Palliative cardiovascular care: The right patient at the right time

Abstract In the increasingly complex world of modern medicine, relationship‐centered, team‐based care is important in geriatric cardiology. Palliative cardiovascular care plays a central role in defining the scope and timing of medical therapies and in coordinating symptom‐targeted care in line with patient wishes, values, and preferences. Palliative care addresses advance care planning, symptom relief and caregiver/family support and seeks to ameliorate all forms of suffering, including physical, psychological, and spiritual. Although palliative care grew out of the hospice movement and has traditionally been associated with care at the end of life, the current model acknowledges that palliative care can be delivered concurrent with invasive, life‐prolonging interventions. As the population ages, patients with serious cardiovascular disease increasingly suffer from noncardiac, multimorbid conditions and become eligible for interventions that palliate symptoms but also prolong life. Management of implanted cardiac support devices at the end of life, whether rhythm management devices or mechanical circulatory support devices, can involve a host of complexities in decisions to deactivate, timing of deactivation and even the mechanics of deactivation. Studies on palliative care interventions have demonstrated clear improvements in quality of life and are more mixed on life prolongation and cost savings. There is and will remain a dearth of clinicians with specialist palliative care training. Therefore, cardiovascular clinicians have a role to play in provision of practical, “primary” palliative care.


| HISTORY AND INITIAL CONCEPTION
"Palliative" comes from the Greek word "pallium," a cloak-like garment that was worn by the Greeks outside of common work-life and was considered a form of protection. In the 15th century, English speakers modified the subsequent Latin word "palliatus" to form "palliate." The term was advanced from the literal sense referring to the cloak one wears to the figurative means of protection and lessening the intensity of harm or disease.

| FROM DEFINITION TO CONCEPTUAL MODELS IN CARDIOVASCULAR MEDICINE
Since the mid-1990s, palliative care was recognized as a supportive approach to medical care that became considered by many to be appropriate for all patients with serious/life limiting disease. This response to the populations' increased triple burden of subacute, acute, and chronic disease was well demonstrated by the older and updated definitions of palliative care as proposed by the World Health Organization (WHO). In 1990, the WHO defined palliative care as "the active, total care of patients with progressive, far advanced disease and limited life expectancy whose disease is not responsive to curative treatment. It refers to the control of pain and other symptoms as well as treatment of social, psychological, and spiritual problems." 1 Nearly a decade later, the WHO updated its definition to "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" 2 ( Figure 1).
The modification of the WHO definition parallels the evolution of medical practice in response to technological advancements, payment models, and health system policies that informed the practice of palliative care. In line with its origins, palliative care initially focused exclusively on the care of patients nearing the end of life (ie, synonymous with hospice). This former conceptual model advocated life prolonging interventions until these interventions were no longer effective, then the patient was turned over to the care of hospice providers, with a stark transition point ( Figure 2A). Medicare/Medicaid funding for hospice services promoted (and still promotes) this conceptual model by requiring a <6 month prognosis for hospice entry and providing limited daily funding that often fails to cover symptom-treating therapies like dobutamine. 3 The contemporary conception of palliative care encompasses medical decision-making, symptom relief, caregiver considerations, and restored quality of life on a much broader scale. There has been a recognition that the medical community must be better prepared to respond to all forms of suffering as important but distinct subjective, personal experiences that include pain, dyspnea, nausea, and so forth but also to feelings of guilt, depression, fear of dying, spiritual uncertainty, and a reflection of the attitudes of others. 4 Moreover, all agree that compassionate responses to suffering must be personalized, con-  who were pacemaker dependent and those who were not. 16 Another study found that a higher percentage of patients who had bradycardia therapies deactivated had died at 1 day and 1 week compared to patients with tachycardia therapies, but these differences were no longer significant by 1 month post deactivation. 17 Conversely, work by Dunlay and colleagues suggest that device deactivation precedes death for most patients with LVADs. 18 Teuteberg demonstrated that a large majority of patients undergoing LVAD deactivation die within 1 hour. 19 Work by Swetz and colleagues illustrate important decisions about LVAD deactivation that can be anticipated in "preparedness planning"-eliciting patient perspectives on LVAD deactivation in certain scenarios, including device failure, catastrophic complications of device therapy (such major stroke), inadequate quality of life and development of a debilitating comorbidity. 20 Swetz and colleagues also prepared a checklist to guide deactivation ( Figure 3).
Decisions about deactivation can be as complicated as deactiva- palliative medicine clinicians viewed deactivation as permissible whenever burdens of the devices were seen to outweigh benefits. 24

| PALLIATIVE CARE IN CARDIOLOGY: OUTCOMES
As evidence-based cardiovascular science has advanced so too has evidence-based evaluation of palliative medicine in the care of patients with cardiovascular disease in the inpatient, outpatient, and home-based settings (Table S1). 25 Most of the randomized controlled trials and observational studies examining the impact of palliative care on patient outcomes have focused on patients older than 67 years of age who could be candidates for advanced heart failure therapies.
Based on predictive calculators, these patients are expected to have tom Assessment Scale. 26 Rogers and colleagues studied a nursepractitioner led palliative care intervention in heart failure patients who has been hospitalized within the previous year and had an estimated 6-month mortality risk of greater than 50%. 27 The 75 patients who were randomized to the palliative care intervention also had a 0.36, P = .03). They also found decreased caregiver-reported decisional conflict. 30

| WORKFORCE CHALLENGES IN CARDIC PALLIATIVE CARE
The rapid output of technologies and the dramatic growth of the older adult population will outpace the clinical and, probably, the funding infrastructure to support them. Relatively few workers now support over 57 million social-security eligible beneficiaries, compared to a much more favorable ratio in the past. 31 In light of the growing need for medical care for patients in older age brackets with cardiovascular disease who will face multimorbity and difficult decisions in an increasingly medically complex world, the need for palliative care will continue to expand. However, it is clear that there are not and will not be enough palliative medicine-trained clinicians to meet the needs.
Clinicians without specialist training in palliative medicine must provide at least basic palliative care. A distinction has been made between "primary palliative care" and "specialist palliative care" to attempt to define what elements of palliative care can be handled by non-specialists, and which require referral to clinicians with specialty training (Figure 4). 32 These definitions will need to be refined and expanded in the cardiovascular context. Medical educators, especially in cardiology, must continue to explore ways in which to help the next generation of cardiovascular clinicians be comfortable and competent in addressing these challenges at the patient's bedside. Widespread adoption of primarily palliative care practices will require education of care teams patients and families/friends, and healthcare policy makers. Educational points of emphasis for each group are detailed in In the current complex hospital environment, it is easy for patients to be led to perceive that these are mutually exclusive. Clinicians should introduce the notion of palliative care and its components early on in the disease process, especially in relation to eventual device deactivation. This introduction can facilitate exploration of patients' values and goals of care (Table S2) The practical aspects of palliative care also include guiding patients to appoint one or more surrogate decision-makers who can speak for the patient in the event the patient loses decision-making capacity (Table S2). These surrogates must be made aware of the patient's preferences regarding interventions the patient would choose. A living will can help to guide surrogate decision-makers in these instances, and there are many tools that can be used to facilitate communication of patient goals, values, and preferences to their surrogates. These tools include documents such as "The Five Wishes," online questionnaires and even card games. 33 Even with adequate preparation, decision-making about withholding and withdrawing therapies, including device deactivation, can become complicated, involving strong emotions among friends and family. Clinicians should be prepared to address feelings, hopes and even conflict, and should seek help as needed from palliative medicine specialists, ethics consultants, and spiritual care providers. 34

| CONCLUSIONS
The practice of palliative care has evolved over time, but the fundamentals of advance care planning, symptom treatment and caregiver support through a relationship-centered, holistic, team-based approach remain.

CONFLICT OF INTEREST
The authors report no conflicts of interest related to this project.
F I G U R E 5 Educational approaches to facilitating palliative care in patients with cardiovascular disease. PC, palliative care; GOC, goals of care. *first area of emphasis in primary palliative care. **second area of emphasis in primary palliative care. ***third area of emphasis in primary palliative care