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Hospice Underutilized for Heart Failure Patients

September 10, 2018

By Marilynn Larkin

NEW YORK (Reuters Health) - Patients with heart failure rarely receive hospice services and those who do are referred late, researchers say.

"Our study shows both that very few patients with heart failure use hospice services and that of those that do, many die very quickly after being discharged to hospice from the hospital," Dr. Haider Warraich of Duke University Medical Center in Durham, North Carolina said by email.

"This can be a traumatic experience for patients and their loved ones, and reflects that perhaps we should be thinking about palliative care and hospice services earlier in patients with heart failure," he told Reuters Health.

Dr. Warraich and colleagues studied all 121,990 heart failure patients age 65 and older in the American Heart Association Get With the Guidelines-HF registry who were discharged from hospitals from 2005 through 2014.

They compared three patient groups: 4,588 discharged to hospice (median age, 86; 55.7% female; and 88.2% white); 4,357 with advanced heart failure who were not discharged to hospice, and had either inpatient inotrope use, low sodium level, high blood urea nitrogen level, high systolic blood pressure or comfort measures during hospitalization; and 113,045 other heart failure patients who did not fall into the other two categories.

As reported online August 29 in JAMA Cardiology, the rate of discharge to hospice rose from 2.0% in 2005 to 4.9% in 2014. Among hospitals with more than 25 hospice discharges, the median hospice discharge rate was 3.5%.

Patients discharged to hospice were older, more often white, and more symptomatic compared to those with advanced HF and others in the registry, according to the authors.

Among those discharged to hospice, 52.8% were discharged to home hospice.

The median post-discharge survival time for those discharged to hospice was 11 days overall, compared with 318 days for those with advanced HF not discharged to hospice and 754 days for other patients in the registry.

Of patients discharged to hospice facilities, 34.1% died within 72 hours, compared to 12.2% of those discharged to home hospice. Fifteen percent of those discharged to hospice lived for six months or more.

The rate of hospital readmission with 30 days was 4.1% in patients discharged to hospice, 27.2% in patients with advanced HF who did not receive hospice, and 22.2% among others in the registry. Black race and younger age were the strongest predictors of readmission from hospice.

"The first thing we can do as physicians is to identify patients at high risk of dying and have honest conversations about their prognosis with them," Dr. Warraich said. "We need to make sure that we talk to patients not only about what would happen if things go to plan, but what if things don't."

"My hope is that this data will shed a light on a phase of life which has been a blind spot for quality improvement," he added. "Societies such as the American College of Cardiology and the American Heart Association need to take a leadership role in highlighting the need to have higher quality research and clinical care for patients with heart disease at the end of life."

Dr. Shunichi Nakagawa of Columbia University Medical Center in New York City, coauthor of a related editorial, told Reuters Health by email, "Advance care planning is needed for everyone."

"The root problem is that we - both physicians and patients/families - are afraid of having a conversation about possible future negative events, despite the fact that they are unavoidable," he said. "We tend to focus too much on 'fixing' the medical problem, which is of course we should continue to focus on, but at the same time, we should also prepare ourselves in case that does not work."

"This conversation is not easy," he acknowledged. "The only way to make it less difficult is to start it early and have it regularly. Physicians also need to spend more time during training (in medical school or residency programs) in communication and palliative care."

"Physicians currently in practice, regardless of years of experience, have to realize that communication is a procedure, and in order to get better, they have to deliberately practice those skills," he noted. "As I described earlier (, they will need to prepare for the conversation (How should I summarize the condition? How should I phrase the question? If they say X, how should I answer?); have the conversation; and review their performance afterwards."

"Without this 'preparation- procedure-review' cycle, you cannot get better, no matter how many times you do it," Dr. Nakagawa concluded.


JAMA Cardiol 2018.

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