Laura P Gelfman1,2, Rebecca L Sudore3,4,5, Harriet Mather1, Karen McKendrick1, Mathew D Hutchinson6, Rachel J Lampert7, Hannah I Lipman8,9, Daniel D Matlock10,11, Keith M Swetz12, Sean P Pinney13, R Sean Morrison1,2, Nathan E Goldstein1,2. 1. Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY. 2. Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.). 3. Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco. 4. Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco. 5. San Francisco Veterans Affairs Health Care System, CA (R.L.S.). 6. Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ (M.D.H.). 7. Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT (R.J.L.). 8. Hackensack University Medical Center, Hackensack, NJ (H.I.L.). 9. Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (H.I.L.). 10. Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (D.D.M.). 11. VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO (D.D.M.). 12. Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama, Birmingham, AL (K.M.S.). 13. Division of Cardiology, Samuel Bronfman Department of Medicine (S.P.P.), Icahn School of Medicine at Mount Sinai, New York, NY.
Abstract
BACKGROUND: Prognostic awareness (PA)-the understanding of limited life expectancy-is critical for effective goals of care discussions (GOCD) in which patients discuss their goals and values in the context of their illness. Yet little is known about PA and GOCD in patients with advanced heart failure (HF). This study aims to determine the prevalence of PA among patients with advanced HF and patient characteristics associated with PA and GOCD. METHODS: We assessed the prevalence of self-reported PA and GOCD using data from a multisite communication intervention trial among patients with advanced HF with an implantable cardiac defibrillator at high risk of death. RESULTS: Of 377 patients (mean age 62 years, 30% female, 42% nonwhite), 78% had PA. Increasing age was a negative predictor of PA (odds ratio, 0.95 [95% CI, 0.92-0.97]; P<0.01). No other patient characteristics were associated with PA. Of those with PA, 26% had a GOCD. Higher comorbidities and prior advance directives were associated with GOCD but were of only borderline statistical significance in a fully adjusted model. Symptom severity (odds ratio, 1.77 [95% CI, 1.19-2.64]; P=0.005) remained a robust and statistically significant positive predictor of having a GOCD in the fully adjusted model. CONCLUSIONS: In a sample of patients with advanced HF, the frequency of PA was high, but fewer patients with PA discussed their end-of-life care preferences with their physician. Improved efforts are needed to ensure all patients with advanced HF have an opportunity to have GOCD with their doctors. Clinicians may need to target older patients with HF and continue to focus on those with signs of worsening illness (higher symptoms). Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01459744.
BACKGROUND: Prognostic awareness (PA)-the understanding of limited life expectancy-is critical for effective goals of care discussions (GOCD) in which patients discuss their goals and values in the context of their illness. Yet little is known about PA and GOCD in patients with advanced heart failure (HF). This study aims to determine the prevalence of PA among patients with advanced HF and patient characteristics associated with PA and GOCD. METHODS: We assessed the prevalence of self-reported PA and GOCD using data from a multisite communication intervention trial among patients with advanced HF with an implantable cardiac defibrillator at high risk of death. RESULTS: Of 377 patients (mean age 62 years, 30% female, 42% nonwhite), 78% had PA. Increasing age was a negative predictor of PA (odds ratio, 0.95 [95% CI, 0.92-0.97]; P<0.01). No other patient characteristics were associated with PA. Of those with PA, 26% had a GOCD. Higher comorbidities and prior advance directives were associated with GOCD but were of only borderline statistical significance in a fully adjusted model. Symptom severity (odds ratio, 1.77 [95% CI, 1.19-2.64]; P=0.005) remained a robust and statistically significant positive predictor of having a GOCD in the fully adjusted model. CONCLUSIONS: In a sample of patients with advanced HF, the frequency of PA was high, but fewer patients with PA discussed their end-of-life care preferences with their physician. Improved efforts are needed to ensure all patients with advanced HF have an opportunity to have GOCD with their doctors. Clinicians may need to target older patients with HF and continue to focus on those with signs of worsening illness (higher symptoms). Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01459744.
Entities:
Keywords:
comorbidities; heart failure; life expectancy; prevalence; prognosis
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Authors: Laura P Gelfman; Harriet Mather; Karen McKendrick; Angela Y Wong; Mathew D Hutchinson; Rachel J Lampert; Hannah I Lipman; Daniel D Matlock; Keith M Swetz; Sean P Pinney; R Sean Morrison; Nathan E Goldstein Journal: J Card Fail Date: 2021-06 Impact factor: 6.592