Palliative Care Consultations in Heart Failure Associated With Higher Rates of Advance Care Planning

Palliative medicine consultations for heart failure were linked with increased rates of advance directives being included in a patient’s electronic medical record (EMR), according to study results published this month in Journal of Maine Medical Center.

A heart failure diagnosis carries with it a median survival of 5 years, and yet most patients do not engage in active end-of-life care planning, including putting together advance directives for when they can no longer make their own medical care decisions.

“The rates of advanced care planning for [heart failure] patients remain low and occur close to the end-of-life rather than as the disease progresses,” the authors stated. They investigated why this was the case, along with contributing factors.

Patients (N = 471) included in the observational, cross-sectional study were admitted to Maine Medical Center between October 2015 and October 2016 with exacerbation of acute heart failure. Their heart failure diagnosis was based on International Classification of Diseases, Tenth Revision codes, and they all also had a Medicare Severity Diagnosis Related Code for heart failure.

The primary predictor of interest was palliative medicine consultation during hospitalization; the primary outcome, an advance directive scanned into the patient’s EMR; and secondary outcomes, discharge disposition and code status change during hospitalization.

Twenty-eight percent of the patients had a primary ejection fraction below 40%, and the rest had heart failure with preserved ejection fraction. However, of the entire cohort, just 13% had a palliative medicine consultation.

Overall, these consultations led to the following results compared with those who did not engage the service, even after accounting for illness severity, sex, age, and ejection fraction:

• Advance directives scanned into EMRs: 46% vs 21% (P < .0001)
• Greater likelihood of dying during hospitalization: 59% vs 19% (P < .0001)
• Decision to change their code status from “full” to “do not resuscitate”: 30% vs 5% (P < .0001)

A palliative medicine consultation was also associated with greater chances of having an advance directive in the EMR (odds ratio [OR], 3.4; 95% CI, 1.9-6.3) and a code change (OR, 8.2; 95% CI, 3.8-18.0).

The authors highlight that although the rate of palliative medicine consultations was low in their study, it still represents an improvement compared with results from previous research.

“We also found that completion of advanced care planning was higher for patients who received palliative medicine consultation,” they stated. “This result is consistent with previous findings that palliative medicine consultation in HF was associated with improved attitudes toward completing advance directives.”

In contrast, less than a quarter of patients not seen by a palliative medicine specialist completed advanced care planning.

The authors believe that advance care planning should occur throughout the course of heart failure, so they recommend additional research into optimal ways to improve advance care planning, to complete that planning, and to include advance directives in end-of-life care planning.

Reference

Crispo M, Sawyer D, Fairfiled K, Hutchinson RN. Association of palliative care consultation with advance directive completion for patients admitted with an acute heart failure exacerbation. J Maine Medical Center. 2020;2(2):15. doi:10.46804/2641-2225.1056