BALTIMORE, MD — Different types of clinicians caring for heart-failure patients vary widely in their attitudes toward and confidence levels in discussing end-of-life plans, such as advance directives or hospice care, and even in their views of which professional has primary responsibility for initiating the discussion, a new survey suggests[1].

Of its 95 respondents, of whom 41 were at tertiary-care cardiology centers, 25 were in community-hospital cardiology, and 29 were in primary care, most specialists considered heart-failure cardiologists to have primary responsibility for engaging the patient on the subject. They included 63% at tertiary-care centers and 58% of those in community cardiology. On the other hand, 66% of clinicians in primary care considered it their responsibility.

Most of the time it's considered a joint responsibility, although there are no clear guidelines, according to lead author Dr Shannon M Dunlay (Mayo Clinic, Rochester, MN).

"As we saw, what sometimes happens is that some providers have certain expectations about what their and others' responsibilities are, but perhaps in practice that leads to some confusion," she told heartwire . Dunlay presented the study here this week at the American Heart Association Quality of Care and Outcomes Research 2014 Scientific Sessions .

The providers also varied on when they initiate the conversation with the patient, but the variation "wasn't as wide as you'd expect," she said. Most said they have it when their patients' health status worsens, and many others said at the time of considering a major intervention, such as a defibrillator or LV-assist-device implantation.

Dr Shannon M Dunlay [Source: American Heart Association

Still, three times as many of the 50 physician respondents, nearly 60% (p<0.001), compared with the 45 nurse practitioners (NP) or physician assistants (PA), would initiate the talk at the initial visit. They were about one-third more likely (p=0.034) to start it at worsening health status and about twice as likely (p=0.001) at the time of an intervention.

Only about 12% of physicians said they discuss prognosis and end-of-life issues annually, as recommended in guidelines, not appreciably more than the 10% of NP/PA group.

The survey approached heart-failure physicians and other clinicians at a tertiary-care center; cardiologists, NPs, and PAs in four nearby community-hospital systems; and primary-care clinicians at one center. The response rate was 52.5%.

About 30% of respondents reported low or very low levels of confidence in discussing one or more aspects of prognosis or end-of-life planning. But confidence levels were proportional to years of clinical experience, which varied widely in all three practice settings. "So a lot of it has to do with getting experience under your belt at having those conversations," Dunlay said.

Confidence levels also varied by aspect of end-of-life planning to be discussed. "For example, the providers who were not cardiologists were actually more comfortable enrolling patients in hospice. They may have more experience with that because [internists and anyone in primary care] deal with a lot of chronic conditions, only one of which is heart failure."

What was often in the way of conducting the discussions? Of the 49 respondents who reported reasons that they might hesitate to discuss end-of-life issues, 21% said their patients and 12% said patients' families weren't ready to have the talk, 9% said "fear of destroying hope," 8% said they didn't have time in their clinical practice, and "discomfort" was the response for 11%.

"All of these are clinician-perceived barriers that may exist to approaching those discussions," according to Dunlay. "I think it's important for us to recognize this and address the learning needs of providers."

Most respondents said they had a high or very high interest in improving how they approach end-of-life discussions; less than 10% had low or very low interest.

"If we expect them to have these conversations, we need to give them the tools and resources to be able to do that well and to feel more empowered to do so in a way they're comfortable with." One of the next steps, she said, is to find ways to incorporate end-of-life discussions into routine care, "like ACE inhibitors, beta-blockers, and other medical therapies."

Neither Dunlay nor her coauthors had disclosures.


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