Who Should Care for End-Stage Heart Failure?

BOCA RATON, FLA. — When it comes to treatment options, palliative care, and decision making for patients with end-stage heart failure, cardiologists, internists, family physicians, and geriatricians are similarly lacking in awareness, according to a national pilot survey.

The American College of Cardiology and the American Heart Association's recommendations for the care of heart failure patients include a call for cardiologists to counsel patients about end-of-life issues.

However, most of the care of heart failure patients is done by noncardiologist physicians, and there is still uncertainty about which physicians should address end-of-life concerns with end-stage heart failure patients.

“The question is, who is going to have 'the talk'?” Dr. Paul J. Hauptman said in an interview.

“More and more patients have heart failure, and more and more patients are going to die from heart failure. What are we going to do with this burgeoning population of patients with heart failure?” asked Dr. Hauptman, professor of medicine, division of cardiology, and director of heart failure/transplantation at St. Louis (Mo.) University.

In an attempt to answer that question, Dr. Hauptman and his associates surveyed cardiologists, family physicians, internists, and geriatricians about the management of patients with end-stage heart failure. The investigators randomly selected physicians from the American Medical Association Master File.

The administration of the 51-question survey is ongoing, with the goal of garnering opinions from 1,450 physicians. Preliminary results from 76 responses were given in a poster presentation at the annual meeting of the Heart Failure Society of America.

The survey indicates a similar lack of awareness about published guidelines for heart failure (44% of cardiologists, 47% of noncardiologists), a similar belief in left-ventricular pacing as a life-extending measure (44% of cardiologists, 41% of noncardiologists), and a similar level of uncertainty about when to refer a patient to hospice care (52% of cardiologists, 53% of noncardiologists).

Almost 85% of the noncardiologists who responded to the survey said they believed that they, and not cardiologists, should initiate end-of-life discussions with their patients. “The noncardiologists really thought they were better [at that] than the cardiologists,” Dr. Hauptman commented.

However, he added, most of the generalists reported that they had never had such a discussion with a patient or a patient's family.

“Cardiologists have an acute-care perspective. We don't really know about what is going on at the end of life,” Dr. Hauptman said. “It's going to take education and discussions at national meetings [to understand that].”

The majority of respondents (91% of cardiologists, 67% of noncardiologists) do not use standard quality of life measurements for patients with end-stage heart failure.

“This would be kind of shocking” if confirmed by the full survey, he said.

Most of the cardiologists who were surveyed (65%) said that they have discussed implantable cardioverter defibrillator deactivation with an end-stage patient or family member, compared with 35% of noncardiologists.

With the increasing prevalence of heart failure, Dr. Hauptman asserted, “more patients are going to show up with a device. Do you turn them off or [do you] not turn them off?”

Dr. Hauptman said that he hoped the final results of the survey would provide even more insight about physicians' attitudes toward end-stage heart failure and that the information will be able to be used to design effective interventions in the future.

BOCA RATON, FLA. — When it comes to treatment options, palliative care, and decision making for patients with end-stage heart failure, cardiologists, internists, family physicians, and geriatricians are similarly lacking in awareness, according to a national pilot survey.

The American College of Cardiology and the American Heart Association's recommendations for the care of heart failure patients include a call for cardiologists to counsel patients about end-of-life issues.

However, most of the care of heart failure patients is done by noncardiologist physicians, and there is still uncertainty about which physicians should address end-of-life concerns with end-stage heart failure patients.

“The question is, who is going to have 'the talk'?” Dr. Paul J. Hauptman said in an interview.

“More and more patients have heart failure, and more and more patients are going to die from heart failure. What are we going to do with this burgeoning population of patients with heart failure?” asked Dr. Hauptman, professor of medicine, division of cardiology, and director of heart failure/transplantation at St. Louis (Mo.) University.

In an attempt to answer that question, Dr. Hauptman and his associates surveyed cardiologists, family physicians, internists, and geriatricians about the management of patients with end-stage heart failure. The investigators randomly selected physicians from the American Medical Association Master File.

The administration of the 51-question survey is ongoing, with the goal of garnering opinions from 1,450 physicians. Preliminary results from 76 responses were given in a poster presentation at the annual meeting of the Heart Failure Society of America.

The survey indicates a similar lack of awareness about published guidelines for heart failure (44% of cardiologists, 47% of noncardiologists), a similar belief in left-ventricular pacing as a life-extending measure (44% of cardiologists, 41% of noncardiologists), and a similar level of uncertainty about when to refer a patient to hospice care (52% of cardiologists, 53% of noncardiologists).

Almost 85% of the noncardiologists who responded to the survey said they believed that they, and not cardiologists, should initiate end-of-life discussions with their patients. “The noncardiologists really thought they were better [at that] than the cardiologists,” Dr. Hauptman commented.

However, he added, most of the generalists reported that they had never had such a discussion with a patient or a patient's family.

“Cardiologists have an acute-care perspective. We don't really know about what is going on at the end of life,” Dr. Hauptman said. “It's going to take education and discussions at national meetings [to understand that].”

The majority of respondents (91% of cardiologists, 67% of noncardiologists) do not use standard quality of life measurements for patients with end-stage heart failure.

“This would be kind of shocking” if confirmed by the full survey, he said.

Most of the cardiologists who were surveyed (65%) said that they have discussed implantable cardioverter defibrillator deactivation with an end-stage patient or family member, compared with 35% of noncardiologists.

With the increasing prevalence of heart failure, Dr. Hauptman asserted, “more patients are going to show up with a device. Do you turn them off or [do you] not turn them off?”

Dr. Hauptman said that he hoped the final results of the survey would provide even more insight about physicians' attitudes toward end-stage heart failure and that the information will be able to be used to design effective interventions in the future.

BOCA RATON, FLA. — When it comes to treatment options, palliative care, and decision making for patients with end-stage heart failure, cardiologists, internists, family physicians, and geriatricians are similarly lacking in awareness, according to a national pilot survey.

The American College of Cardiology and the American Heart Association's recommendations for the care of heart failure patients include a call for cardiologists to counsel patients about end-of-life issues.

However, most of the care of heart failure patients is done by noncardiologist physicians, and there is still uncertainty about which physicians should address end-of-life concerns with end-stage heart failure patients.

“The question is, who is going to have 'the talk'?” Dr. Paul J. Hauptman said in an interview.

“More and more patients have heart failure, and more and more patients are going to die from heart failure. What are we going to do with this burgeoning population of patients with heart failure?” asked Dr. Hauptman, professor of medicine, division of cardiology, and director of heart failure/transplantation at St. Louis (Mo.) University.

In an attempt to answer that question, Dr. Hauptman and his associates surveyed cardiologists, family physicians, internists, and geriatricians about the management of patients with end-stage heart failure. The investigators randomly selected physicians from the American Medical Association Master File.

The administration of the 51-question survey is ongoing, with the goal of garnering opinions from 1,450 physicians. Preliminary results from 76 responses were given in a poster presentation at the annual meeting of the Heart Failure Society of America.

The survey indicates a similar lack of awareness about published guidelines for heart failure (44% of cardiologists, 47% of noncardiologists), a similar belief in left-ventricular pacing as a life-extending measure (44% of cardiologists, 41% of noncardiologists), and a similar level of uncertainty about when to refer a patient to hospice care (52% of cardiologists, 53% of noncardiologists).

Almost 85% of the noncardiologists who responded to the survey said they believed that they, and not cardiologists, should initiate end-of-life discussions with their patients. “The noncardiologists really thought they were better [at that] than the cardiologists,” Dr. Hauptman commented.

However, he added, most of the generalists reported that they had never had such a discussion with a patient or a patient's family.

“Cardiologists have an acute-care perspective. We don't really know about what is going on at the end of life,” Dr. Hauptman said. “It's going to take education and discussions at national meetings [to understand that].”

The majority of respondents (91% of cardiologists, 67% of noncardiologists) do not use standard quality of life measurements for patients with end-stage heart failure.

“This would be kind of shocking” if confirmed by the full survey, he said.

Most of the cardiologists who were surveyed (65%) said that they have discussed implantable cardioverter defibrillator deactivation with an end-stage patient or family member, compared with 35% of noncardiologists.

With the increasing prevalence of heart failure, Dr. Hauptman asserted, “more patients are going to show up with a device. Do you turn them off or [do you] not turn them off?”

Dr. Hauptman said that he hoped the final results of the survey would provide even more insight about physicians' attitudes toward end-stage heart failure and that the information will be able to be used to design effective interventions in the future.