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.
Overcoming barriers
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
None declared.
Editors’ note
See also the article by Ismail et al. in this issue.
References
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