By Van Selby, MD

Assistant Professor of Medicine, University of California, San Francisco Cardiology Division, Advanced Heart Failure Section

Dr. Selby reports no financial relationships relevant to this field of study.

SYNOPSIS: Among patients with advanced heart failure, implementation of an interdisciplinary palliative care intervention was associated with improved quality of life.

SOURCE: Rogers JG, Patel CB, Mentz RJ, et al. Palliative care in heart failure: The PAL-HF randomized, controlled clinical trial. J Am Coll Cardiol 2017;70:331-341.

Advanced heart failure (HF) is associated with substantial morbidity, mortality, and reduced quality of life (QOL). Standard therapies focus on slowing disease progression and improving survival, but do not address patient suffering. Palliative care has been shown to improve QOL among patients with cancer and may be helpful in those with advanced HF.

The Palliative Care in Heart Failure (PAL-HF) trial randomized patients with advanced HF and a high predicted six-month mortality to usual care (UC) alone or UC with an additional palliative care intervention (UC+PAL). The palliative care intervention was led by a nurse practitioner who assessed and managed multiple domains of QOL, including physical symptoms, psychosocial and spiritual concerns, and advance care planning. The nurse practitioner worked with a palliative medicine physician in close collaboration with the advanced HF clinic. Nearly all patients were enrolled during an HF hospitalization and subsequently followed in the outpatient setting for six months. The two co-primary endpoints were validated measures of HF-specific QOL and general and palliative care-specific, health-related QOL.

A total of 150 patients were randomized, with an average age of 71 years. Most patients exhibited New York Heart Association Functional Class III symptoms. Over six months of follow-up, patients randomized to UC+PAL saw significantly greater improvement in measurements of HF-specific QOL (P = 0.03) as well as palliative care-specific QOL (P = 0.035). Compared to those randomized to UC alone, patients receiving the palliative care intervention also demonstrated significantly greater improvement in depressive symptoms (P = 0.02), anxiety (P = 0.048), and spiritual well-being (P = 0.03). There were no significant differences in rehospitalization rate or mortality. The authors concluded that an interdisciplinary palliative care intervention improves health-related QOL in advanced HF patients and represents an important component of the holistic care of these patients.

COMMENTARY

Incorporating palliative care into the management of chronic HF receives a class I recommendation in current HF practice guidelines. However, the evidence supporting the use of palliative care in HF is sparse. PAL-HF is the first randomized, controlled trial of a palliative care intervention in advanced HF and shows clear improvements in a wide range of patient-reported outcomes, including QOL, depression, anxiety, and spiritual well-being.

PAL-HF is an important study for many reasons, particularly the focus on endpoints not usually studied in HF clinical trials. Although reducing hospitalizations and mortality are important goals, measures of suffering and QOL may be more important to some patients and are inadequately assessed with the current treatment approach.

The primary limitation of this study is its single-center design. All patients were followed at Duke University Medical Center, a large academic hospital with access to resources not always available in the community. With 5.7 million Americans living with HF, one major limitation of any plan to expand access to palliative care programs is availability of palliative care specialists. Comprehensive, longitudinal follow-up similar to what was implemented in PAL-HF just may not be feasible in many areas of the country. That said, one major strength of this study is the use of a nurse practitioner as the team leader. When faced with the current nationwide shortage of palliative care physicians, shifting care to other members of the healthcare team may help scalability of palliative care-focused interventions. For many HF patients, the important job of implementing palliative care ultimately will fall on cardiologists and other providers already caring for them. Therefore, palliative care will have to fit into already-full clinic visits. With that in mind, another limitation of PAL-HF is that we don’t know exactly which components of the palliative care intervention are most effective in HF patients. The multicomponent program implemented in PAL-HF is likely too complex for the average cardiologist. Hopefully, future studies will help clarify exactly which components are most beneficial to patients with advanced HF.

For now, providers caring for patients with advanced HF should try to incorporate principles of palliative care into their practice to the extent possible. This will require basic training in palliative care for cardiologists and other providers who care for patients with HF. Those who do not feel comfortable implementing palliative care and do not have access to palliative care specialists should consider referral to a HF specialty center for patients with advanced disease who are not responding to guideline-based therapies.