Palliative care in heart failure - do we know when to refer?

Introduction

Patients living with heart failure (HF) often endure significant progressive physical and psychological symptoms, yet there is no accepted standard to guide the integration of palliative care services into HF care. The recent national mapping exercise reviewing the palliative care service for patients with HF within Northern Ireland were able to identify seven key gaps, including the lack or delayed identification of patients with palliative care needs. This may partly be explained by prioritisation of active medical treatment within resource-constrained services, differences in local service provision, and lack of knowledge to identify those patients approaching the end-stages of disease.

Aim

This study aimed to review the potential knowledge gap regarding identification of HF patients who are approaching the end-stages of disease using resuscitation status and subsequent referral to palliative care services.

Methods

This was a single-centre retrospective study of patients admitted with HF over one year (September 2022-2023). Electronic health records were reviewed for documentation of resuscitation status, onward referral to palliative care teams (both inpatient and community), mortality incidence during index admission and at one-year.

Results

Of 313 patients included, 31 (10%) died during the index admission and 110 (35%) died within one year of discharge. The average age was 78.8 years, and average number of co-morbidities was 3.8 per patient.

Of the 31 patients who died during the index admission, 14 (45%) were documented to have DNACPR in place and 10 (32%) were documented to have been referred to the inpatient palliative care service.

Of the 110 patients who died within one year of discharge, 16 (15%) were documented to have a DNACPR in place and 12 (11%) had a documented referral to the palliative care service (inpatient or community).

Conclusion

Patients living with HF have considerable palliative care needs but are less likely to be referred to specialist palliative care services, as demonstrated in this study. Allowing for limitations including documentation accuracy, our study highlights the need for improvement in the recognition of patients approaching end-stages of disease and subsequent onward referral to palliative services.Palliative Care Referrals in HFFor image description, please refer to the figure legend and surrounding text.