Few Cardiologists Referring Patients for Palliative Care

May 08, 2019

Although heart disease is the leading cause of death in the United States, few patients with heart disease are referred to palliative care, and for those that do receive such a referral this occurs much too late, a new study shows.

"There is confusion about when is the right time to refer to palliative care, which is dedicated support to improve a patient's quality of life. Our data shows that cardiologists are waiting too long," senior author Arif H. Kamal, MD, Duke University Medical Center, Durham, North Carolina, told Medscape Medical News.

"Cardiologists, like many other clinicians, appear to think that palliative care just happens at the end of life, but actually palliative care can be appropriate at any stage of a serious or life-changing illness," he added.

The study was published online May 3 in JAMA Network Open.

The authors examined changes in characteristics among 1801 patients with cardiovascular disease referred to palliative care specialists during a 3-year period, from 2015 through 2017.

Results showed that 29% of patients had low palliative performance scores, consistent with being bedbound and requiring total care, with a short life expectancy, and this percentage did not change through time. 

By comparison, only about 10% of patients with cancer, who are the largest group referred to palliative care, fall into this category.   

It also found that referrals from cardiologists were low at the start of the study and fell further over a 3-year period, from 16.5% to 10.5%.

Most cardiovascular patients referred to palliative care had a primary diagnosis of heart failure (70%), with the remaining 30% having coronary artery disease and valvular heart disease.

In addition, only a small proportion of patients referred to palliative care were black (11.9% in 2015, decreasing to 6.3% in 2017).

The authors note that "substantial proportions" of patients in this study reported moderate to severe symptoms, including poor well-being (52%), tiredness (50.3%), anorexia (35.7%), dyspnea (27.9%), and pain (19.7%).  

"Although palliative care can be of particular value for patients in the last days of life, more value could be gained by patients if they were able to access palliative care earlier,” the authors suggest. "Given that Medicare beneficiaries admitted with heart failure have a median survival of 2 years, hospitalization might be an opportunity to introduce palliative care to patients with heart failure."

Kamal explained that the goal of palliative care is to improve both the quality and quantity of a patient's life with specific focus on improving symptoms, pain, and mood; reducing anxiety; and developing coping mechanisms.

"While many patients with serious illnesses receive some of this type of care from their primary care doctor or their specialist, sometimes their needs are too complex so that they need an extra level of support," he said. "That's when palliative care can help." 

Kamal noted that patients with advanced heart failure can have a high symptom burden — with pain, low mood, and anxiety. 

"Cardiologists are more focused on interventions to manage the heart failure rather than these other symptoms. Many patients cope well with this but some need more support," Kamal said. "Palliative care specialists take those conversations away from the time-stretched specialists and primary care doctors. Also, patients with advanced heart disease can have other conditions — palliative care can bring the whole picture together."  

The current results show that only about 12% of patients with heart disease referred to palliative care came from cardiologists, with the other 88% recognized as having complex needs that could be helped by palliative care — but by another member of the healthcare team, Kamal reported. 

"Over the 3 years of our study things weren't really changing," he said. "We have a lot more work to do communicating what palliative care does and building trust with cardiologists."

Kamal explained that most clinicians misunderstand what palliative care is. "Many clinicians practicing today trained before palliative care really existed, and as it started out as hospice care it is often thought about as end-of-life care." 

While hospice care is one part of palliative care, in recent years, Kamal said, another distinct clinical specialty has developed: managing patients with complex, time-intensive illnesses. "With many conditions, life can be turned upside down even if the patient is not dying."

In an accompanying editorial, David B. Bekelman, MD, Eastern Colorado Health Care System, Aurora, Colorado, says the low proportion of referrals to palliative care from cardiologists in this study is concerning, especially considering there is evidence showing its benefits in cardiovascular disease, particularly heart failure.

He points out that primary palliative care requires collaboration among different healthcare professionals, including cardiologists, palliative care specialists, primary care specialists, mental health specialists, physicians, nurses, social workers, and chaplains.

"Leveraging the skills of affiliate health care professionals and engaging patients and caregivers using technology are approaches to improve primary palliative care in cardiovascular disease," Bekelman writes.

"We should be encouraged that practitioners, professional societies, health care systems, and research funding agencies are starting to recognize the importance of palliative care for patients with serious cardiovascular disease. Future work should focus on fostering capacity and competency among cardiologists and other health care practitioners to provide early, primary palliative care and to appropriately refer patients to palliative care specialists," Bekelman concludes.

JAMA Network Open. Published online May 3, 2019. Full text, Editorial 

For more from Medscape Neurology, join us on Twitter and Facebook


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: