Promoting Upstream Integration of Palliative Care in Elderly Heart Failure Patients

Heart failure (HF) is a devastating disease that inordinately affects the elderly. Although palliative care (PC) can be an invaluable tool in promoting symptom management and quality of life (QOL) for elderly end-stage heart failure (ESHF) patients, it is a resource that is often underutilized by HF clinicians because many providers do not know when in the disease trajectory to refer patients for PC. The purpose of this project was to assess HF clinicians' understanding of PC to determine barriers preventing appropriate referrals for elderly ESHF patients. The obtained information was then used to develop an evidence-based guideline called, ARISE, for promoting earlier PC referrals. Baseline data were collected from the PC team about the number of inpatient (IP) and outpatient (OP) referrals for PC that were received from the HF attending physicians prior to the ARISE guideline launch, and for three months following the introduction to, education on, and deployment of the guideline. A pretest-posttest design was the approach employed to measure changes in provider attitude toward PC, frequency of PC referrals, and barriers to consulting PC. The posttest had the additional aim of assessing HF clinicians' perception of the usability and feasibility of the ARISE guideline. Analysis of the pretest and posttest indicated that the ARISE guideline launch did not alter HF clinicians' perceptions of PC or result in an increased frequency of self-reported PC referrals. Referral data from the PC team indicated that although IP referrals decreased slightly (17%) in the 3 months after the guideline launch, OP referrals increased by 40%. In general, pilot feedback from the ARISE guideline was positive with 100% of clinicians indicating they felt the guideline was "very" or "extremely" useable. In addition, 75% of clinicians in the posttest indicated they anticipated using the guideline in the future.