Terminal heart failure care for women: better or more of the same?

Abstract

Background: Women with chronic heart failure (CHF) experience an increased symptom burden, activity impairment and frailty. Although receiving palliative care services has been shown to improve the quality of life of people with CHF, few patients access this in a timely manner.

Aim: Explore whether there were differences in either referral to specialist palliative care or provision of elements of palliative care to women and men with CHF during their terminal admission in Australia.

Methods: This is a retrospective review of medical records for all admissions resulting in death from chronic heart failure (July 2011 to December 2019).

Results: The cohort (n = 439) was elderly (median age 83.7 years, IQR = 77.6-88.7) and composed of 199 (45.1%) women. There was no association between sex and receiving an inpatient referral to specialist palliative care (P = 0.80). Women were less likely to receive life-sustaining interventions (intubation, inotropes, resuscitation, ICU stay) (odds ratio [OR] = 1.71, 1.04-2.83; P = 0.04) compared to men. Women were more likely to receive terminal symptom-related management (opioids or benzodiazepines) (OR = 3.19, 1.54-6.63; P = 0.01) or a palliative approach (OR = 1.68, 1.14-2.45; P < 0.01). Women were less likely to present to the emergency department (OR = 0.50, 0.31-0.79; P = 0.04) or be referred to an outpatient chronic disease programme (OR = 0.58, 0.34-0.98; P = 0.04) in the 12 months prior to death compared to men.

Conclusion: Given accepted differences in the timeliness of cardiac care for women, the apparent finding of better end-of-life care for women is intriguing and merits further research.

Keywords: heart failure; palliative care; sex difference; terminal admission.

Figure 1

Terminal care admission analysed by sex. Data are presented as counts with frequencies or medians with interquartile ranges. Odds ratio as well as the 95% confidence interval is presented for all results. *Palliative approach indicates whether a patient meets at least three of five of the following criteria: (i) no life‐sustaining interventions, (ii) specialist palliative care referral within 48 h of admission, (iii) active cessation of disease‐directed medications, (iv) documented goals of care aiming for comfort (palliation) within 24 h of admission and (v) symptom‐related management. CCU, coronary care unit; GOC, goals of care; ICU, intensive care unit; SPC, specialist palliative care.