International experts have agreed on 25 criteria for the referral of advanced heart failure patients to specialist palliative care in a new Delphi study. The criteria – based on the responses of 44 experts in cardiology and/or palliative care across North America (16), Asia (15), Europe (nine), South America (three) and Australia (one) – were published Monday online ahead of the July 26 issue of the Journal of the American College of Cardiology. “Patients with advanced heart failure have substantial supportive care needs,” said the paper’s authors, led by Yuchieh Kathryn Chang, DO, of the University of Texas MD Anderson Cancer Center. “Specialist palliative care can be beneficial, but it is unclear who is most appropriate for referral and when patients should be referred.” The current study, therefore, asked an international Delphi panel to rate 34 disease-based, 24 needs-based and nine time-based criteria over three online survey rounds between February and July 2021, the first of which garnered 44 responses, the second 41 and the third 43. The experts reported a median of 15 years’ experience in cardiology and 11 years’ experience in palliative care. Consensus was defined as ≥70% agreement, and a criterion was tagged “major” if the experts believed that it could justify a referral without any other criterion. Advanced heart failure was agreed by consensus in rounds 1 and 2 to be defined as patients in New York Heart Association functional class (NYHA-FC) III, NYHA-FC IV, and American College of Cardiology/American Heart Association (ACC/AHA) advanced stage D. Criteria by consensus The final 25 major referral criteria defined by the experts and categorized under six topics were as follows: Advanced/Refractory Heart Failure, Comorbidities, and Complications Persistent left ventricular ejection fraction <20% Cardiorenal syndrome Persistent malignant arrhythmias Implantable cardioverter-defibrillator shock Cardiac cachexia Inability to tolerate or resistant to guideline-directed therapies Multiorgan failure Presence of one or more noncardiac life-threatening diseases in addition to heart failure Advanced Heart Failure Therapies Chronic inotropes Mechanical circulatory support Cardiac transplant evaluation Eligible for, but did not receive for a specified reason, advanced heart failure therapies Hospital Utilization ≥2 Emergency Room visits within the past 3 months ≥2 Hospitalizations within the past 3 months Prognostic Estimate Clinician estimated life expectancy of ≤6 months Symptom Burden/Distress Severe physical symptoms Severe emotional symptoms Severe spiritual or existential distress Dependent in ≥3 basic activities of daily living Refractory symptoms requiring palliative sedation Request for hastened death/assisted suicide Decision Making and Social Support Assistance with goals of care discussions/decision making/care planning Discussion regarding withdrawal/de-escalation of life-prolonging interventions Hospice referral/discussion Patient/family/care team request The majority (68%) of the major criteria garnered ≥90% agreement. “Inconsistent and inappropriate utilization of specialist palliative care resources in heart failure management compelled this Delphi study,” said the authors. “These criteria, especially the needs-based ones, may be the warranted paradigm shift toward early integration, because current accepted practices reflect referrals late in the disease trajectory, when patients are in advanced stages of heart failure.” Still, they stressed that the criteria are “just an initial step” toward standardizing clinical care, pushing for further research to help validate and implement such criteria in the primary and cardiology care settings. Skew towards disease-based criteria ‘surprising’ In an accompanying editorial, Spectrum Health’s Sarah Badran, MD, MACM, (also from Michigan State University), and Sangjin Lee, MD, MSc, branded the seeming bias toward more disease-based criteria over needs-based as surprising. “Disease-based criteria, such as persistently low ejection fraction or referral for ventricular assist device, are expected to resonate more with cardiologists, whereas the needs-based symptoms, such as patient or family concerns, should resonate more with palliative care physicians. “The panel, however, were experts in the intersection of palliative care and cardiology, with 68% with palliative care training and 43% with cardiology training—so why were there more disease-based than needs-based referral criteria?” The editorialists suggested that a skew to a cardiology perspective in the initial list of referral criteria (51% disease-based, 34% needs-based) could offer some explanation. However, the COVID-19 pandemic could also have led caregivers to a disease-based bias, they suggested. “This does not rule out the possibility, however, that the results reflect a subconscious bias among all of the experts toward disease-based criteria, born from their real-world experience; patients were, at the time of the study, presenting cautiously and with more advanced disease, having ‘socially distanced’ and avoided doctors’ offices during the first year of the pandemic. With so much upheaval, did any of us even feel like experts during that time?” In any case, the editorialists stressed the importance of defining such criteria. “We doubt that a global pandemic will be hovering around the next chapter, but heart failure sadly is not going anywhere, and effective integration of palliative care into the management of our patients will remain crucial if we are to provide exemplary care,” they said. Sources: Chang YK, Allen LA, McClung JA, et al. Criteria for Referral of Patients With Advanced Heart Failure for Specialized Palliative Care. J Am Coll Cardiol 2022;80:332-344. Badran S, Sangjin L. Even in Heart Failure, Integrating Palliative Care and Aggressive Medical Therapy Is a Thing. J Am Coll Cardiol 2022;80:345-347. Image Credit: Monkey Business – stock.adobe.com