Palliative Care in Advanced HF Makes a Big Difference in Rare Controlled Trial

July 14, 2017

DURHAM, NC — Patients with end-stage heart failure who received palliative care from an interdisciplinary team, along with usual evidence-based care, significantly improved in functional, psychosocial, and spiritual well-being compared with a control group getting usual care alone, in a rare randomized trial in this setting[1].

The small, single-center study's intervention was coordinated by a palliative-care nurse practitioner with expertise in heart failure, who ensured patients received support and treatment that addressed "physical symptoms, psychosocial and spiritual concerns, and advance care planning," says a July 12, 2017 report in the Journal of the American College of Cardiology. The intervention started in the hospital and continued after discharge.

"One of the unique aspects of our intervention is that we actually embedded that palliative-care expert into our outpatient practice. So she's seeing these patients longitudinally and continuing to address all of these issues," lead author Dr Joseph G Rogers (Duke University School of Medicine, Durham, NC) told | Medscape Cardiology.

The Palliative Care in Heart Failure (PAL-HF) trial randomized 150 patients to usual care with vs without the palliative-care intervention. The 75 patients in the intervention group scored significantly better after 6 months, compared with the 75 on usual care only, on the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Functional Assessment of Chronic Illness Therapy–Palliative Care (FACIT-PAL) assessments, which were co–primary end points.

They also improved in secondary assessments of depression, anxiety, and spiritual well-being. But the harder clinical end points of mortality and rehospitalization were not significantly different between the groups.

As a reminder that hospital-based palliative-care efforts aren't likely to be as effective as those continued over the long term, Rogers noted that the KCCQ and FACIT-PAL scores started to improve right away in both randomized groups, but improvements in the intervention group didn't surpass controls until after about 3 months.

PAL-HF underscores that palliative care in advanced HF doesn't work well as a one-time intervention, Rogers said. "It's not an acute illness, it's a chronic disease that requires chronic intervention."

The current study shows that "palliative care delivers an aspect of care important to our patients and lacking from our medical armamentarium," write Drs Eric D Adler and Nicholas Wettersten (University of California San Diego) in an accompanying editorial[2].

"Considering the effect of the interventions applied in PAL-HF, it highlights that all practitioners should incorporate palliative-care practices into their care of HF patients."

Because some kinds of palliative care may be more effective than others in most patients, they write, "determining which [palliative-care] interventions are more broadly helpful . . . can help non–palliative-care practitioners regularly integrate these modalities into their practice. A practitioner could then refer specific HF patients to an advanced palliative-care team to receive more advanced interventions or those beneficial to a specific population."

Not all clinicians grasp what palliative care means in this setting, Rogers said. "I think there's still a reasonable amount of confusion, at least in the cardiology space, because we're not using palliative-care approaches very often," he said.

It's "another layer of support for people with serious illness," to make sure issues they care about are addressed. It's really "a specialized disease-management approach," he said.

"Generally speaking, heart-failure programs have integrated palliative-care principles in their management algorithms. They just may not be calling them palliative-care principles."

The study has limitations; it's a single-center experience led by a few specialists, but also, the center had already been using many of the palliative-care practices before the study, so to some extent they were part of usual care.

Blinded randomization wasn't possible. "We've integrated palliative care in the heart-failure group for 5 years or so," Rogers said. "So, surely and unintentionally, palliative-care principles were also being applied in the usual-care group." That's a potential confounder, "but it probably makes the data stronger."

"You might find an even more profound effect in centers that haven't necessarily invested or engaged in palliative care."

The study entered 150 patients with a predicted survival of 6 months or less, their disease status assessed more by heart-failure symptoms than by more objective criteria.

The nurse practitioner led the intervention in conjunction with a palliative-care physician, coordinating with patients' cardiologists, and continued it on an outpatient basis for 6 months. Patients were then contacted every 3 months as part of their continuing care.

During the 6 months, 30% of patients were hospitalized for heart failure, and the entire cohort's all-cause mortality was 29%; the two randomized groups didn't differ significantly for the two end points.

Mean Difference in 6-Month Assessment Scores, Usual Care With vs Without Palliative Care, in End-Stage HF

Assessment tool Unadjusted for age and sex (P) Adjusted for age and sex (P)*
KCCQ 9.49 (0.030) 9.14 (0.037)
FACIT–Pal 11.77 (0.035) 11.09 (0.046)
HADS–Depression 1.94 (0.020) 1.94 (0.021)
HADS–Anxiety 1.83 (0.048) 1.70 (0.063)
FACIT–Sp 3.98 (0.027) 3.93 (0.031)
*Adjusted analyses not prespecified
KCCQ=Kansas City Cardiomyopathy Questionnaire
FACIT–Pal=Functional Assessment of Chronic Illness Therapy–Palliative Care scale
HADS=Hospital Anxiety and Depression Scale
FACIT–Sp=Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being scale

The dedicated HF and palliative-care nurse practitioner may be the trial's one feature that would be currently hard to reproduce at a lot of other centers, Rogers said. "I think we should try to, in the next round of studies, come up with protocol-driven approaches," perhaps with randomization patients by center, those with vs without a palliative-care–oriented approach.

PAL-HF was funded by the National Institute of Nursing Research (NINR). Rogers reports no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

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