Home-Based Palliative Care Improves Heart Failure Outcomes

A home-based palliative care program involving primary care physicians, cardiologists, and palliative care specialists is associated with a lower likelihood of dying in the hospital for patients with chronic heart failure, data indicate.

The program is also associated with fewer visits to the emergency department, more clinician home visits, shorter hospital stays, and more days spent at home.

Sarina R. Isenberg PhD

“The trajectory for cancer at the end of life is very much a rapid downward slope, but for those living with heart failure, it fluctuates,” senior author Sarina R. Isenberg, PhD, Bruyère chair in mixed methods palliative care research at Bruyère Research Institute and the University of Ottawa, Ottawa, Ontario, Canada, told Medscape Medical News. “There are really bad days and there are good days, and that makes it more complicated to deliver palliative care. Hopefully, these findings will encourage others to provide this care or to test models that provide this care,” Isenberg said.

The findings were published Sept. 26 in the Canadian Medical Association Journal.

Less Costly Approach?  

The collaborative home-based program was started in 2013 by Leah Steinberg, MD, a palliative care physician at Sinai Health System, Toronto, and Susanna Mak, MD, PhD, a cardiologist in the department of medicine at the University of Toronto, Toronto, Ontario, Canada.

In the current study, the researchers conducted a retrospective chart review of 245 patients with heart failure who were enrolled in the program and who died between April 2013 and December 2019. The patients were matched with a cohort of 1172 patients with acute heart failure who received usual care, which consisted of home visits by nurses, personal support workers, and occupational therapists. Such care is available to all people living in Ontario.

The patients who received home-based palliative care had a 48% lower associated risk of dying in hospital (relative risk [RR], 52%), compared with patients who received usual care.

Of the patients who received home-based palliative care, 101 (41.2%) died in the hospital. Of those who received usual care, 917 (78.2%) died in the hospital.

In addition, patients who received home-based palliative care spent more time at home (median 29 days) than those who received usual care (median 20 days).

Risk for hospital admission also was lower among patients receiving home-based palliative care (RR, 64%), as was use of the emergency department (RR, 67%) and admission to the intensive care unit (RR, 57%).

Providing palliative care at home to patients with chronic heart failure may also be less costly to the healthcare system, said Isenberg.

“We didn’t test the cost of the program in this study, but that’s certainly something we want to explore in the future,” she added. The program does require resources, since it involves palliative care physicians who provide care in the home. But the most expensive care one can receive in Ontario’s healthcare system is in hospital, said Isenberg. “I think it is relatively safe to assume that when you weigh the costs of providing this care in the home vs the cost of acute care in hospital, it would be less expensive, although I can’t say that for sure, because that is not what we tested.”

Access for Everyone

It is time for home-based palliative care in Canada to be an option for everyone, wrote Andreas Laupacis, MD, MSc, senior deputy editor of CMAJ, in an accompanying editorial. Laupacis practiced as a palliative care physician at St. Michael’s Hospital in Toronto for the last 10 years of his clinical career.

Commenting on the findings for Medscape, he said that the results of this research resonated with him, in part because the study focused on caring for people with heart failure, not cancer.

Dr Andreas Laupacis

“Palliative care is all about improving the quality of life of people whose life expectancies are clearly limited. Traditionally, it has been focused on cancer, but many people with other severe chronic diseases, such as severe heart failure, severe chronic obstructive lung disease, severe emphysema, have a prognosis as bad as people with advanced cancer, but we don’t think as much about providing palliative care to them,” said Laupacis.

“This research says we can really help people who have end-stage heart failure by giving them a program that integrates family physicians, palliative care physicians, and cardiologists, and make it a home-based program,” he added. “It didn’t require any fancy new expensive technology” for many more people to die at home.

What the program did require, however, was close cooperation among the different specialties to work together, including the family doctor, the palliative care doctor, and the cardiologist, to manage patients at home.

“The key ingredients of good palliative care include having a nurse or doctor who is comfortable talking about the fact that the end of life is near, asking what the patient’s priorities and goals are, and this requires certain skills,” said Laupacis. The program thus requires clinical training.

Moreover, for people with heart failure, managing symptoms is key. “People with heart failure can suddenly get very short of breath, and when this happens, they will go to the hospital, because gasping for breath is one of the worst things that can happen. You need to have clinicians who are expert at managing shortness of breath and symptoms of heart failure without having to admit the patients all the time,” said Laupacis.

Palliative care at home also requires clinicians to be available to attend to patients 24 hours a day. “If someone gets acutely short of breath at 2 in the morning, it’s no good to tell the patient, ‘We’ll talk to you at 9 in the morning or when the clinic opens.’ You have to be able to coach the patient and the family through what meds to take, or to actually have someone go into the home. This is the kind of care that this program provided, and it was effective,” said Laupacis.

He added that he would like to see people with heart failure who live in a long-term care facility have access to the same palliative care service. “They excluded these patients from their study, but I think the results apply to long-term care. We’ve got to find a way, whether it’s having the patient’s original family doctor, or the family doctors and the nurses who are caring for these patients, provide this care so these patients don’t always have to go to the emergency department when they get short of breath in the middle of the night.”

The study was supported by a grant from the Global Institute of Psychosocial, Palliative & End-of-Life Care, the University of Toronto Division of Palliative Medicine and the Dalla Lana School of Public Health, the Bruyère Centre for Individualized Health, the Canadian Institutes of Health Research, and a donation from the Grafstein family to the Sinai Research Foundation. Isenberg and Laupacis reported no relevant financial relationships.

CMAJ. Published online Sept. 26, 2022. Full text.

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