Hospice, Palliative Medicine Should Be First-Line Care Options for Advanced Cardiac Disease

• First, progress is being made in referring patients early in their disease process to hospice and palliative care to manage their symptoms and support quality of life near the end of life.

• Second, opportunities remain to ensure that all eligible cardiac patients are offered hospice and palliative care as legitimate treatment options in more healthcare settings and early enough to take full advantage of aggressive, comfort-focused interventions that can now be offered at home – the setting where the majority of them prefer to be near the end of life.

 

For example, a 2015 Mayo Clinic study found that the rate of hospice use among patients with heart failure increased from 28.6% to 42.2% over a 10-year period (2003-2012), while palliative care consultations increased from 10.8% to 43.6%. As hospice and palliative care increased, their trips to the hospital, emergency department and outpatient clinic decreased near the end of life – even though 82% were hospitalized at least once in their last year and 28.4% died in the hospital.

 

In a 2017 study by the Icahn School of Medicine at Mount Sinai, the median length of stay on hospice for heart failure patients was a short 15 days, with 40% dying within a week of hospice enrollment. The U.S. Department of Health and Human Services recommends at least 30 days of hospice care for patients to receive the full benefit of its focus on comfort and quality of life.

 

Those of us who care for patients with advanced cardiac disease know that their health usually deteriorates over months and years. They typically spend a great deal of time in healthcare clinics and hospitals, worrying about when their next cardiac event will happen. Will they end up back in the hospital, and if so, is that where they really want to be? If the patient’s medical management has been maximized and no surgical options remain, what are their care options?

 

What’s important for South Florida’s healthcare providers to understand is that many of the medical interventions currently provided in hospitals can now be delivered in outpatient settings and at home on hospice care; both options offer a benefit to patients and healthcare providers alike. Hospice offers an alternative treatment option at a point when their disease and symptom management are virtually one and the same therapy.

 

Some of our hospice teams in South Florida, for example, now offer complex modalities at home – including inotropes, IV diuretics, respiratory therapy, palliative-focused medications, LVAD support and other interventions – to manage the high-acuity symptoms associated with heart disease and related comorbidities.

 

Given the choice, heart disease patients should be evaluated for future care based on a simple question: Which cardiac care option will provide the most benefit?

• More medications and surgeries, knowing that many will be re-hospitalized and might die there?

• Or aggressive, comfort-focused cardiac care from a hospice team that comes to them over weeks and months?

 

If severely ill cardiac patients are offered comfort-focused palliative care and hospice care early in their process of functional decline, they can avoid excessive interventions and recurring hospitalizations, and worry less about their next cardiac event. Healthcare providers, likewise, can benefit from fewer rehospitalizations, and lower costs and reduced burdens of unnecessary care.

 

Ideally, the next evolution of care for patients with advanced cardiac disease will introduce palliative care earlier in the disease process and in more settings, including outpatient clinics, specialty clinics, community health settings, nursing homes, assisted living communities and the like. Doing so supports patient-centered care focused on improved quality of life and reduced symptom burden, allowing patients to stay at home or in their preferred setting of care.