Feb. 15, 2008 Less than one fourth of physicians specializing in geriatrics, internal or family medicine or cardiology believe they can accurately predict the whether patients with heart failure are at risk of dying, new Saint Louis University research found.
The ability to determine whether patients are within six months of death is crucial to clinical care, impacting key patient-care decisions such as therapeutic approaches and referral for palliative care, which is focused on symptom relief rather than cure.
"Our findings are important not only in light of the increasing prevalence of heart failure in the United States but because the data show that there are considerable gaps in knowledge regarding end-stage heart failure that ultimately affect a patient's experience with their illness," says Paul Hauptman, M.D., professor of internal medicine at Saint Louis University School of Medicine and the study's lead author.
"Palliative measures can be adopted to ease the pain of patients with terminal heart failure, but these measures are not always utilized because of uncertainty about the patient's prognosis. Unlike cancer, for example, predicting death is not always clear with end-stage heart failure."
Across the board, physicians reported that they were unlikely to refer a patient with end-stage heart failure for hospice care. Their reluctance was due in part to uncertainty about timing and patient acceptance of the recommendation.
"This study will provide valuable insight into physicians' beliefs and biases in regards to end-stage heart failure," Hauptman said. "This area has not been previously explored, but is essential if we are to design interventions to help physicians select appropriate care options for their patients."
Among the three specialties studied, geriatricians were the most confident in predicting six-month mortality. Physicians who work in group practices, have large clinical volume, and those who had formal training in palliative care, express a willingness to objectively measure functional status and refer patients to hospice care were more confident in predicting six-month mortality.
End-stage heart failure or terminal heart failure is characterized by fatigue, shortness of breath, progressive muscle wasting and inability to exercise despite optimal medical and surgical therapy.
The study also provides insight into existing knowledge gaps regarding appropriate monitoring of patients and selection of management options.
Very few physicians, for example, ask patients to complete quality-of-life questionnaires or objectively measure functional status, two key factors that help determine a patient's status.
"This failure suggests that physicians may not appropriately recognize the impact of heart failure on their patients," Hauptman says.
The study also found that doctors rarely discuss deactivating implantable cardioverter defibrillators with very sick heart failure patients and their families.
Implantable cardioverter defibrillators detect cardiac arrhythmias and correct the condition by delivering an electrical shock. For people who are at risk of sudden cardiac death, this device can be a life saver.
For patients with advanced heart disease, though, an implantable cardioverter-defibrillator can cause unnecessary discomfort and stress because it can continue to deliver shocks as the patient is dying. While the majority of physicians surveyed agreed that deactivating the device is appropriate with end-stage heart failure, very few heed this advice.
Using a random stratified survey, 1,450 physicians (600 cardiologists, 300 geriatricians and 300 internal and family medicine doctors), were polled for the study. Approximately 60 percent of physicians polled responded to the survey.
Co-authors of the study include Jason Swindle, M.P.H., Zainal Hussain, M.D., and Thomas Burroughs, Ph.D. of Saint Louis University and Lois Biener Ph.D. of the University of Massachusetts-Boston.
The study was funded by a grant from the National Institute on Aging of the National Institute for Health. The findings were published in the February 2008 issue of The American Journal of Medicine.
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