Improving end-of-life care in heart failure

In the past few decades, forms of heart failure have become increasingly common. The aging population is one of the contributing factors to this rise.[1] Understanding the natural history of a disease allows a clinician to have a good conversation with a patient or their caregivers about the expected course. Providing a prognosis is an often difficult conversation, fraught with uncertainty. In heart failure, there are generally episodes in a stepwise decline.

The trajectory of a stepwise decline in heart failure usually presents with hospitalizations for exacerbations from which the individual does not fully regain their pre-exacerbation baseline.[2] Retrospective studies have shown that a hospitalization for congestive heart failure (CHF) regardless of symptom severity and duration correlates with a 1-year mortality of 10% to 25%.[2] Each additional hospitalization compounds this percentage.

Frailty can be used to further evaluate an individual for prognostication. One common tool is the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA Scale). A category 5 clinical frailty score correlates with declining function at home with the need for help with instrumental activities of daily living and predicts a 50% mortality in 5 years.[2]

If we add the stepwise trajectory of the normal course of heart failure with the CSHA score, we can better predict a prognosis for our patients. One can see that a frailty score of 5 added to one to two hospitalizations in a year significantly reduces life expectancy. This leads to an opportune time to discuss palliative measures.

There is increased recognition that early symptom management and high-quality end-of-life care is just as important for individuals with chronic disease as it is for cancer patients.[2,3] This is even more important for the elderly, who often have high frailty scores in addition to one or more chronic diseases.[4] If clinicians place more emphasis on patient-centred outcomes such as improving function and quality of life in heart failure patients,[5] we provide better patient outcomes. Further, families may report better satisfaction with care[2] and clinicians may report better job satisfaction.

For a clinician, early recognition of a patient’s declining function, increase in symptoms, and increase in frequency of clinic visits or hospitalizations provide the impetus to have the conversation that palliation should be initiated soon. Clinicians can explain that palliation does not mean allowing someone to die. Palliation increases symptom management and maximizes function and quality of life. This helps the individual and their caregivers understand that life expectancy is decreased and conversations about care goals, scope of treatment, and financial and legal affairs can take place.

The progression of palliative measures as an individual declines with heart failure can provide good end-of-life outcomes and improve satisfaction for patients, caregivers, physicians, and other health care providers.
—Lauri McCoy, MD, CCFP

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This article is the opinion of the Geriatrics and Palliative Care Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Azad NA, Molnar FJ, Byszewski AM. Multidisciplinary congestive heart failure clinic for older women: A randomized controlled trial. J Am Geriatr Soc 2006;54:874-875.

2.    Sanderse NM. Prognostication in chronic disease. Hosp Med Clin 2014;3:e15-e31.

3.    Wachterman MW, Pilver C, Smith D, et al. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Inter Med 2016;176:1095-1102.

4.    Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18:891-975.

5.    Dodson JA, Matlock DD, Forman DE. Geriatric cardiology: An emerging discipline. Can J Cardiol 2016;32:1056-1064.