A survey of clinician attitudes and self-reported practices regarding end-of-life care in heart failure

Dunlay, Shannon M.; Foxen, Jilian L; Cole, Terese; Feely, Molly A.; Loth, Ann R.; Strand, Jacob J.; Wagner, Jean A.; Swetz, Keith M.; Redfield, Margaret M.

doi:10.1177/0269216314556565

Cited by 97 publications

(109 citation statements)

References 25 publications

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“…Finally, clinicians may not be routinely engaging patients with DT-LVAD and their families in goals of care discussions. Clinicians often hesitate to have these discussions for many reasons, including a fear of destroying hope, sensing that the patient or family are not ready, or because they lack confidence in their ability to approach these important conversations 18 . However, these conversations are critically important to understanding the patient’s goals, values and preferences so that we can provide goal-concordant care at the end-of-life.…”

Section: Discussionmentioning

confidence: 99%

Dying With a Left Ventricular Assist Device as Destination Therapy

Dunlay

Strand

Wordingham

et al. 2016

Circ: Heart Failure

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Background Despite the ability of left ventricular assist device as destination therapy (DT-LVAD) to prolong survival for many patients with advanced heart failure (HF), little is known about the eventual end-of-life care that patients with DT-LVAD receive. Methods and Results All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota from January 1, 2007 through September 30, 2014 who subsequently died prior to July 1, 2015 were included. Information about end-of-life care was obtained from documentation in the electronic medical record. Of 89 patients that died with a DT-LVAD, the median (25th–75th percentile) time from LVAD implantation to death was 14 (4–31) months. The most common causes of death were multiorgan failure (26%), hemorrhagic stroke (24%), and progressive HF (21%). Nearly half (46%) of patients saw palliative care within one month prior to death; however, only 13 (15%) patients enrolled in hospice a median 11 (range 1–315) days prior to death. Most patients (78%) died in the hospital, of which 88% died in the intensive care unit. In total, 49 patients had their LVAD deactivated prior to death, with all but 3 undergoing deactivation in the hospital. Most patients died within an hour of LVAD deactivation, and all within 26 hours. Conclusions In contrast to the general HF population, most patients with DT-LVAD die in the hospital and very few utilize hospice. Further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.

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Section: Discussionmentioning

confidence: 99%

Dying With a Left Ventricular Assist Device as Destination Therapy

Dunlay

Strand

Wordingham

et al. 2016

Circ: Heart Failure

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“…Furthermore, discussion of resuscitation preferences upon admission to the hospital is amongst a host of issues addressed in a short amount of time. This may be the first time that some patients have engaged in dialogue about their resuscitation preference, as end-of-life discussions have been shown to occur infrequently in HF (11). As such, their initial preference may change after further self-reflection and discussion with loved ones.…”

Section: Discussionmentioning

confidence: 99%

Discordance of Patient-Reported and Clinician-Ordered Resuscitation Status in Patients Hospitalized With Acute Decompensated Heart Failure

Young

Wordingham

Strand

et al. 2017

Journal of Pain and Symptom Management

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Context Accurate documentation of preferences for cardiopulmonary resuscitation at hospital admission is critical to ensure that patients receive resuscitation or not in accordance with their wishes. Objectives We sought to identify and characterize inconsistencies in patient-reported and clinician-ordered resuscitation status in patients hospitalized with acute decompensated heart failure (ADHF). Methods Southeastern Minnesota residents hospitalized with ADHF were prospectively enrolled into a study that included the administration of face-to-face questionnaires from January 2014 through February 2016. Patient-reported resuscitation status was assessed at enrollment using a validated question. Clinician-ordered resuscitation preferences at hospital admission were abstracted from the electronic medical record. Results Of the 400 patients administered the questionnaire; 213 (53.3%) stated their resuscitation preference as Full Code, 166 (41.5%) do-not-resuscitate (DNR), and 21 (5.3%) were unsure. In comparison, clinician-ordered resuscitation status was Full Code in 263 (65.8%) patients, DNR in 133 (33.3%), and not documented in 4 (1.0%). Patient-reported and clinician-ordered resuscitation status was discordant in 20% of patients, of whom 5.6% elected Full Code by questionnaire and had a DNR clinician order, and 14.4% elected DNR by questionnaire but had a Full Code clinician order. Differences in age, comorbidities, health literacy, marital status, completion of advance directives, hospital length of stay, and discharge destination in patients with discordant versus concordant resuscitation preferences were observed. Conclusions Patient-reported and clinician-ordered resuscitation preferences were discordant in 20% of patients hospitalized with ADHF. The underlying etiology of these inconsistencies may reflect factors such as patient indecisiveness or patient-clinician miscommunication, and requires further exploration.

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“…Such barriers stem from an inaccurate perception of palliative care as synonymous with hospice. 30,31 Palliative care should not be seen as “giving up” or “accepting death,” but as one component of a collaborative, supportive approach to patient care (Figure 4). …”

Section: The Logistics Of Team-based Palliative Care In Heart Failurementioning

confidence: 99%

Team-based Palliative and End-of-life Care for Heart Failure

Fendler

Swetz

Allen

2015

Heart Failure Clinics

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SYNOPSIS Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is no longer seen as “giving up” or “accepting death,” but is now conceptualized as “supportive care” afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, we will comment on the current state of multidisciplinary care for such patients, explore evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identify high-priority areas for research. Ultimately, patients require a “heart failure medical home”, where various specialties may take a more central role in coordination of patient care at different times in the disease span, sometimes transitioning leadership from primary care to cardiology to palliative care.

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A survey of clinician attitudes and self-reported practices regarding end-of-life care in heart failure

Abstract: Clinicians vary in their views and approaches to end-of-life discussions and care. Some lack confidence and most are interested in further skills acquisition.

Cited by 97 publications

References 25 publications

Dying With a Left Ventricular Assist Device as Destination Therapy

Dying With a Left Ventricular Assist Device as Destination Therapy

Discordance of Patient-Reported and Clinician-Ordered Resuscitation Status in Patients Hospitalized With Acute Decompensated Heart Failure

Team-based Palliative and End-of-life Care for Heart Failure

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