacIntyre et al.

    Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995

    Circulation

    (2000)
  • S. Stewart et al.

    More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure

    Eur J Heart Fail

    (2001)
  • J.R. Lunney et al.

    Patterns of functional decline at the end of life

    JAMA

    (2003)
  • Cited by (0)

    View full text