The Role of Primary Palliative Care in Cardiovascular Medicine: A Guide

 Introduction

Primary palliative care is a core aspect of cardiovascular (CV) medicine, enhancing patients' quality of life by addressing symptom burdens and supporting shared decision-making. It is integral to managing patients with serious illnesses, such as heart failure (HF) and other cardiovascular diseases.

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Providing Supportive Care for CV Patients

A 75-year-old woman with heart failure and reduced ejection fraction illustrates the challenges in symptom management and the pivotal role of palliative care in improving her quality of life.
Her declining independence, worsened by edema, dyspnea, fatigue, and low mood, highlights the need for comprehensive care that addresses physical, emotional, and social well-being.

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Primary Palliative Care Principles

1. Definition and Impact:

   • Palliative care improves patients' quality of life, reduces depression and anxiety, and ensures alignment of care with patients' values and goals.
   • It is primarily delivered by the patient's main cardiovascular care team.

2. Guideline Recommendations:

   • The ACC/AHA/HFSA Heart Failure Guideline recommends employing palliative care skills to:
     • Communicate prognosis.
     • Clarify goals of care through shared decision-making.
     • Manage cardiovascular symptoms.
     • Support caregivers.

3. Scope of Care:

   • Conditions such as HF, chronic ischemia, valvular disease, and pulmonary hypertension benefit from symptom management integrated into palliative care.

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Symptom Management and Advance Care Planning (ACP)

1. Symptom Management:

   • Conduct comprehensive reviews to address angina, hypervolemia, and exercise tolerance.
   • Utilize guideline-directed medical therapy, diuretics, and antianginal drugs to relieve symptoms.
   • Address fatigue and dyspnea through aerobic exercise and referral to physical therapy.

2. Mental Health Care:

   • Treat anxiety and depression or refer patients to mental health specialists.

3. Advance Care Planning (ACP):

   • Discuss disease progression and care preferences.
   • Identify a surrogate decision-maker and reassess care plans over time.
   • Address caregiver support needs through referrals to social workers and community resources.

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Specialized Care and Ethical Considerations

1. Specialty Palliative Care Referrals:

   • Necessary for complex cases such as pain management, cachexia, or end-of-life care.
   • Avoid potentially harmful medications like NSAIDs and gabapentin.

2. Device Deactivation:

   • ICD deactivation discussions should align with patients' goals to avoid unnecessary distress.
   • Decisions about pacemaker or LVAD deactivation require multidisciplinary collaboration due to ethical complexities.

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Hospice Care for CV Patients

1. Definition:

   • Hospice focuses on comfort and symptom control for patients with a prognosis of six months or less.
   • Ideal for patients prioritizing symptom relief over hospitalization.

2. Levels of Care:

   • Hospice provides four levels of care, offering flexibility to meet patients' evolving needs.

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Take-Home Points

• Primary palliative care is integral to cardiovascular medicine, addressing physical and emotional symptom burdens.
• Shared decision-making and ACP are key to aligning care with patients' goals and values.
• Referral to specialty palliative care is crucial for managing advanced symptoms or complex cases.
• Hospice care provides a compassionate option for end-of-life support.