Too Few Patients With End Stage Heart Disease Receive Palliative Care Discussion

MedicalResearch.com Interview with:

James N. Kirkpatrick, MD Director of the Echocardiography Laboratory Division of Cardiology Ethics Consultation Service University of Washington, Seattle

Dr. James Kirkpatrick

James N. Kirkpatrick, MD
Director of the Echocardiography Laboratory
Division of Cardiology
Ethics Consultation Service
University of Washington, Seattle

MedicalResearch.com: What is the background for this study?

Dr. Kirkpatrick: With significant advances in technology, implanted cardiac devices like pacemakers and defibrillators, replacement heart valves, and mechanical pumps which assist or replace the pumping function of the heart have become standard therapies for patients with severe cardiac disease. Many patients who would previously have died after living with severe symptoms live longer and with improved quality of life. This is particularly true for elderly patients who receive transcatheter aortic valve replacement (TAVR—valve replacement that doesn’t require open heart surgery) and ventricular assist device (VAD—a durable mechanical heart pump) implantation.

However, like everyone, these patients will die, and some of the patients will experience device complications which will shorten their lives. Elderly patients, in particular, are at risk for device complications, high symptom burden, and loss of the ability to make healthcare decisions, due to illnesses like strokes or dementia. Symptom management and advance care planning are the hallmarks of the medical specialty of Palliative Care and are particularly important in patients with TAVR and VADs, yet patients and clinicians don’t often think of Palliative Care when considering high tech, life-prolonging therapies. The Palliative Care Working Group of the American College of Cardiology’s Geriatrics Section therefore sought to gather data on the attitudes toward Palliative Care among cardiovascular clinicians and the current state of involvement of Palliative Care in the care of patients with TAVR and VAD.

MedicalResearch.com: What are the main findings?

Dr. Kirkpatrick: We restricted our study to members of the American College of Cardiology who care for patients with TAVR, VAD or both. Of the 323 respondents to our on-line survey, most indicated that Palliative Care consultation can be helpful in the care of patients with TAVR and VAD, but only 10% reported that they had received any Palliative Care formal instruction during their cardiovascular training. Few knew of any protocols in their institution for formal palliative care involvement in the care of these patients. A small number of respondents who care for patients with VAD knew about the Centers for Medicare and Medicaid Services (CMS) coverage determination that mandates the involvement of a Palliative Care specialist on the teams caring for patients with destination therapy VADs (heart pumps implanted permanently, not as a temporary measure in patients expected to receive heart transplant). Arguably, Palliative Care is particularly important for patients who are turned down for these TAVR and VAD (most often because they are too sick to benefit and would therefore be candidates for hospice), but only half of providers who care for patients with VADs and only 1/3 of those who care for patients with TAVR reported frequent involvement of Palliative Care consultation in these situations.

MedicalResearch.com: What should readers take away from your report?

Dr. Kirkpatrick: This study is one of the first to benchmark practices related to Palliative Care in TAVR and VAD, and to assess attitudes toward Palliative Care among cardiovascular clinicians. The low rate of formal inclusion of Palliative Care into the care of patients with TAVR and VAD, combined with the national shortage of Palliative Care specialist clinicians suggests that cardiovascular clinicians need more “basic training” in Palliative Care. However, few in the study reported they had received any such training. We believe that cardiovascular training programs need to consider including some training in Palliative Care, particularly advance care planning (helping patients to consider their values, preferences and goals and apply them to the “big picture” of their overall care, including end of life care and what they would want done or not done if they lose the ability to make decisions for themselves).

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Kirkpatrick: More research is necessary into the barriers obstructing provision of Palliative Care for patients with TAVR and VAD and how these barriers can be surmounted.
Some questions include:

  • Are there too few Palliative Care specialists who understand these devices?
  • Are there other limitations in resources?
  • Does inclusion of Palliative Care in formal protocols meet needs of patients with TAVR and VAD?
  • What are the best ways to ensure that the end of life care needs of patients with TAVR and VAD are met?
  • How can we provide better Palliative Care for patients who are too sick to receive TAVR or VAD?

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Kirkpatrick JN, Hauptman PJ, Swetz KM, et al. Palliative Care for Patients With End-Stage Cardiovascular Disease and Devices: A Report From the Palliative Care Working Group of the Geriatrics Section of the American College of Cardiology. JAMA Intern Med. Published online May 23, 2016. doi:10.1001/jamainternmed.2016.2096.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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