Planning System, Video Helps Advanced HF Patients Choose Level of End-Of-Life Care

Deborah Brauser

July 04, 2016

BOSTON, MA — A video-assisted decision-support tool can help patients who have advanced heart failure to better understand advance-care options while also improving patient-clinician discussions, according to findings from a new study known as VIDEO-HF[1].

Among 123 HF patients randomized to verbal education plus a 6-minute video depicting scenes of different levels of care, 99% said they were comfortable watching the video and 96% said they would recommend it to other patients.

Interestingly, 51% of this group chose comfort-focused care after the video-assisted intervention vs 30% of those randomized to verbal education only (control group)—while only 22% of the video group vs 41% of the control group chose life-prolonging care (both comparisons, P<0.001).

Further, significantly more of the video group said no to future CPR attempts (68% vs 35% of the control group) and no to intubation (76% vs 48%, respectively). They were also more informed, as shown with a mean knowledge score of 4.1 vs 3.0 (all comparisons, P<0.001).

"Videos can help patients to imagine the unimaginable and to see that these interventions are quite different from the way they're shown on television shows," lead author Dr Areej El-Jawahri (Massachusetts General Hospital, Boston) told heartwire from Medscape.

El-Jawahri noted that extreme care was given while producing the video to not show any specific care option in a better or worse light in an effort to not influence viewers. "Images can speak a thousand words. So one of our main goals was to ensure that this provided an unbiased representation of what the options are for patients," she said.

The results were published online June 29, 2016 in Circulation.

Conversation "Sparkers"

The investigators are part of the Video Images of Diseases for Ethical Outcomes (VIDEO) Consortium and have developed other decision support aids, including for cancer patients. Their previous work "suggests that video tools serve as catalysts to spark [advance-care planning] conversations, leading to care decisions that are more aligned with patients' preferences and values," they write.

"Extending this research to patients with heart failure is important, given its high prevalence and associated morbidity and mortality," they add.

"Even though heart disease is the leading cause of death in the world, advance-care planning discussions have been really slow to come to the arena," said El-Jawahri. "Other studies have shown that patients with advanced heart failure have much lower rates of utilization of end-of-life care resources."

In addition, she noted that many clinicians find bringing up this topic to be difficult. "So we were hoping that this video would prove to be a valuable tool to supplement, not replace, the patient-doctor relationship during these care planning discussions."

The investigators enrolled 246 advanced HF patients >64 years (61% men; mean age 81 years) from seven centers in the US. After filling out baseline questionnaires, half of the participants were randomized to verbal education plus video and half were randomized to verbal education only.

For the verbal-education arm, the participants were read a description of the following three goals of care: life-prolonging care, limited medical care, or comfort care.

Video Depictions

For the video-assisted intervention, the patients were read the care level descriptions and then shown a 6-minute video on an office iPad. The video depicted scenes from each of the care levels, including intubation on a mannequin and a ventilated patient (illustrating life-prolonging care), patients receiving medication through peripheral intravenous catheter or wearing a nasal cannula in a medical ward (limited care), and oral medications distributed in a home and a home-based patient wearing a nasal cannula (comfort care).

A team of cardiology, palliative care, geriatric, and critical-care experts reviewed the video at each step of its developmental process (from scripting through completion) "for accuracy and appropriateness," report the researchers.

After watching the video, the participants were given a checklist about advance-care planning, which they were encouraged to discuss with their personal physicians.

At baseline, the preferred goals of care were statistically similar: 37% of the video group and 31% of the verbal group preferred life-prolonging care; 11% vs 14% preferred limited medical care; and 36% vs 37% preferred comfort care.

After the intervention, as mentioned earlier, significantly more of the video-assisted arm chose comfort care and more of the verbal-only arm chose life-prolonging care. In addition, 25% of the video group vs 22% of the verbal group said they would prefer limited care and 2% vs 7%, respectively, said they were uncertain. Neither comparison was significant.

When asked at baseline if they would want CPR attempts, 54% and 56% of each group said yes vs 31% and 59% who said yes postintervention. In addition, 45% of the video group said yes to intubation at baseline but only 20% said yes postintervention; 41% and 47% of the verbal group said yes at each checkpoint, respectively.

Finally, 40% of the video group vs 6% of the verbal group reported at 1-month follow-up that they had had conversations with their healthcare providers about their goals-of-care preferences. At the 3-month follow-up, the numbers were 61% vs 15%, respectively.

Standardized, Cost-Effective Tool

"Video decision-support tools provide a standardized and cost-effective means to address the immediate communication needs of our healthcare system and to ensure that patients receive care that reflects their well-informed wishes," write the investigators.

El-Jawahri added that the takeaway is that patients who watched the video "were more informed and more knowledgeable about their options, which in turn caused them to make different decisions about what they wanted.

"The message is that this type of tool is a way to augment conversations," she said. "It's a way to empower patients to bring up these issues and to discuss them honestly with their physicians."

The video used in this study is available to view on Circulation's website. El-Jawahri said that although the video was created specifically for this study and that it needs to be further evaluated, clinicians can contact her team directly about using it in further research or even in their practice to open up conversations.

The study was funded by a grant from the National Heart, Lung, and Blood Institute. El-Jawahri reported no relevant financial relationships. Disclosures for the other study authors are listed in the article.

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