Abstract and Introduction
Background Advances in heart failure (HF) treatments have prolonged survival, but more patients die of HF than of any type of cancer. Little is known about the current practice in end-of-life (EOL) care in HF.
Methods Two EOL cohorts (HF and cancer) were identified using Medicare data linked with pharmacy and cancer registry data. We assessed use of hospice, opiates, and acute care services (hospitalizations, emergency department [ED] visits, intensive care unit [ICU] admissions, and death in acute care). Time trends and predictors of use were assessed using multivariate regression including demographics and cardiovascular and noncardiovasuclar comorbidities.
Results Among 5,836 HF patients with median age of 85, 77% female and 4% black, 20% were referred to hospice compared to 51% of 7,565 cancer patients. A modest rise in hospice use over time was parallel in the 2 groups. Twenty-two percent of HF patients filled opiate prescriptions during 60 days before death compared to 46% of cancer patients. Use of acute care services in the 30 days before death was higher for HF (64% vs 39% for ED visits, 60% vs 45% for hospitalizations, and 19% vs 7% for ICU admission). More HF patients died during acute hospitalizations than cancer patients (39% vs 21%).
Conclusion Patients dying of HF were less likely to be supported by hospice and opiates but more likely to die in hospitals than patients with cancer. Our study suggests that opportunities may exist to improve hospice and opiate use in HF patients.
Advances in understanding the pathophysiology of heart failure (HF) introduced many effective therapies, which have prolonged survival in trial and community populations. As more patients survive into late-stage HF, they carry a longer burden of dyspnea, pain, and other end-of-life symptoms before death. Studies have shown that 20% to 78% of HF patients report pain and/or severe dyspnea that may be more severe closer to death. As for pain and dyspnea in late-stage diseases, opiates can be effective for HF as well as for cancer. Hospice has been associated with better patient satisfaction, better quality of death, and less emotional stress in patients and families. Although more patients die of HF than of any type of cancer, quality of care improvement for HF has focused largely on education and initiation of lifesaving treatments.
We previously reported that the number of HF hospitalization is an independent predictor of prognosis in HF patients, and the median survival decreased progressively with repeated hospitalizations (median survival <1.5 years after 2 hospitalizations and <1 year after 3 hospitalizations). These patients with repeated hospitalizations may be particularly appropriate for studying the use of hospice and opiates.
The purposes of the current study were to (1) describe the use of hospice, opiates, and acute care services at the end-of-life in HF patients with repeated hospitalizations and (2) compare HF and cancer patients with respect to their use of these medications and services.