Palliative Care for Acute CVD: Quality Indicators Formulated

A multidisciplinary group of clinicians identified 21 quality indicators of palliative care practices, to be followed for the treatment of acute cardiovascular disease (CVD), with the goal of encouraging clinicians to begin and/or improve palliative care in this patient population, according to a study published in the Journal of Cardiology.

Palliative care focuses on pain relief and quality of life improvement. Despite the fact that clinicians are starting to integrate palliative care to the acute CVD setting, specific recommendations on how to best implement such practices are scarce. This complicates the care of patients with acute CVD who often have an unpredictable trajectory. Authors also developed quality indicators in terms of applicability and appropriateness of palliative care in the acute CVD setting.

In this study, a 20-member (mean age, 49.5±13.7 years; 80% men) multidisciplinary team and 7 (mean age, 41.9±5.5 years) additional external validation practitioners comprising clinical cardiologists, intensivists, palliative care specialists, a primary care specialist, a catheterization specialist, a hospitalist, a clinical psychologist, a physiotherapist, a nutritionist, and nurses were recruited to develop quality indicators and reach a consensus. Following development of an initial list of potential indicators, a 1 to 9 Likert scale Delphi rating was applied to each proposed item (9, maximal feasibility and appropriateness). Candidate indicators with a total mean score ≥7 were adopted and included in the final list. Exploratory factor analysis was used to subdivide this list into several domains.

There were 32 potential indicators under initial consideration, 23 of which (71.8%) gained approval by consensus for inclusion after external validation. Of this 23 indicators, 21 summary measures were adopted, based on feasible time variations. In addition, a single outcome measure, a bereaved family survey, reached agreement for inclusion. “Symptom palliation” and “supporting the decision-making process” were the 2 major domains selected.

Although factor analysis failed to identify an optimal model, 8 narratively crafted indicator sub-categories were selected: “presence of palliative care team,” “multidisciplinary team approach,” “patient-family relationship,” “symptom screening and management,” “policy of approaching patients “collecting and providing information for decision-maker”, “presence of ethical review board,” and “determination of treatment strategy and the sharing of the care team’s decision”.

Of 21 indicators in the final list, 9 involve the structural setup of an institution, 11 deal with institutional processes and procedures, and the remaining one is the bereaved family survey, the sole outcome indicator.

Early screening for dyspnea or pain (ie, within 24 hours of admission) is regarded as a crucial and overarching palliative care indicator.

Quality indicators within the “symptom palliation” domain include: presence of and access to a multidisciplinary care team (“presence of palliative care team” sub-domain); around-the-clock intensive care unit visiting hours for relatives (“patient family relationship”); weekly or more multidisciplinary team discussions,  with an option for psychiatric referral and a discharge support meeting  (“multidisciplinary team approach”); pain assessment and evaluation of patient preferences using questionnaires (“policy to approach patients”); and pain assessment and documentation in the first24 hours after admission, palliative care intervention screening, treatment of strong pain with pharmacotherapy and nonpharmacologic therapies, opioid medication consideration for refractive dyspnea, psychiatric symptom screening, and family member grief care planning prior to patient expiration (“symptom screening and management”).

In the “support decision-making process” domain, quality indicators include management of ethical dilemmas (“presence of ethical committee” subdomain), presence of an institutional policy and clinician manual regarding advanced care planning, along with family communication on those issues within 24 hours of admission (with documentation of conversation and of any decisions reached; “collecting and providing information for decision-maker”), and documentation of all discussions involving implantable cardioverter defibrillator deactivation and/or withholding or cessation of life-sustaining therapy (“determination of treatment strategy and the sharing of their decision”).

Healthcare practitioners who are not familiar with palliative care practices are advised to learn appropriate palliative approaches in order to facilitate “primary palliative care.” Cardiologists should become familiar with the notion of “total pain,” which encompasses physical, psychiatric, social, and spiritual pain.

Study limitations include the possibility that some indicators may have been omitted, and the fact that results are likely to vary based on team member selection.

“These measures need to be validated, but many healthcare providers might find these categorizations to be useful for the initiation and enhancement of palliative care practice in Japan,” noted the authors.

Reference

Mizuno A, Miyashita M, Kohno T, et al. Quality indicators of palliative care for acute cardiovascular diseases. J Cardiol. 2020;76(2):177-183. doi:10.1016/j.jjcc.2020.02.010