Heart Failure Patients Need Palliative Care as Much
as Cancer Patients
'Palliative care has been markedly under-used in
heart failure patients'
May 2, 2008 - People suffering from heart failure
endure symptoms, depression and need for spiritual support even more
severe than many of those suffering from advanced lung and pancreatic
cancer. Researchers say, however, these heart outpatients do not receive
equal concern and palliative care, and suggest it is time for a change.
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The report was presented at the American Heart
Association’s 9th Scientific Forum on Quality of Care and Outcomes
Research in Cardiovascular Disease and Stroke.
In their study, researchers from the University of
Colorado Denver School of Medicine also found that heart failure
patients with “poor” health status had greater symptoms and depression
and worse spiritual well-being than patients with advanced cancer.
The study compared 60 ambulatory heart failure
patients to 30 outpatients with advanced cancer being treated at Johns
Hopkins Hospital or Bayview Medical Center in Baltimore, Md. Those with
heart failure were outpatients, able to attend clinics and complete
questionnaires.
“There has been a lot of attention on improving the
quality of life and reducing suffering in cancer patients, but less on
patients with heart failure,” said David Bekelman, M.D., M.P.H., lead
author of the study. “Heart failure patients, particularly those with
poor health status, need the option of palliative care.”
Palliative care — care devoted to improving quality
of life and reducing suffering for patients with severe,
life-threatening illnesses and their families — is often used to help
advanced cancer patients.
Disease and death in chronic heart failure is high,
with the average survival of 1.6 years after a hospitalization. Heart
failure can have a major impact on a patient’s health status,
contributing to symptom burden, functional limitations, and in turn
depression, researchers said.
Researchers used the Memorial Symptom Assessment
Scale-Short Form to assess symptom burden; Geriatric Depression
Scale-Short Form for depression; Functional Assessment of Chronic
Illness Therapy-Spiritual Well-Being Scale for spiritual well-being; and
Kansas City Cardiomyopathy Questionnaire (KCCQ) for heart failure
severity.
Researchers found no statistical difference among
heart failure and cancer patients in measured physical symptoms,
depression scores and spiritual well-being. The study also compared the
same three parameters in heart failure patients with different ejection
fractions. Ejection fraction is a common measure of heart function.
Symptoms, depression and spiritual well-being were similar among heart
failure patients with ejection fractions above and below 30, showing
that while ejection fraction is a useful marker of heart failure
severity, it did not correlate with quality of life domains.
However, heart failure patients with worse health
status had a statistically greater number of physical symptoms (13.2
versus 8.6), higher depression scores (6.7 vs. 3.2) and lower spiritual
well-being (29 vs. 38.9) than the cancer patients — even after adjusting
for age, gender, marital status, education and income.
“The main finding was that patients with heart
failure have a similar burden of symptoms, depression and low levels of
spiritual well-being as advanced cancer patients,” said Bekelman,
assistant professor of medicine at the University of Colorado Denver
School of Medicine. “Advanced cancer patients are often quite sick and
need care focused on quality of life in addition to care focused on the
disease. We don’t usually think about providing similar care to
outpatients with heart failure.”
“Patients with heart failure who are not at the end
of life have palliative care needs,” Bekelman said. “But palliative care
has been markedly under-used in heart failure patients.”
When researchers compared heart failure patients
who had scores 50 or lower on the 100-point KCCQ (indicating poor health
status) to the cancer patients, the heart failure patients had a
statistically higher rate of symptoms and depression and a worse score
on spiritual well-being.
Little research-based evidence exists to guide
practitioners on which heart failure patients may benefit from
palliative care. The study showed that KCCQ scores of under 50 can help
identify patients who may benefit, Bekelman said.
“Heart failure patients’ symptoms such as shortness
of breath, fatigue, pain, constipation and dry mouth can be improved
with medical management,” he said. “Depression, which is common in
patients with heart failure, can be treated with medications and
counseling. Persistent symptoms can also contribute to depression, and
treating persistent symptoms can help improve mood.”
“Clinicians should not underestimate the importance
of using supportive communication and empathy with heart failure
patients to reduce both symptoms and depression,” Bekelman said.
It may be helpful for physicians to get a chaplain
or clergy member involved in the patient’s care to improve spiritual
well-being, Bekelman said, noting that other approaches used to improve
spiritual well-being in cancer patients, such as dignity therapy and
meaning-centered psychotherapy, should also be evaluated for heart
failure patients.
Editor's Notes:
Co-authors are: John S. Rumsfeld, M.D., Ph.D.;
Edward P. Havranek, M.D.; Traci E. Yamashita, M.S.; Evelyn Hunt, M.D.;
and Jean S. Kutner, M.D., M.S.P.H.
The study was funded by the Johns Hopkins Center
for Complementary and Alternative Medicine; the Johns Hopkins General
Clinical Research Center; and the National Center for Complimentary and
Alternative Medicine, NIH.
Statements and conclusions of abstract authors
presented at American Heart Association/American Stroke Association
scientific meetings are solely those of the abstract authors and do not
necessarily reflect association policy or position. The association
makes no representation or warranty as to their accuracy or reliability.
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