Heart failure patients’ use of hospital services in the last year of life - timely palliative care is needed
A blog post written by Dr Gursharan Singh, Research Fellow, Centre for Healthcare Transformation & Cancer and Palliative Care Outcomes Centre, School of Nursing, QUT
Individuals with heart failure experience severe symptoms that reduces their quality of life.  This syndrome is complex and results in the use of acute hospital services, including the emergency department and the intensive care unit right up until death.
Our research study, which is currently underway, found that for individuals who died of heart failure in Queensland between 2008 to 2018, hospital use in the last year of life was extensive:
- 83% had at least one hospital episode.
- Of this group, there was a median of 3 hospital episodes per person.
- Each episode in hospital had a median length of stay of 2 days.
- 67% of individuals with a hospital episode had one in the last 7 days.
- 13% of individuals had at least one palliative care episode.
- A palliative episode occurred after 5 hospital episodes in the last year of life.
- 10% of individuals with a palliative care episode were discharged to their home or usual residence, while 88% died in hospital.
- 64% of individuals had at least one emergency department presentation.
- Of these individuals, 34% presented to the emergency department in the last 7 days of life.
While care within the hospital may be appropriate to address the needs of the patients and manage acute exacerbations, there are instances where the use of hospital services can indicate poor-quality end-of-life care.  These instances include where patients would prefer home-based or community-based care and where complex physical and social issues may be better treated in non-specialist community-based palliative care services. 
The extensive use of hospital services in the last year of life by Queenslanders who died of heart failure is reflective of the progressive and chronic nature of the illness. The data suggests more timely and greater use of palliative care for individuals with heart failure is needed as palliative care focuses on quality of life, alleviating symptoms and improving patient function to reduce hospital use. 
When considering how to improve the delivery of timely palliative care for individuals with heart failure to reduce hospital use in the last year of life, it is important to implement strategies across the care continuum. Research suggests that patient, provider, and system-level factors influence the delivery of timely palliative care in heart failure. These include the patient's clinical profile; education needs of healthcare professionals in palliative care and chronic heart failure and improving access to services and resources. 
Understanding the interacting and influencing elements of the patient, provider and system needs to be considered in the next step to improving palliative care for individuals with heart failure, and ultimately, reducing the strain on acute hospital services.
- Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs. 2005 Sep;4(3):198-206. doi: 10.1016/j.ejcnurse.2005.03.010
- McNamara BA, Rosenwax LK, Murray K, Currow DC. Early admission to community-based palliative care reduces use of emergency departments in the ninety days before death. J Palliat Med. 2013 Jul;16(7):774-9. doi: 10.1089/jpm.2012.0403. Epub 2013 May 15.
- Bekelman DB, Hutt E, Masoudi FA, Kutner JS, Rumsfeld JS. Defining the role of palliative care in older adults with heart failure. Int J Cardiol. 2008 Apr 10;125(2):183-90. doi: 10.1016/j.ijcard.2007.10.005. Epub 2007 Nov 26.
- Singh GK, Ramjan L, Ferguson C, Davidson PM, Newton PJ. Access and referral to palliative care for patients with chronic heart failure: A qualitative study of healthcare professionals. J Clin Nurs. 2020 May;29(9-10):1576-1589. doi: 10.1111/jocn.15222. Epub 2020 Mar 12.
Dr Gursharan Singh, Research Fellow, Centre for Healthcare Transformation & Cancer and Palliative Care Outcomes Centre, School of Nursing, QUT
This work will be presented at the Oceanic Palliative Care Conference 2021.