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End of Life Care

NIHR Signal Routine engagement in end of life planning can improve health outcomes for people with heart failure

Published on 30 July 2019

doi: 10.3310/signal-000801

Interventions that encourage healthcare professionals to engage in advance care planning with heart failure patients can work more effectively than stand-alone training activities in improving health outcomes. Approaches that involve patients to change clinicians’ professional practice behaviours, the use of reminder systems and educational meetings may offer the best potential.

There is no cure for heart failure, and palliative care is known to help this patient group. Advance care planning promoting discussions about living wills, future care needs and healthcare proxies are widely considered to provide better end-of-life support for patients with end-stage heart failure. Previous studies showed that these conversations often do not happen.

This review used moderate-quality evidence from thirteen trials, mainly in the US. These findings may help identify the most effective approaches to start difficult conversations about choices at the end of life. The study recommendations are likely to be of relevance to those involved with health service improvement for end-stage heart failure and healthcare practitioners working in the field.

Share your views on the research.

Why was this study needed?

Heart failure affects around 900,000 people in the UK and is the most common cause of hospital admissions in people over 65. One million bed days are attributable to heart failure annually, and as the population ages, these figures are predicted to rise.

Patients with end-stage heart failure who have no further treatment options have significant palliative care needs. Advance care planning can facilitate end-of-life care for better patient outcomes, but clinicians are often slow to engage with it.  Only 6% of those dying with heart failure are currently referred to palliative care.

The best ways of supporting clinicians to initiate appropriate discussions about end-of-life care are not well understood. Past reviews had not looked at interventions directed at clinicians and had not provided much detail on different approaches used. This study aimed to identify which methods carry the best potential to engage clinicians with advance care planning for their heart failure patients.

What did this study do?

The systematic review included 13 randomised controlled trials that examined the effectiveness of interventions supporting behaviour change in clinicians to engage in advance care planning.

Studies included 3,709 participants representing both mixed and heart failure only populations in any healthcare setting. This included primary care, secondary care, community or hospice settings.

The overall quality of evidence was rated as moderate, though wide variability between the trials meant that there was some uncertainty in the results. Trials were predominantly from the USA and may have some limitations within a UK setting due to differences in definitions, legal frameworks and healthcare systems.

What did it find?

  • The most effective intervention for engaging clinicians in advance care planning with heart failure patients were patient-mediated interventions. This is where patients were randomised to prompt their physician to talk about end of life care, and this increased clinician engagement five-fold (odds ratio [OR] 5.23, 95% confidence interval [CI] 2.36 to 11.61).
  • Reminder systems – electronic or paper – more than tripled the odds of clinician engagement (OR 3.65, 95% CI 1.47 to 9.04).
  • Educational meetings about advance care planning doubled the likelihood of clinician engagement (OR 2.35, 95% CI 1.29 to 4.26).
  • Methods that helped clinicians and patients talk about advance care planning were found to have the greatest potential.
  • Interventions to improve clinical behaviour are more likely to be effective when combined with a variety of techniques rather than using training as a stand-alone tool.

What does current guidance say on this issue?

Current NICE and SIGN guidelines focus predominantly on managing the physical aspects of heart failure rather than advance care planning. Stronger recommendations in this area are provided by the British Heart Foundation and the Royal College of Physicians. Both identify advance care planning as imperative for improving heart failure care.

The Royal College of Physicians acknowledges that all medical practitioners have a duty to discuss issues of advance care planning with heart failure patients to prevent deterioration in the quality of life. Communication skills training in this area for healthcare professionals is recommended by the Royal College of Physicians and NICE.

What are the implications?

Advance care planning in end-stage heart failure is complex, and healthcare professionals may not regard it as part of their role. Service providers looking to embed advance care planning within routine practice need to influence behaviour change by encouraging clinicians to communicate with patients about end-of-life care.

This is more likely to be achieved by promoting combined interventions favouring patient mediated activities, reminder systems and educational meetings rather than stand-alone training and professional development.

The results of this study have the potential to support policy and guideline developers, clinicians working with heart failure patients, general ward staff and palliative care service workers.

Citation and Funding

Schichtel M, Wee B, Perera R et al. Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis. Heart. 2019; May 24. doi: 10.1136/heartjnl-2019-314758. [Epub ahead of print]. 

No funding was attached to this study.

Bibliography

Adler ED, Goldfinger JZ, Kalman J et al. Palliative care in the treatment of advanced heart failure. Circulation. 2009;120:2597–606.

British Heart Foundation. Focus on heart failure: 10 recommendations to improve and transform lives. London: British Heart Foundation; 2016.

Hancock K, Clayton JM, Parker SM et al. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med. 2007;21:507–17.

National Cardiac Audit Programme. National heart failure audit 2016/17 summary report. London: British Society for Heart Failure; undated.

NHS Improving Quality. End of life care in heart failure: a framework for implementation. London: NHS Improving Quality; 2014.

NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.

NICE. Chronic heart failure in adults. QS9. London: National Institute for Health and Care Excellence; 2011.

SIGN. Management of chronic heart failure. SIGN 147. Edinburgh: Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland; 2016.

Stuart B. The nature of heart failure as a challenge to the integration of palliative care services. Curr Opin Support Palliat Care. 2007;1(4):249–54.

Ward, C. Improving the care of patients with advanced heart failure. J R Coll Physicians Edinb. 2009;39:209-15.

Why was this study needed?

Heart failure affects around 900,000 people in the UK and is the most common cause of hospital admissions in people over 65. One million bed days are attributable to heart failure annually, and as the population ages, these figures are predicted to rise.

Patients with end-stage heart failure who have no further treatment options have significant palliative care needs. Advance care planning can facilitate end-of-life care for better patient outcomes, but clinicians are often slow to engage with it.  Only 6% of those dying with heart failure are currently referred to palliative care.

The best ways of supporting clinicians to initiate appropriate discussions about end-of-life care are not well understood. Past reviews had not looked at interventions directed at clinicians and had not provided much detail on different approaches used. This study aimed to identify which methods carry the best potential to engage clinicians with advance care planning for their heart failure patients.

What did this study do?

The systematic review included 13 randomised controlled trials that examined the effectiveness of interventions supporting behaviour change in clinicians to engage in advance care planning.

Studies included 3,709 participants representing both mixed and heart failure only populations in any healthcare setting. This included primary care, secondary care, community or hospice settings.

The overall quality of evidence was rated as moderate, though wide variability between the trials meant that there was some uncertainty in the results. Trials were predominantly from the USA and may have some limitations within a UK setting due to differences in definitions, legal frameworks and healthcare systems.

What did it find?

  • The most effective intervention for engaging clinicians in advance care planning with heart failure patients were patient-mediated interventions. This is where patients were randomised to prompt their physician to talk about end of life care, and this increased clinician engagement five-fold (odds ratio [OR] 5.23, 95% confidence interval [CI] 2.36 to 11.61).
  • Reminder systems – electronic or paper – more than tripled the odds of clinician engagement (OR 3.65, 95% CI 1.47 to 9.04).
  • Educational meetings about advance care planning doubled the likelihood of clinician engagement (OR 2.35, 95% CI 1.29 to 4.26).
  • Methods that helped clinicians and patients talk about advance care planning were found to have the greatest potential.
  • Interventions to improve clinical behaviour are more likely to be effective when combined with a variety of techniques rather than using training as a stand-alone tool.

What does current guidance say on this issue?

Current NICE and SIGN guidelines focus predominantly on managing the physical aspects of heart failure rather than advance care planning. Stronger recommendations in this area are provided by the British Heart Foundation and the Royal College of Physicians. Both identify advance care planning as imperative for improving heart failure care.

The Royal College of Physicians acknowledges that all medical practitioners have a duty to discuss issues of advance care planning with heart failure patients to prevent deterioration in the quality of life. Communication skills training in this area for healthcare professionals is recommended by the Royal College of Physicians and NICE.

What are the implications?

Advance care planning in end-stage heart failure is complex, and healthcare professionals may not regard it as part of their role. Service providers looking to embed advance care planning within routine practice need to influence behaviour change by encouraging clinicians to communicate with patients about end-of-life care.

This is more likely to be achieved by promoting combined interventions favouring patient mediated activities, reminder systems and educational meetings rather than stand-alone training and professional development.

The results of this study have the potential to support policy and guideline developers, clinicians working with heart failure patients, general ward staff and palliative care service workers.

Citation and Funding

Schichtel M, Wee B, Perera R et al. Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis. Heart. 2019; May 24. doi: 10.1136/heartjnl-2019-314758. [Epub ahead of print]. 

No funding was attached to this study.

Bibliography

Adler ED, Goldfinger JZ, Kalman J et al. Palliative care in the treatment of advanced heart failure. Circulation. 2009;120:2597–606.

British Heart Foundation. Focus on heart failure: 10 recommendations to improve and transform lives. London: British Heart Foundation; 2016.

Hancock K, Clayton JM, Parker SM et al. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med. 2007;21:507–17.

National Cardiac Audit Programme. National heart failure audit 2016/17 summary report. London: British Society for Heart Failure; undated.

NHS Improving Quality. End of life care in heart failure: a framework for implementation. London: NHS Improving Quality; 2014.

NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.

NICE. Chronic heart failure in adults. QS9. London: National Institute for Health and Care Excellence; 2011.

SIGN. Management of chronic heart failure. SIGN 147. Edinburgh: Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland; 2016.

Stuart B. The nature of heart failure as a challenge to the integration of palliative care services. Curr Opin Support Palliat Care. 2007;1(4):249–54.

Ward, C. Improving the care of patients with advanced heart failure. J R Coll Physicians Edinb. 2009;39:209-15.

Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis

Published on 24 May 2019

Schichtel, M.,Wee, B.,Perera, R.,Onakpoya, I.,Albury, C.,Barber, S.

Heart , 2019

OBJECTIVE: Advance care planning (ACP) is widely advocated to contribute to better outcomes for patients suffering from heart failure. But clinicians appear hesitant to engage with ACP. Our aim was to identify interventions with the greatest potential to engage clinicians with ACP in heart failure. METHODS: A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO for randomised controlled trials (RCTs) from inception to January 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (GRADE) and intervention synergy according to Template for Intervention Description and Replication. ORs were calculated for pooled effects. RESULTS: Of 14 175 articles screened, we assessed the full text of 131 studies. 13 RCTs including 3709 participants met all of the inclusion criteria. The intervention categories of patient-mediated interventions (OR 5.23; 95% CI 2.36 to 11.61), reminder systems (OR 3.65; 95% CI 1.47 to 9.04) and educational meetings (OR 2.35; 95% CI 1.29 to 4.26) demonstrated a favourable effect to engage clinicians with the completion of ACP. CONCLUSION: The review provides evidence from 13 published RCTs and suggests that interventions that involve patients to change clinical practice, reminder systems and educational meetings have the greatest effect in improving the implementation of ACP in heart failure.

Expert commentary

If you are caring for people with heart failure, this systematic review answers the question: what clinician-targeted interventions best support advance care planning for people with heart failure? It shows that patient-mediated interventions have the greatest positive effect (with a five-fold increase in completion of advance care planning), followed by reminder systems (about three to four-fold increase) and educational meetings (with about two-fold increase).

This systematic review should change clinical practice, and help ensure that every service which sees patients with heart failure:

  1. has either a question prompt list, advance care plan, or shared-decision tool for patients with heart failure to use, with appropriate explanation and support,
  2. considers how to build in reminders for clinicians to ensure this is routinely done, and
  3. provides educational meetings to support the implementation of these interventions.

Fliss Murtagh, Professor of Palliative Care, Hull York University Medical School; Consultant in Palliative Medicine, Hull University Teaching Hospitals NHS Trust

The commentator declares no conflicting interests