Need for hospice and palliative care services in patients with end-stage heart failure treated with intermittent infusion of inotropes.

BACKGROUND: Hospice and palliative care programs to relieve suffering and optimize management of terminally ill patients have grown rapidly in the United States. However, there are no data on the need for these services among patients with end-stage heart failure receiving intermittent infusion of intravenous inotropes.

HYPOTHESIS: The need for hospice and palliative care programs among patients in end-stage heart failure who receive intermittent infusion of inotropes is investigated.

METHODS: The study included all stable patients with refractory heart failure symptoms treated with inotropes in our outpatient unit. A total of 73 patients (65 +/- 12 years; left ventricular ejection fraction 22 +/- 9%; New York Heart Association class 3.6 +/- 0.4) were seen during a 49-month period. Of these, 35 patients (48%) met hospice or palliative care evaluation criteria upon referral but were offered, and accepted, the alternative of parenteral inotropes. In all, 1,737 individual outpatient treatment sessions were given, with a mean of 24 +/- 19 sessions per patient (range 5 to 118 sessions), representing a minimum of 9,948 h of inotrope therapy.

RESULTS: A total of 18 (25%) patients died, 6 (8%) patients were withdrawn from the program (3 by their primary physicians and 3 because of significant travel limitations); 4 (5%) patients required continuous intravenous home therapy; and 44 (61%) patients were discharged with significant improvement in their heart failure symptoms. Only 7 of the 18 patients who died had received hospice or palliative care intervention, mainly for the sake of comfort and to ease the transition among family members. The rest of the patients were comfortable and had accepted the natural evolution of their disease; they were not interested in or did not require hospice or palliative care intervention. Of the patients discharged from the outpatient cardiac infusion unit, the interval free of heart failure symptoms after the final infusion treatment ranged from 201 to 489 days, with no need for hospitalization or emergency room visits.

CONCLUSION: Our results demonstrate that intermittent infusion of intravenous inotropes can be safely administered and can improve symptoms in a significant number of patients, probably by slowing the natural progression of heart failure. Although the full clinical impact of inotrope therapy in an outpatient setting has not been fully defined, other nonhemodynamic-related benefits should be sought and investigated. Our results suggest that intermittent infusion of intravenous inotropes is one of the prominent variables that requires particular attention. In our experience, the institution of intermittent infusions of intravenous inotropes can, in fact, modify end-stage heart failure symptoms that, in most patients, are currently perceived to lead to a terminal event. Thus, appropriate use of intermittent infusion of intravenous inotropes may not only improve functional class and symptoms in a significant number of patients identified as terminal by their poor response to conventional therapy, but it may also facilitate better utilization of hospice and palliative care resources among patients with end-stage heart failure. Furthermore, the need for hospice and palliative care in patients with heart failure should be revisited in view of adjuvant treatment options such as intermittent infusion of intravenous inotropes.