Medicine Today: Palliative care can help ease symptoms

Heart failure
affects over 5 million Americans and is responsible for approximately
20 percent of all admissions to hospitals. The heart is responsible for pumping blood to the rest of the body. Over time this function can worsen, causing heart failure.

 

Treatment of heart failure involves many strategies. A new paper in Journal of the American Medical Association Cardiology sheds light on the use of palliative care services in veterans with severe heart failure.

Heart failure initially presents with trouble breathing, feeling more fatigue with activity, swelling in the legs or needing more pillows at night to breathe comfortably. Risk factors for heart failure are high blood pressure, blockages in arteries around the heart, smoking and diabetes.

When diagnosed, pa­tients are placed on medi­cations to limit a de­cline in heart function. Un­for­tunately, approximately 50 percent of patients die within five years of diagnosis. As the heart loses its ability to pump, patients have worsening symptoms, including the inability to perform daily tasks. Such symptoms account for frequent hospital admissions. During late-stage heart failure even simple activities like walking to the mailbox can be limited. Unfortunately, after being hospitalized for heart failure, one third of patients over age 65 die within a year.

Treatment of late-stage heart failure involves many strategies. If a reversible cause can be identified, like a blockage around the heart or an infection, it is treated. If medications are unsuccessful, patients can be referred for evaluation for a ventricular assist device (VAD), a mechanical pump that is surgically implanted into the heart, or a heart transplant. Another important resource for patients is seeing a provider who specializes in palliative care.

Palliative care is a field focused on improving patient symptoms. In an era of physicians having to see more and more patients in less and less time, the patient’s voice is at times not heard. Palliative care teams can be that voice for the patient. They focus on learning about the patient’s goals and needs, which is particularly important for a chronic disease like heart failure.

Palliative care has at times been incorrectly associated with giving up on treatment. Rather, palliative care teams spend time to understand the patient and advocate for the patient’s goals, be that for a surgical pump or transplant, or continuing as best one can with medications at home, or even simply being the voice for the patient’s desire to have a better diet.

In a new paper led by Dr. Deepak Bhatt, a professor of medicine at Harvard Medical School, and me, we studied approximately 4,500 veterans from across the country with late-stage heart failure. We analyzed trends in the rate of palliative care in veterans with severe heart failure between 2007 and 2013. Over the seven-year period, we found an increase in the use of palliative care from 5.5 percent in 2007 to 10.3 percent in 2013. However, rates of palliative care use in heart failure remained lower than palliative care rates in the patients with cancer.

Our paper showed that rates of palliative care increased in recent years. However, there is potential to improve care as rates in heart failure remained lower than rates in cancer. The study has several limitations. It was performed on data from the Veterans Administration, and the increase in the rates of palliative care use may not be reflective of all hospital systems. In particular, 99 percent of the patients were male, and rates may be different for females. In addition, some physicians are already in tune to patient symptoms and may not feel the need to involve a palliative care team, which may make the rates of use artificially low. Even with these limitations, palliative care services can be an important resource for patients and their rate of use appears to be increasing.

 

ANANT MANDAWAT, A GRADUATE OF LAKESIDE HIGH SCHOOL AND YALE UNIVERSITY’S MEDICAL SCHOOL, IS A DOCTOR OF INTERNAL MEDICINE AT MASSACHUSETTS GENERAL HOSPITAL.

 

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