ReviewNew Dimensions in Palliative Care Cardiology
Section snippets
History of Cardiac Palliative Care
Palliative care has long been integrated with cancer patients, with studies showing improved quality of life, better symptom control, and perhaps prolonged life expectancy in select cancer populations.11, 12 In the modern literature, we see that surgeons were the first clinicians to publish their palliation interventions in cardiac patients in the 1960s, with these efforts focused on pediatric patients with congenital heart disease.13 Around the same time, the symptom burdens of adult patients
The Need for Palliative Care
HF is a progressively symptomatic disease associated with general clinical decline. HF patients experience a host of symptoms in addition to dyspnea, including pain, fatigue, nausea, poor appetite, anxiety, depression, fatigue, and an overall decreased sense of well-being.18 Cardiologists are very well versed in assessing dyspnea and use measurement instruments such as New York Heart Association (NYHA) class to convey clinical status. Although patients with a higher NYHA class have a poorer
Barriers to the Integration of Cardiac and Palliative Care
Despite the increased recognition of cardiac palliative care, the magnitude of the unmet palliative care need in the cardiovascular patient population is significant. According to the World Health Organization and the Worldwide Palliative Care Alliance, there are > 7 million people with cardiovascular disease worldwide who would benefit from palliative care.24 Western countries have the great fortune of having access to palliative care teams to help integrate this care. Despite this access,
Supportive Data
Most evidence in support of palliative care comes from the cancer literature. Supportive data for cardiac patients is significantly lacking in comparison. Indeed, palliative articles with a cancer focus outnumber palliative cardiology articles by a factor of 10-fold (Fig. 3). Many of the cardiac palliative articles that have been published are position statements. However, several small randomized control trials have also been carried out, on inpatient as well as outpatient interventions, and
Integrating Cardiac and Palliative Care
Many models for integrating cardiac and palliative care have been described in the literature. The models most in favour at the present time feature a gradual transition from curative/therapeutic treatment to supportive/palliative care (Fig. 4).
Although at first glance it is tempting to have palliative specialists take on all palliative aspects of care, the number of palliative specialists is quite limited, and they cannot provide this volume of care. A paradigm of primary and specialist
The Use of Intravenous Medications in the Palliative Patient Population
Intravenous inotropic medications have been used for the treatment of acutely decompensated HF for more than 4 decades. Although inotropic agents have not been shown to result in any significant survival benefit in patients with advanced HF, continuous infusions of medications such as milrinone or dobutamine have been shown to improve symptoms as well as decrease hospitalization.54 Although several cardiovascular societies advocate for continuous inotrope therapy as a palliative measure, only
Special Patient Populations
Cardiology patients have access to a host of device therapies. Indications for implantation of these devices are well documented in practice guidelines. As clinical status deteriorates, patient goals might change. Correspondingly, some of the device therapies might no longer be in alignment with these changed goals. ICDs and VADs in particular warrant further discussion in this regard.
Conclusion and Future Directions
Palliative care has the potential to significantly improve the quality of life for cardiac patients. At the present time, few cardiac patients get access to palliative care. For the small subset of patients who do get access, this typically occurs quite late in the disease trajectory, limiting the benefit that these patients receive.5 Goal-directed cardiac disease management and symptom-focused management need to be regarded as complementary as opposed to conflicting care options.
Several
Disclosures
The author has received speaker fees from Novartis.
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Cited by (11)
Elements of Integrated Palliative Care in Chronic Heart Failure Across the Care Continuum: A Scoping Review
2022, Heart Lung and CirculationCitation Excerpt :A multidisciplinary, collaborative team based approach is an element of integrated palliative care in CHF [26,33,34,40,43,46,71,72] and each individual within the team should understand their role [66]. It is recommended the team consist of primary care, advanced CHF clinicians, palliative care specialists, geriatricians, nurses, social workers, chaplains, pharmacists and allied health, through team meetings and collaboration, partnering health care professionals with patients and carers [14,17,19,21,23,32,36,39,40,42,48,50,51,53,60,62,63,65,71, 3-80]. In order to integrate palliative care, a cardiologist should be the care champion to ensure buy-in from other cardiologists [81], and can identify and manage comorbidities and patient needs in collaboration with palliative care and not a siloed approach [42,74,81].
Management of the Dying Cardiac Patient in the Last Days and Hours of Life
2020, Canadian Journal of CardiologyCitation Excerpt :Many patients are not aware that deactivation of ICD tachyarrhythmia therapies is an option available to them for eliminating not only their distress, but also the anxiety and distress of their family members and caregivers.33 Ideally, conversations about ICD therapy discontinuation should start at the time of initial implantation assessment.34,35 In practice, ICD deactivation conversations are usually deferred until death is imminent, as highlighted by a recent review that showed that the median time from discussion of end-of-life preferences in ICD patients to death was only 7 days.36
Supportive cardiology: Bridging the gaps in care for late-stage heart failure patients
2023, British Columbia Medical JournalUse and Discontinuation of Milrinone for Advanced Heart Failure in an Academic Palliative Care Unit: A Case Report and Discussion of Recommendations
2022, Journal of Pain and Palliative Care Pharmacotherapy
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