The Palliative Approach and Terminal Heart Failure Admissions - Are We Getting it Right?

Abstract

Background: Chronic heart failure has a high mortality and early provision of palliative care supports complex decision-making and improves quality of life.

Aim: To explore whether and when a palliative approach was adopted during the last 12 months of life in patients who experienced an in-hospital death from heart failure.

Design: Retrospective medical record review of all deaths from chronic heart failure (January 2010 to December 2019).

Participants: Admissions with chronic heart failure resulting in death were analysed from an Australian tertiary referral centre.

Results: The cohort (n=517) were elderly (median age 83.8 years IQR=77.6-88.7) and male (55.1%). Common comorbidities were ischaemic heart disease (n=293 56.7%) and atrial fibrillation (n=289 55.9%). Life sustaining interventions occurred in 97 (18.8%) patients. In 31 (6.0%) patients referral to specialist palliative care occurred prior to, and in 263 (50.9%) during, the terminal admission. Opioids were prescribed to 440 (85.1%) patients. Comfort care was the documented goal in 158 patients (30.6%). A palliative approach was significantly associated with prior admission in the preceding 12 months (OR=1.5 95% CI=1.0-2.1 p<0.043), receiving outpatient care (OR=2.6 95% CI=1.6-4.1 p<0.01), and admissions in the latter half of the decade (OR=1.5 95% CI=1.0-2.0 p<0.038).

Conclusion: Despite greater adoption of a palliative approach in the terminal admission over the last decade, a significant proportion of patients receive palliative care late, just prior to death.

Keywords: Dyspnoea; Heart failure; Palliative care; Terminal care.