Chronic Disease

Physicians could improve end-of-life communication and decision-making for elderly patients with advanced heart failure

Caring for elderly persons with advanced heart failure (HF) is challenging. HF has a high mortality rate, but prognosis is often difficult to gauge, especially when complicated by the presence of multiple chronic illnesses that affect most elderly patients. Given these challenges, there are substantial opportunities for improving physician skills in patient-centered counseling, palliative care, and care decisionmaking conclude researchers at the Medical University of South Carolina. They surveyed 89 internal medicine and geriatric faculty and resident physicians about perceived skills and barriers to HF care, adherence to HF guidelines, and understanding of patient prognosis. Case studies were used to explore their practice approaches.

Physicians scored well on clinical knowledge of HF. They scored lower, however, on population-specific issues, such as median survival for female patients with HF. Among 17 self-assessed skills, physicians reported lowest ratings for addressing cultural and racial differences in end-of-life care and knowledge of how to help patients and families cope with fears, guilt, and grief.

Physicians reported highest on skills related to management of physical symptoms such as shortness of breath or respiratory distress; clinical management (organ evaluation, laboratory tests); initiation and documentation of discussion about the patient's end-of-life issues; and patient instructions concerning sodium and fluid intake and diuretic titration. Physicians rated themselves as "less than moderately prepared" in management of patient anxiety and depression; management of emotional suffering at the end of life; and patient/family communication related to issues such as prognosis, spiritual and psychosocial needs, and dying of HF; assessment of patients for referral to hospice; and use of a health care-team approach to care. Physicians saw medication noncompliance, lack of patient motivation to make lifestyle changes, and lack of insurance coverage for medications as significant barriers to care.

The study was supported by the Agency for Healthcare Research and Quality (HS10871).

See "Advanced heart failure: Prognosis, uncertainty, and decision making," by Jane Zapka, ScD., William P. Moran, M.D., Sarah J. Goodlin, M.D., and Kelly Knott, M.S., in the September-October 2007 Chronic Heart Failure 13, p. 268-274.

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