Knowledge and Barriers to Palliative Care Screening and Referral for Patients with Advanced Heart Failure

Purpose: With heart disease as the leading cause of morbidity and the death rate of heart-related chronic diseases (including heart failure) increasing more each year in southern Nevada, the purpose of this quality improvement project is to assess if the healthcare providers from an outpatient clinic in southern Nevada have knowledge and/or barriers to screening or referral of patients with advanced heart failure (HF) to palliative care (PC). Background: The prevalence of HF is expected to increase by 46% from 2012 to 2030 and an estimated 5% of 23 million people have advanced HF (Mcllvennan & Allen, 2016; Ghashghaei et al., 2016). Because of the limited curative options for patients with advanced HF (e.g., heart transplant or mechanical ventricular assist devices), knowledge and referral to PC would provide relief of symptom burden including pain, depression and fatigue, and improve quality of life (QoL) for these patients and their families. Methods: Healthcare providers of the Healthcare Partners Nevada Cardiology were recruited as participants to respond to a survey regarding their knowledge and practice of incorporating PC concepts and to identify their perceived barriers for referral or consultation to PC services. Paper surveys were used to collect data and descriptive statistics was performed to analyze the data. Results: Of the 14 respondents, 100% were male and Doctors of Medicine, 57.1% were between the ages of 35 and 49 years old, 57.1% had more than 10 years of experience as a healthcare provider and 35.7% provides care to an estimated 30 to 50 patients with advanced HF in the outpatient setting. Majority of the respondents practice discussing with their patients about avoiding aggressive procedures that are associated with significant risks such as intubation or performing CPR (100%); discontinuing medications (e.g., ACEIs and beta-blockers) that can cause hypotension and fatigue; using low dose opioids and nitrates to provide symptom relief for dyspnea (50%); prescribing appropriate antidepressants to control depression associated with advanced HF (57.1%); and discussion of deactivation of devices such as ICDs (64.3%). Majority of the respondents perceived that major barriers for screening and referral for PC include the lack of coordination or communication between medical disciplines (e.g., general medicine, cardiology, palliative care, nursing staff, social worker medical disciplines (e.g., general medicine, cardiology, palliative care, nursing staff, social worker) (50%); fear of the patient’s reaction towards direction of care when referred to PC (50%); and family’s reluctance about PC for the patient (42.9%). Conclusion: This study demonstrates current knowledge, practice and perceived barriers to screening and referral of patients with advanced HF to PC services. The lack of coordination and communication between care teams and the fear of perceived abandonment and reluctance by the patient and family were identified as barriers to PC consult. Data and findings from this project may guide future research in the implementation of evidence-based guidelines and strategies that could improve the utilization of PC services in the clinical area