Doctors and other clinicians looking after patients with heart failure may avoid ‘Advance Care Planning’ conversations with the patient because they seem like an admission of failure, according to a new review of research looking at how these conversations are helped or hindered. Some clinicians feared that such conversations would ‘destroy hope’. Cardiologists in particular may think that such conversations may act as a setback to curative treatment.
Advance Care Planning, or ACP, is widely advocated in case the patient deteriorates and loses the capacity to discuss their treatment with their healthcare team. When patients with heart failure do talk with their doctors and nurses about how they would want to be treated should their condition deteriorate, their end-or-life care outcomes are likely to improve. Yet such conversations frequently do not occur: only 37% of end-stage heart failure patients knew that their prognosis was poor, only 8% were told that time was short and 36% of these patients died alone.
Markus Schichtel, post-doctoral researcher at the Cambridge Palliative and End of Life Care Group, is lead author of the new study, which looked at published research focused specifically on the barriers and facilitators for clinicians to engage with Advance Care Planning (ACP) in heart failure. The review shows that – as well as facing the high emotional cost of initiating these conversations – clinicians often lack disease-specific knowledge about the clinical management of advanced heart failure and the confidence to address end-of-life issues and ACP.
To address these issues, the research team suggest that clinicians would benefit from training to help them to identify the level of a patient’s need for information and in conducting difficult conversations, as well as disease-specific knowledge and a better understanding of the legal framework surrounding end-of-life.
Our review shows that training clinicians in the delivery of ACP in heart failure might be as important as assisting patients to start the ACP conversation. This twofold approach could help tackle the high emotional impact for the clinicians. The next step is to develop interventions that could support both the clinicians and the patients.”
– Dr Markus Schichtel, post-doctoral researcher at Cambridge Palliative and End-of-Life Care Group
This review was part of Dr Schichtel’s doctoral studies at the Nuffield Department of Primary Care Health Sciences, Oxford.
M Schichtel, B Wee, J MacArtney, S Collins, ‘Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis’. BMJ Supportive and Palliative Care. DOI 10.1136/bmjspcare-2018-001747
Queries: Lucy Lloyd, Communications Manager, Primary Care Unit
Image: CDC/ Dr. Thomas Hooten