Steven Z. Pantilat

Objective: The objective of this study is to describe preferences of patients with heart failure (HF) for having advance care planning (ACP) discussions with clinicians and to identify characteristics associated with those preferences. Background: National guidelines call for having ACP discussions with patients with serious illnesses such as HF. Many patients with HF do not discuss ACP with their physician despite wanting to have them. Methods: We conducted a cross-sectional cohort study between July 2007 and November 2009 within HF clinics affiliated with a large, urban, academic medical center. Patients with New York Heart Association HF classes II and III were surveyed about whether they had or would like to have discussions with their clinician about what to expect in the future regarding their HF, prognosis, ACP, and their surrogate choice. Results: Patients ( n = 104) were on average 53 years old (standard deviation = 14.3; range: 21–84) and had Class II (57%) or Class III (43%) HF. Most patients had discussed what to expect in the future regarding HF (76.5%, 78/102), prognosis (68.0%, 68/100), surrogate choice (90.3%, 93/103), and ACP (46.5%, 47/101). Most of those who did not have these discussions would have liked to discuss expectations regarding their HF (87.5%, 21/24), prognosis (80.6%, 25/31), and ACP (59.6%, 31/52). Men were more likely than women to report having had discussions about their HF (83.6% vs. 62.9%; p = 0.02), prognosis (78.5% vs. 48.6%; p = 0.002), and ACP (56.1% vs. 28.6%; p = 0.01). On average younger patients were more likely to report having discussed what to expect regarding their HF (50 years vs. 59 years; p = 0.007), and to be asked about their spirituality (43 years vs. 56 years; p = 0.0001). Discussion: Conforming to national guidelines, most patients with HF have discussed ACP with clinicians and most of those who have not, want to. Findings should embolden clinicians to routinely discuss ACP.

Objective: Describe the etiology of pain among HF patients and examine the relationship between pain and QoL. Background: Little is known about the etiology of pain in patients with heart failure (HF) and the impact it has on quality of life (QoL). Methods: A prospective cohort study of outpatients with NYHA Class II or III HF were surveyed at baseline and at three-month follow-up. The study was conducted in Heart Failure clinics affiliated with a large, urban, academic medical center. Results: Of 104 patients that completed a baseline survey, 73 (70%) completed a follow-up survey. At baseline, 48% of patients reported having pain the previous week. Patients on prescription pain medication (n = 16) had more severe pain (Mean = 4.5 vs. 2.6; p = 0.001). Physician documented pain etiologies included: musculoskeletal (50%, n = 16), cardiac (22%, n = 7), and headache/neurological (22%, n = 7). Linear regression revealed that significant contributions to QoL included HF Class (p = 0.0001), dyspnea (p = 0.0001), and depression (p = 0.01). Pain was not independently associated with QoL (p = 0.17), but moderately correlated with depression (r = 0.49). Although 15% (n = 11) of patients reported a clinically meaningful improvement in pain scores, it was not associated with improvements in QoL (χ² = 1.6, p = 0.2). Discussion: Pain is prevalent and persistent, due largely to non-cardiac causes. Although pain did not predict QOL, it was associated with depression, which did adversely affect QoL. Clinicians should screen for and treat both symptoms.

Opinion from JAMA Internal Medicine — When It's the Right Care, More Is Better — Comment on “Palliative Care and Quality of Life” and “Pain as a Cause of Agitated Delirium”

Background: Although hospital palliative care consultation services (PCCS) can improve a variety of clinical and nonclinical outcomes, little is known about how these services are structured. Methods: : We surveyed all 351 acute care hospitals in California to examine the structure and characteristics of those hospitals with PCCS. Results: We achieved a 92% response rate. Thirty-one percent ( n =107) of hospitals reported having a PCCS. Teams commonly included physicians (87%), social workers (80%), spiritual care professionals (77%), and registered nurses (71%). Nearly all PCCS were available on-site during weekday business hours; 50% were available on-site or by phone in the weekday evenings and 54% were available during weekend daytime hours. The PCCS saw an average of 347 patients annually (median=310, standard deviation [SD]=217), or 258 patients per clinical full-time equivalent (FTE; median=250, SD=150.3). Overall, 60% of consultation services reported they are struggling to cope with the workload. On average, patients were in the hospital 5.9 days (median=5.5, SD=3.3) prior to referral to PCCS, and remained in the hospital for 6 days (median=4, SD=7.9) following the initial consultation. Patient and family meetings were an aspect of the consultation in 74% of cases. Overall, 21% of consultation patients were discharged home with hospice services and 25% died in the hospital. Conclusions: : There is variation in how PCCS in California hospitals are structured and in the ways they engage with patients. Ultimately, linking PCCS characteristics and practices to patient and family outcomes will identify best practices that PCCS can use to maximize quality.

BACKGROUND: Pain, dyspnea, and anxiety are common among patients with cancer, heart failure (HF), and chronic obstructive pulmonary disease (COPD), yet little is known about the severity of symptoms over time.OBJECTIVE: To determine the prevalence, severity, burden, and predictors of symptoms during the course of hospitalization and at 2 weeks after discharge.DESIGN: A prospective cohort study.SETTING: A large academic university.PATIENTS: Patients were 65 years or older with a primary diagnosis of cancer, COPD, or HF.MEASUREMENTS: Daily living skills and depression were recorded at enrollment. Symptoms were assessed daily and 2 weeks postdischarge.RESULTS: At baseline, most participants reported moderate/severe pain (54%), dyspnea (53%), and anxiety (62%). Almost two‐thirds (64%) had 2 or more symptoms at a moderate/severe level. The prevalence of moderate/severe symptoms decreased at the 24‐hour assessment (pain = 42%, dyspnea = 45%, anxiety = 55%, burden = 55%) and again at follow‐up (pain = 28%, dyspnea = 27%, anxiety = 25%, burden = 30%). While there was no association between primary diagnosis and symptom severity at baseline or 24‐hour assessment, at 2‐week follow‐up, a higher percentage of patients with COPD had moderate/severe pain (54%, χ² = 22.0, P = 0.001), dyspnea (45%, χ² = 9.3, P = 0.05), and overall symptom burden (55%, χ² = 25.9, P = 0.001) than those with cancer (pain = 22%, dyspnea = 16%, symptom burden = 16%) or HF (pain = 25%, dyspnea = 24%, symptom burden = 28%). Predictors of symptom burden at follow‐up were COPD (odds ratio [OR] = 7.5; 95% confidence interval [CI] = 2.0, 27.7) and probable depression (OR = 6.1; 95% CI = 2.1, 17.8).CONCLUSION: The majority of inpatients with chronic illness reported high severity of symptoms. Symptoms improved over time but many patients, particularly those with COPD, had high symptom severity at follow‐up. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Hospital-based palliative care is becoming increasingly prevalent. There is growing evidence that it is having a positive impact on patients and their loved ones. In 2008, national data indicated that 58.5% of hospitals with 50 or more beds had a palliative care program. Data from a 2008 survey of California acute care hospitals showed that although 33% of sites had inpatient consultation services, one in five had been operational for only one year. As nascent palliative care programs grow, new issues arise and needs and plans change. Just as palliative care programs benefit from marketing and education plans, they also benefit from a plan to leverage external resources. Largely a missed opportunity, external resources such as organizations, networks, and experts can help palliative care service (PCS) leaders and team members gain information on everything from best practices to funding opportunities, while serving as sources for personal and professional support. The growing number of active PCSs and the increasing availability of support and expertise ensure that new programs no longer have to face challenges alone. Further, the steady increase in the number of new programs has created opportunities for those who are more experienced to serve as mentors for peers who are navigating the challenges of growing and sustaining a clinical service. The authors encourage both mentors and mentees to seek support from or provide support to others in the field. Leveraging the collective expertise and experiences in our field can ensure that palliative care continues to thrive and grow.

Letter from JAMA Internal Medicine — Prevalence and Characteristics of Outpatient Palliative Care Services in California

Hospital-based palliative care consultation services increase patient and family satisfaction,^1,2 improve quality of life,³ reduce intensive care unit length of stay,⁴ and decrease costs.^2,5 Clear evidence of the effectiveness of palliative care consultation services in improving symptoms has been more elusive.^2,3,6 We conducted a randomized trial to evaluate the impact of a proactive palliative medicine consultation (PMC) on the care of chronically ill, hospitalized elderly patients.