Communication Study
“There's no cure for this condition”: How physicians discuss advance care planning in heart failure

https://doi.org/10.1016/j.pec.2012.12.016Get rights and content

Abstract

Objective

To evaluate the extent to which physicians engage in recommended elements of advance care planning (ACP) communication during outpatient clinic visits with heart failure (HF) patients.

Methods

We conducted a qualitative content analysis of 71 audio-recorded and transcribed outpatient visits with 52 patients ≥65 years recently hospitalized for HF and their physicians (n = 44).

Results

We identified 25 instances of ACP-related communication over 15 of the 71 visits: in 17 instances, physicians explained the nature of HF but only once was the life-limiting potential of HF mentioned. Physicians discussed goals of care in 6 instances but elicited their patients’ preferences in only 2 of those instances. Finally, physicians encouraged documentation of preferences in 2 instances.

Conclusions

Despite recommendations for early ACP with HF patients, physicians rarely engaged in fundamental elements of ACP discussions during outpatient visits. We suggest a stepwise approach to supporting the process of ACP communication in practice.

Practice implications

Given the importance of ACP in helping patients plan for their future care, outpatient clinicians should be helped to incorporate these discussions in the routine care of their HF patients. Using a simple heuristic might help physicians engage in fundamental elements of ACP during busy outpatient visits.

Introduction

Patient–clinician communication about advance care planning (ACP) is critical to helping patients prepare and plan for their future care, by enhancing their understanding about their diagnosis, treatment, prognosis, and choices in end of life care [1]. ACP is especially important for patients with heart failure (HF), who face a highly uncertain and variable trajectory, marked by frequent exacerbations and increasingly complex treatment decision-making. HF patients report wanting to engage in ACP discussions with their physician as early as at the time of diagnosis [2], and recent guidance recommends that clinicians initiate ACP discussions in the outpatient setting, prior to and in anticipation of clinical decline, when a considered evaluation of treatment preferences is possible [3]. However, evidence that HF patients are unaware of their choices and alternatives related to future care [4], [5], [6] suggests that ACP is often underused or delayed until the end of life, or an emergent clinical need arises [5].

Providing physicians with practical guidance for conducting these often difficult and time-intensive discussions might increase the use of ACP in the outpatient setting. Although little guidance regarding the structure and process of an ACP discussion exists, various elements of ACP have been highlighted as important for physicians to engage in with their patients, including explaining the nature and trajectory of heart failure [2], [7], [8], [9], eliciting patient preferences for care [10], [11], [12], [13], and encouraging patients to document their identified treatment preferences [14], [15], [16], [17]. As part of a complete ACP discussion, these elements can help patients understand the implications of their disease, calibrate their expectations within the context of their illness, and articulate their care preferences to their providers. We previously examined if and how patients raised ACP discussions with their physicians and whether physicians responded to this opportunity [18]. In the current study we sought to evaluate the extent to which physicians engaged in these recommended ACP elements (i.e., explaining, eliciting, and encouraging) in actual practice during outpatient clinic visits with recently hospitalized HF patients.

Section snippets

Participants and data collection

We obtained data from a prospective observational cohort of patients hospitalized for heart failure at two Veterans Affairs (VA) Medical Centers. Patients in this study had one or more audio-recorded outpatient post-discharge follow-up visits with a participating primary care internist or cardiologist within 6 months of their hospital discharge. From this study cohort, we selected patients age 65 years or older (N = 52), because we believed ACP communication would be more likely in an older

Participant characteristics

Patient participants (n = 52) had a mean age of almost 71 years, were predominantly male (98.0%), Black/African American (51.9%), and were unmarried/single (63.5%) (Table 2). Patients had mean EF of 34.4% (SD 14.5) within 12 months of study enrollment. Physicians reported AHA/ACC HF stage for 29 out of the 52 patients, rating 93.1% as Stage C or D. Physician participants (N = 44) had a mean age of almost 38 years, were predominantly male (57.5%) and White (42.5%), and were in practice for an

Discussion

In this study of recently hospitalized heart failure patients, physicians infrequently used ACP communication during clinic visits after the HF hospitalization, and those who did often raised only a single element of ACP rather than engaging in more complete discussions that addressed all three elements as recommended in the literature. These physicians frequently explained the nature and course of heart failure by providing a general definition of HF and its mechanisms, but rarely mentioned

Funding

Supported in part by grant ECV-02-254 from VA Health Services Research and Development (HSR&D), Department of Veterans Affairs. Dr. Ahluwalia is supported by an Office of Academic Affiliation's VA Associated Health Postdoctoral Fellowship Program at the VA Greater Los Angeles HSR&D Center of Excellence.

Role of the sponsor

The funding organizations did not participate in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

Conflict of interest

The authors have no conflicts of interest or any relevant financial interest in this manuscript.

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