By Connor Emdin
September 20, 2017
Heart failure (HF) is the leading cause of hospitalization for adults over the age of 65 in the United States and is associated with poor short-term survival, with an estimated median survival of 1.5-3 years after diagnosis.1,2 In addition to causing significant morbidity and mortality, HF is associated with reduced quality of life, spiritual distress, depression, and anxiety.3
Palliative care, an interdisciplinary approach that aims to improve quality of life by treating pain, symptoms of disease, and associated psychological distress, is commonly used to treat patients with life-limiting diseases such as cancer and neurologic disease.4 However, the efficacy of palliative care for reducing suffering in HF is unknown.
Researchers from Duke University conducted a single-center, randomized trial to determine whether palliative care reduces suffering in patients with advanced HF.5 They enrolled 150 patients who were at high risk of rehospitalization for HF and death, defined as >50% predicted mortality at six months.6 Patients were randomized to receive usual care or a multidisciplinary palliative care intervention, which was coordinated by a certified palliative cure nurse practitioner, working with a palliative medicine physician. Each patients’ physical symptoms, mental health and psychosocial well-being was assessed and care was coordinated with the treating-HF team to improve symptoms and meet palliative care goals. The intervention included screening patients for depression and anxiety, and referring patients for psychiatric treatment where indicated. Goals of care were repeatedly addressed with patients and follow-up continued in the outpatient as well as the inpatient setting.
Patients were reassessed at 2, 6, 12 and 24 weeks after enrollment. The primary end points were improvement in two quality-of -ife scores; one HF-specific score, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and a more general, palliative care-specific score, the Functional Assessment of Chronic Illness Palliative Care (FACIT-Pal) score. Both questionnaires address a wide range of factors including physical, emotional, and functional well-being to give an overall summary score. A five-point increase in KCCQ score and a 10-point increase in FACIT-Pal are considered clinically meaningful improvements.
Of the one hundred and fifty patients enrolled in the trial, the mean age was 71 years, 41% of patients were women and 88% of patients were in New York Heart Association Class III or IV HF (indicating advanced heart failure). Patients had a large burden of comorbid disease and impaired functional status; for example, greater than one third of patients in both groups had spent almost all of their time in a bed or chair in the month prior to enrollment. No significant differences in baseline demographic characteristics were observed, suggesting the randomization was successful.4
At six months follow-up, 29% of patients had died, reflecting the disease burden in the population. Of those remaining, the palliative care group scored significantly higher on both quality-of-life scores than the control group. KCCQ score was 9.14 points higher (95% CI 0.94-18.05, p = 0.03) and the FACIT-Pal score was 11.07 points higher (95% CI 0.19-21.99, p=0.04) in the intervention group, as compared to the usual care group (Table 1).5 Furthermore, palliative care was associated with greater spiritual well-being and reduced depression and anxiety scores. No significant differences in rates of hospitalization or mortality were observed between the palliative care and control groups, although the trial was underpowered to detect a difference in these outcomes.
Table 1. Assessment of quality of life, spiritual well-being, depression and anxiety among patients with advanced heart failure at six months.
|Palliative Care Intervention (n=75)||Control (n=75)||p-value|
|Kansas City Cardiomyopathy Questionnaire – Overall Summary Score1
(Quality of Life)
|63.1 points||52.1 points||p=0.03|
|Functional Assessment of Chronic Illness – Palliative Care Score1
(Quality of Life)
|136.5 points||125.8 points||p=0.04|
|Functional Assessment of Chronic Illness – Spiritual Well-Being Scale1
|39.6 points||35.5 points||p=0.03|
|Hospital Anxiety and Depression Scale –Depression Subscale2 (Depression)||4.6 points||6.4 points||p=0.02|
|Hospital Anxiety and Depression Scale –Anxiety Subscale2 (Anxiety)||3.7 points||6.2 points||p=0.05|
1Higher scores correspond to increased quality of life/spiritual well being.
2Lower scores correspond to reduced depression/anxiety.
This was a single-center, randomized trial, therefore replication in a wider population may give a clearer picture of the actual benefit. However, the sample size was reasonable given the intensity of the intervention, the patient population was diverse and had a large range of comorbidities, suggesting that these findings may be broadly applicable.
Despite similar mortality risks, palliative care is commonly used for patients with cancer, but referral of HF patients for palliative care is unusual. In a recent study, 46% of patients with advanced cancer were referred for palliative care, while only 7% of HF patients were referred.7 The findings of this randomized trial suggest that palliative care may add significant benefit to HF patients and should be considered as an important additional tool to relieve suffering in this vulnerable patient population.
- Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012;126(4):501-506. doi:10.1161/CIRCULATIONAHA.112.125435.
- Ho KK, Pinsky JL et al. The epidemiology of heart failure: the Framingham study. J Am Coll Cardiol. 1993;22(4 Supp A):6A.
- Selman L, Beynon T, Higginson IJ, Harding R. Psychological, social and spiritual distress at the end of life in heart failure patients. Curr Opin Support Palliat Care. 2007;1(4):260-266. doi:10.1097/SPC.0b013e3282f283a3.
- Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. Campion EW, ed. N Engl J Med. 2015;373(8):747-755. doi:10.1056/NEJMra1404684.
- Rogers JG, Patel CB, Mentz RJ, et al. Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol. 2017;70(3):331-341. doi:10.1016/j.jacc.2017.05.030.
- Mentz RJ, Tulsky JA, Granger BB, et al. The palliative care in heart failure trial: rationale and design. Am Heart J. 2014;168(5):645–651.e1. doi:10.1016/j.ahj.2014.07.018.
- Thomas JM, O’Leary JR, Fried TR. Understanding their options: determinants of hospice discussion for older persons with advanced illness. J Gen Intern Med. 2009;24(8):923-928. doi:10.1007/s11606-009-1030-9.
Connor Emdin is a post-doctoral research fellow in Sek Kathiresan’s lab at the Broad, specializing in the genetics of cardiovascular disease. He completed his doctorate in cardiovascular epidemiology at the University of Oxford from 2009-2013.