Palliative Care in Heart Failure

Heart failure currently affects over 5 million Americans. Symptomatic patients have a median
life expectancy of less than 5 years and those with late-stage disease have 1-year mortality
rates approaching 90%. Despite recent therapeutic advances that reduce morbidity and
mortality, heart failure continues to cause enormous suffering. Patients with advanced
disease suffer not only from the physical effects of the illness, but also from psychosocial
and spiritual distress. In addition, heart failure costs more than $34 billion annually to
the healthcare system and a disproportionate amount is spent on patients in the last 6
months of life when some of the treatments may be either ineffective or undesired. Selected
patients are candidates for aggressive treatments such as cardiac transplantation or
mechanical circulatory support, but the application of these therapies to the broader heart
failure population is limited by resource scarcity and their untested usefulness in older
patients with significant co-morbidities.

The progressive nature of heart failure coupled with high mortality rates and poor quality
of life mandates greater attention to palliative care as a routine component of heart
failure management. Patients with advanced heart failure, particularly the elderly and those
with significant co-morbidities, ought to be ideal candidates for palliative care that aims
to relieve suffering and improve quality of life. Yet, several challenges have limited the
use of palliative care approaches in heart failure:

1. Determination of Prognosis. Several validated multivariable models have been developed
to predict survival, yet considerable uncertainty remains and physicians are frequently
unsure whether they are caring for a patient near or far from the end of life. Patients
have an even harder time and are typically overly optimistic about their survival
relative to that observed or predicted by multivariable models.

2. Timing of Implementation. This prognostic uncertainty and the highly variable disease
trajectories of individual patients with heart failure pose a challenge as to when
palliative care interventions ought to be implemented. The most appropriate time to
introduce palliative care concepts, particularly with regard to end-of-life planning,
remains undefined and is linked to patient prognosis and preferences.

3. Untested Interventions. There is limited evidence from randomized controlled trials of
palliative care interventions in heart failure and the majority focus on resuscitation
preferences. Further, practice guidelines from major cardiovascular societies are
limited on this subject.

4. Lack of Palliative Care Training of Cardiovascular Specialists . The education of
cardiovascular specialists typically excludes formalized training in the principles and
practice of palliative care.

Given these limitations, a properly designed and powered study is required to determine
whether a multidimensional palliative care intervention in addition to usual care improves
health-related outcomes relative to usual care alone in advanced heart failure patients with
a highly probable short-term mortality.

PAL-HF is prospective, controlled, unblinded, 2-arm, single-center clinical trial of
approximately 200 advanced heart failure patients with >50% predicted 6-month mortality
randomized to usual, state of the art heart failure care or usual care combined with the
PAL-HF intervention.

Patients will be randomized in a 1:1 ratio to either of 2 treatment regimens:

- Usual advanced HF care

- Usual advanced HF care + interdisciplinary palliative care focused on symptom relief;
assessment and management of anxiety, depression, and spiritual concerns; as well as
advance care planning that includes definition of care goals, resuscitation
preferences, and participation in the Outlook intervention.

The primary endpoint will be health-related quality of life as measured by the Kansas City
Cardiomyopathy Questionnaire (KCCQ) and the Functional Assessment of Chronic Illness Therapy
with Palliative Care Subscale (FACIT-Pal) score at 6 months

The duration of the intervention in PAL-HF is 6 months, but patients in both groups will be
followed until death, or the end of the study.

The study will be completed in both arms of the trial with a post-death interview with the
caregiver.

Inclusion Criteria:

- Duke University Hospital inpatient adults

- Hospitalization for acute decompensated heart failure

- Dyspnea (shortness of breath) at rest or minimal exertion plus at least 1 sign of
volume overload

- Previous heart failure hospitalization within the past 1 year

- At significant risk of dying from heart failure in the next 6 months

- Anticipated discharge from hospital with anticipated ability to return to outpatient
follow-up appointments

Exclusion Criteria:

- Are not an inpatient at Duke University Hospital

- Acute coronary syndrome within 30 days

- Cardiac resynchronization therapy (CRT) within the past 3 months or current plan to
implant CRT device

- Active myocarditis, constrictive pericarditis

- Severe stenotic valvular disease amenable to surgical intervention

- Anticipated heart transplant or ventricular assist device within 6 months

- Renal replacement therapy

- Non-cardiac terminal illness

- Women who are pregnant or planning to become pregnant

- Inability to comply with study protocol

- Are not proficient in the English language