Authors: Winson Y. Cheung, Kristen Schaefer, Christopher W. May, Robert J. Glynn, Lesley H. Curtis, Lynne W. Stevenson, and Soko Setoguchi
Journal of Pain and Symptom Management, 2012
Heart patients receiving less benefit from hospice than those with cancer
Advances in life-sustaining therapy in the fields of cardiology and oncology have provided longer lives to an increasing number of patients with both heart failure and cancer. However, these patients will often have a significant burden of symptoms near the end of life, and these symptoms contribute to suffering among both patients and caregivers. The use of hospice services by patients with terminal cancer has been proven to increase satisfaction, improve quality of death and minimize personal and caregiver distress. But, studies suggest that the delivery of hospice services to end-stage heart failure patients lags that of cancer patients.
A retrospective comparison of 7930 heart failure patients and 7565 advanced cancer patients evaluated hospice enrollment patterns and clinical events. Twenty percent of heart failure patients and more than half of cancer patients were admitted to hospice at least once before their death. Heart failure patients were older, and more likely to have associated cognitive disorders, diabetes and kidney disease than cancer patients. Heart failure patients were more likely to be referred to hospice from an acute care setting, while cancer patients were more likely to be referred from home. Heart failure patients were more likely to be discharged from hospice prior to death, had a greater number of emergency room visits and hospitalizations, and were more likely to die in the acute care setting.
Several factors may explain the different patterns of hospice use in heart failure and cancer patients. The trajectory of end-stage heart failure is less predictable than cancer. Patients may experience waxing and waning symptoms that cloud the ability to predict survival. Studies indicate physicians are unable to reliably predict six month mortality in heart failure; most tend to overestimate survival. Cardiologists generally receive less formal training and exposure to palliative and end of life care, and hospice services may not be available to meet the specific needs of their patients. Understanding the needs of those with heart failure, the knowledge deficit of physicians and the appropriate structure to educate and care is the first step to improve the end of life care for patients with heart failure and their caregivers.