Provision of palliative care for chronic heart failure inpatients: how much do we need?

BACKGROUND: Clinical guidance recommends early CHF palliative care intervention, but the magnitude of need is unknown and evidence-based referral criteria absent. This study aimed to: 1) Measure point prevalence of inpatients appropriate for palliative care. 2) Identify patient characteristics associated with palliative care appropriateness. 3) Propose evidence-based clinical referral criteria. METHODS: Census: all adult medical inpatient files in a UK tertiary teaching hospital were reviewed, identifying patients with CHF as a reason for current admission, using NYHA stage 3/4 classification, cross referenced with existing ECHO data. Each CHF patient was classified according to appropriateness for palliative care against a definition of unresolved pain and/or symptoms and/or psychosocial problems 7 days post admission. RESULTS: Three hundred and sixty-five patient files were reviewed, and 28 clinically identified as having CHF. Of these, 11 had confirmed unpreserved ejection fraction,16 of the 28 patients were appropriate for palliative care. Of the total inpatient population reviewed, 10 (2.7%) had both confirmed ejection fraction ≤45%, and were appropriate for palliative care. Of the 17 clinically-identified CHF patients with no recorded evidence of ejection fraction ≤45%, 5 (29.4%) were still appropriate for palliative care. A total of 4.4% of the reviewed inpatient population had a clinical diagnosis of CHF and were appropriate for palliative care. CONCLUSION: CHF patients with ejection fraction >45% also require palliative care. Our conservative criteria suggest a point prevalence of 2.7% of patients having both ejection fraction ≤45% and palliative care needs, although this may be a conservative estimate due to the file review methodology to identify unresolved palliative care problems. It is important to note that the point prevalence of patients with clinical diagnosis and palliative care needs was 4.4% of the population. We present evidence-based referral criteria from the larger multi methods study.