Supportive Cardiology Quality Improvement Project: Identifying Symptomatic, Advanced Heart Failure Patients for Palliative Care Consultation (QI723)

Introduction: Hospitalizations associated with advanced heart failure (HF) requiring mechanical circulatory support (MCS) are usually associated with a high morbidity, mortality and a protracted hospital course. Prior studies have shown that the early inclusion of palliative care specialist is associated with better end-of-life experiences. Methods: The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes to identify patients above 18 years with advanced HF admitted with cardiogenic shock requiring MCS. Baseline characteristics and in-hospital outcomes were compared among patients evaluated by palliative care and those who were not. A p-value of <0.001 was considered statistically significant. Results: There were 748,360 patients hospitalized for advanced HF complicated by cardiogenic shock requiring MCS, of these a palliative care consult was placed in 118,015 (15.8%) patients. Patients evaluated by palliative care were older (70.6±14.9 vs. 64.9±16.3 years old, p<0.001) and had a higher prevalence of atrial fibrillation (39.3 vs. 35.1%,p<0.001) and chronic kidney disease (40.4 vs. 33.3, p<0.001), however had lower hypertension (57.4 vs. 59.7%, p<0.001), diabetes (35.4 vs. 36.5%, p<0.001), coronary artery disease (51.2 vs. 58.4%, p<0.001) and acute coronary syndromes (39.2 vs. 45.0%, p<0.001). Consulting palliative care was associated with a shorter length of stay (8.8±12.0 vs. 11.9±15.5 days, p<0.001), lower total hospital cost ($161,972±265,156 vs. $219,114±318,387, p<0.001) and higher Do Not Resuscitate (DNR) orders (30.8 vs. 5.8%, p<0.001). Mortality rates were higher in the palliative care cohort (73.4 vs. 29.4%, p<0.001). Conclusions: Despite the high morbidity and mortality associated with advanced HF patients with cardiogenic shock requiring MCS, the overall prevalence of palliative care consultation is exceedingly low. DNR orders were more prevalent in patients seen by the palliative care service. This study highlights the underutilization of palliative care services in this patient population, precluding any perceived benefit in end of life experiences.

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Palliative Care Consultation Affects How and Where Heart Failure Patients Die

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909120963565 ◽

2020 ◽

pp. 104990912096356

Author(s):

Richard Pham ◽

Casey McQuade ◽

Alex Somerfeld ◽

Sandra Blakowski ◽

Gavin W. Hickey

Keyword(s):

Heart Failure ◽

Palliative Care ◽

Chi Square ◽

Code Status ◽

Heart Failure Patients ◽

Palliative Care Consultation ◽

Care Consultation ◽

Dying At Home ◽

The Impact ◽

At Home

Objective: Determine the role of palliative care on terminal code status and setting of death for those with heart failure. Background: Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis. Methods: Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate. Results: 334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient’s chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001). Conclusion: Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.

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Pilot Study of Palliative Care Consultation in Patients with Advanced Heart Failure Referred for Cardiac Transplantation

Journal of Palliative Medicine ◽

10.1089/jpm.2011.0256 ◽

2012 ◽

Vol 15 (1) ◽

pp. 12-15 ◽

Cited By ~ 47

Author(s):

Ernst R. Schwarz ◽

Afshan Baraghoush ◽

Ryan P. Morrissey ◽

Ankit B. Shah ◽

Arvind M. Shinde ◽

...

Keyword(s):

Heart Failure ◽

Palliative Care ◽

Pilot Study ◽

Cardiac Transplantation ◽

Advanced Heart Failure ◽

Palliative Care Consultation ◽

Care Consultation

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Bringing Sexy Back: Sexuality and Intimacy Concerns in an Advanced Heart Failure Population Receiving Palliative Care Consultation

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2016.01.054 ◽

2016 ◽

Vol 35 (4) ◽

pp. S19-S20

Author(s):

A. Kelemen ◽

J. Groninger ◽

J. Cagle ◽

K. Walker

Keyword(s):

Heart Failure ◽

Palliative Care ◽

Advanced Heart Failure ◽

Palliative Care Consultation ◽

Care Consultation

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Evaluation of a Quality Improvement Intervention to Improve Pediatric Palliative Care Consultation Processes

American Journal of Hospice and Palliative Medicine® ◽

10.1177/10499091211026675 ◽

2021 ◽

pp. 104990912110266

Author(s):

Jennifer Forsman Stoyell ◽

Megan Jordan ◽

Anne Derouin ◽

Julie Thompson ◽

Sarah Gall ◽

...

Keyword(s):

Palliative Care ◽

Quality Improvement ◽

Physical Symptoms ◽

Pediatric Palliative Care ◽

Family Needs ◽

Emotional Needs ◽

Improvement Project ◽

Symptom Screening ◽

Palliative Care Consultation ◽

Care Consultation

Background: A critical aspect of pediatric palliative care consultations is the assessment and documentation of patient and family needs. While these assessments usually include a focus on physical pain, there is less standardization of assessments of other physical symptoms and psychosocial, emotional, or spiritual needs. Aims: To improve the breadth of assessment of psychosocial and emotional needs, screen for symptoms other than pain among pediatric patients utilizing palliative care services, and to increase documentation of assessment data from 30%-40% to 80% through practice changes implemented in 2 Plan-Do-Study-Act (PDSA) cycles. Methods: This quality improvement project involved implementing provider education and adapting the palliative care consultation template in the electronic health record to improve breadth and consistency of assessment and documentation during consultations by the interdisciplinary pediatric palliative care team. Two PDSA cycles were performed. Chi squared tests and statistical control charts were used for data analysis. Results: There was statistically significant improvement in the inclusion of documentation of a pediatric palliative care social work note from baseline (32%) to Cycle 2 (57%). Physical symptom screening declined slightly, but not significantly (p = .32) and socio-emotional discussions also declined but not significantly (p = .05). Conclusions: Screening for physical symptoms and discussions with patients and families about psychosocial/emotional needs during the initial palliative care consultations are extremely important in providing effective, holistic, patient-centered care. There is a need for development of pediatric-centric guidelines and quality measures to evaluate pediatric palliative care programs; further research is indicated to determine methods for evaluating compliance with these guidelines.

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