Competencies in Palliative Care for Cardiology Fellows

Abstract

A n 87-year-old man with a history of coronary artery disease, and having had 1-vessel coronary artery bypass surgery 10 years prior to admission, was admitted in a severe coma to the cardiovascular intensive care unit (CCU) for an acute myocardial infarction complicated by cardiogenic shock. He was intubated and started on inotropic and vasopressor support along with insertion of an intra-aortic balloon pump. Cardiac catheterization revealed 90% stenosis of the proximal left anterior descending artery, and a drug-eluting stent was implanted. However, he remained comatose and dependent on mechanical circulatory support. He rapidly developed acute kidney injury, requiring initiation of continuous venovenous hemodialysis. On the fourth hospital day, the family reported that the patient had stated on multiple occasions that he would not want to undergo aggressive diagnostic and treatment modalities if he was very sick and the prognosis was grim. The family requested to withdraw invasive and aggressive means of care. All life-sustaining measures were stopped, including inotropes/vasopressors, enteral feedings, the intraaortic balloon pump, and continuous venovenous hemodialysis. He was provided with pain medication (for pain/dyspnea) and sedatives (for distress), with subsequent extubation. A few hours later, he peacefully passed away. In this case, intensive care was withdrawn at the family's request. The team and family agreed that this course of action best honored the patient's wishes. It is sometimes painful to us, as physicians, to admit that our interventions do nothing else but prolong patient suffering. We often encounter situations like this during our fellowship training, especially in the CCU, where we deal with sick and complex patients who also have complicated end-of-life issues; thus, the following are some skills that we should seek to master to effectively and compassionately care for our terminal patients. 1. Prognostication. Prognostication, along with diagnosis and treatment, is a traditional core clinical skill of every physician (1) and should be part of every clinical encounter. For example, we now know that mortality rates among patients who develop refractory cardiogenic shock range from 50% to 80% and that only one-half of the patients with refractory heart failure who receive mechanical circulatory support survive to hospital discharge (2). However, in patients with compensated advanced heart failure, this is difficult to predict, because unlike many cancers that are characterized by a steep linear decline in performance status during the last few months of life, heart failure is characterized by unpredictable decompensations and improvements, with a subtler decline over time (3). Hyponatremia, hypotension, decline in functional status, and cachexia are associated with an increased mortality risk. Therefore, we should seek to develop a treatment plan but also formulate an individualized prognosis for each of our patients. 2.Communication. Most of the time, we avoid telling the patient that...

Palliative Care in Heart Failure

“…Indeed, all clinicians caring for patients with serious illness, like HF, should possess a fundamental palliative proficiency to alleviate suffering (e.g., basic management of physical and psychological symptoms, eliciting goals of care, responding to family concerns) (14). Initial efforts to educate cardiology fellows in palliative care competencies, such as communication, are underway (60,61). Research is needed to understand how to improve education regarding primary palliative care domains that are relevant to patients with advanced HF, such as elicitation of goals of care, advance care planning, and caregiver support.…”

Evaluating Hospice and Palliative Medicine Education in Pediatric Training Programs

“…[22][23][24][25][26] This is markedly different when compared to adult medicine, where there are several specialty-based consensus competencies for various trainee levels that have been established. [27][28][29][30][31] Perhaps HPM would be taught in a more comprehensive manner if clear, universal objectives were mandated by each subspecialty for board certification. Creating guidelines and structure to pediatric HPM training regarding team composition, funding, and consultation standards will minimize wide variability in experience for trainees.…”

Diagnósticos e intervenções de enfermagem para pacientes cardiológicos em cuidados paliativos

“…The open questions were compiled in Excel, after completing the instrument, using the North American taxonomy of Nursing diagnosis (NANDA) 6 and the classification of Nursing interventions (NIC) 7 , already adopted by the institution, for the specific description of each diagnosis and Nursing intervention listed to each patient of the study, and then the comparison and the grouping between them were given. This database was submitted to statistical analysis by checking the absolute (N) and relative frequencies (%).…”