We know that people with advanced heart failure have unmet supportive and palliative care needs, and the burden of these concerns is comparable with people with cancer.1–2 Palliative care services in the UK and elsewhere have grown up around oncology services. Randomised controlled trials (RCTs) have confirmed that early integration of palliative care, alongside cancer treatment, improves patient outcomes.3–7 In contrast, experience of and the evidence base for integration of palliative care alongside heart failure treatment has been slow to develop. However, this is changing. A pilot RCT comparing the addition of a palliative care intervention to usual care for people with advanced heart failure has reported benefit in health-related quality of life, symptom control and health service utilisation (reduced hospital admission)8 and several phase three RCTs are ongoing.
The misunderstanding that palliative care is only for those in the last few days or weeks of life, only to be implemented once all other options are gone and irreversible deterioration is certain, forms a major barrier to access to palliative care. Attempts to identify a prognostic tool to identify when palliative care should be employed have failed, and the consensus is that a problem-based approach is more fit for purpose.11–12 Such a model would enable the “concerns of today” facing the patient to be addressed in the context of the management options appropriate at their stage of disease; a discussion which may lead on to include appropriate options for the future and involve other professionals such as palliative care services if needed. Therefore it is imperative that the cardiology team is able to assess and manage symptom and quality of life issues, and have the expert communication skills required for complex and difficult conversations regarding device and other therapies, ceilings of medical care and cardiopulmonary resuscitation, as heart failure advances. With these competences, the majority of patients’ supportive and palliative care needs will be addressed by their cardiac or primary care team, and specialist palliative care services only needed for complex or persistent problems.
In this light, the article by Ismail and colleagues13 in this issue, is concerning. Despite changes to the UK cardiology specialist curriculum and a recognition that the care of people with advanced disease is important, these trainees report a lack of expertise. A systematic reluctance to recognise the dying, poor communication, and inadequate engagement with and from palliative care teams is described by some. Various solutions are suggested by the authors including joint teaching for cardiology and palliative care trainees and the introduction of a fellowship scheme. However, cardiology trainees also need their seniors to be good role models; training tools such as case-based discussion and mini-clinical examinations will be less effective if the clinical/educational supervisors are not confident and competent in basic palliative care skills themselves, or do not see the importance of this area. Lessons could be learned from the field of oncology where providing advanced communication skills for consultants as well as trainees was considered a crucial part of improving services.14
There is an urgent need to overcome the deadlock preventing access to palliative care. Clinicians caring for people with advanced heart failure need to be equipped with the skills they require to assess and address the palliative care concerns of this group of patients.
Conflict of interest
See also the article by Ismail et al. in this issue.
1. Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. Br Med J 2002;325:929. http://dx.doi.org/10.1136/bmj.325.7370.929
2. Pantilat SZ, O’Riordan DL, Dibble SL, Landefeld CS. Longitudinal assessment of symptom severity among hospitalized elders diagnosed with cancer, heart failure, and chronic obstructive pulmonary disease. J Hosp Med 2012;7:567−72. http://dx.doi.org/10.1002/jhm.1925
3. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. J Am Med Assoc 2009;302:741−9. http://dx.doi.org/10.1001/jama.2009.1198
4. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721−30. http://dx.doi.org/10.1016/S0140-6736(13)62416-2
5. Farquhar MC, Prevost A, McCrone P, et al. Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Med 2014;12:194. http://dx.doi.org/10.1186/s12916-014-0194-2
6. Higginson IJ, Bausewein C, Reilly C, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med 2014;2:979–87. http://dx.doi.org/10.1016/S2213-2600(14)70226-7
7. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733−42. http://dx.doi.org/10.1056/NEJMoa1000678
8. Brannstrom M, Boman K. Effects of person-centred and integrated chronic heart failure and palliative home care. PREFER: a randomized controlled study. Eur J Heart Fail 2014;16:1142–51. http://dx.doi.org/10.1002/ejhf.151
9. Gadoud A, Kane E, Macleod U, Ansell P, Oliver S, Johnson M. Palliative Care among heart failure patients in primary care: a comparison to cancer patients using English family practice data. PLoS One 2014;9:e113188. http://dx.doi.org/10.1371/journal.pone.0113188
10. Unroe KT, Greiner MA, Hernandez AF, et al. Resource use in the last 6 months of life among medicare beneficiaries with heart failure, 2000−2007. Arch Intern Med 2011;171:196−203. http://dx.doi.org/10.1001/archinternmed.2010.371
11. Haga K, Murray S, Reid J, et al. Identifying community based chronic heart failure patients in the last year of life: a comparison of the Gold Standards Framework Prognostic Indicator Guide and the Seattle Heart Failure Model. Heart 2012;98:579−83. http://dx.doi.org/10.1136/heartjnl-2011-301021
12. Hogg KJ, Jenkins SM. Prognostication or identification of palliative needs in advanced heart failure: where should the focus lie? Heart 2012;98:523−4. http://dx.doi.org/10.1136/heartjnl-2012-301753
13. Ismail Y, Shorthose K, Nightingale AK. Trainee experiences of delivering end-of-life care in heart failure: key findings of a national survey. Br J Cardiol 2015;22. http://dx.doi.org/10.5837/bjc.2015.008
14. Fallowfield L, Lipkin M, Hall A. Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom. J Clin Oncol 1998;16:1961−8.