Advancing the Science

Mayo Clinic Medical Science Blog – an eclectic collection of research- and research education-related stories: feature stories, mini news bites, learning opportunities, profiles and more from Mayo Clinic.

November 8, 2019

Strengthening the case for palliative care

By Elizabeth Zimmermann
student team simulating intensive care activities for simulated patient

The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery is the group at Mayo Clinic charged with driving practice transformation. Basically, this means to help Mayo Clinic improve the way health care is delivered, reaching patients where they are, with the right answers when they are needed.

Center researchers work within multi-disciplinary teams across Mayo Clinic on projects ranging from better ways to support women during pregnancy, to faster visits in the ER and new ways to help elderly patients stay out of the hospital.

One recent research project with the Department of Cardiovascular Medicine looked at how often palliative care is part of the care plan for patients who suffer a heart attack accompanied by cardiogenic shock. Public Affairs sat down with two of the study authors to find out more about their project, and how it may lead to better care for patients.

The study first author, Saraschandra Vallabhajosyula, M.B.B.S., is a cardiology fellow at Mayo Clinic, with prior training in critical care medicine. His mentor and the study’s senior author is Gregory Barsness, M.D., the medical director of the Mayo Clinic Cardiac Intensive Care Unit with additional expertise in interventional cardiology and radiology.

Dr. Vallabhajosyula, what made you decide to study this topic?

Saraschandra Vallabhajosyula, M.B.B.S.

Cardiogenic shock after acute myocardial infarction is my clinical and research interest. These patients are often admitted to the cardiac intensive care unit with multi-organ failure needing cardiac and non-cardiac organ support.

They have a high risk of death in the cardiac intensive care unit and the hospital. Therefore, there is an important need to understand the issues surrounding end-of-life in these complex patients.

Furthermore, palliative care is frequently mistaken as ‘futile care’ rather than ‘patient-centric care’ by both patients and physicians. We sought to understand the national trends and predictors in this population.

Dr. Vallabhajosyula: What is cardiogenic shock, and what makes these heart attacks different for patients experiencing them?

Cardiogenic shock is a state of low cardiac output (pumping ability of the heart) and about 80% of these cases are due to an acute myocardial infarction – commonly known as a heart attack. While there are other reasons a person might develop cardiogenic shock, when it occurs as a result of cardiac muscle damage during a heart attack, it happens very quickly. It is difficult to predict how well a patient will do in this situation, and in fact, nearly a third of these patients die in the hospital.

This results in a rather urgent need to quickly develop a patient-centric care plan, one that incorporates the patient’s condition and wishes, as well as that of their family when they are unable to communicate.

The typical health care team surrounding a patient who has had a heart attack is well versed in the technologies and procedures needed to extend life. However, this has to be balanced with detailed conversations about the risks and benefits of each with patients and families, or to develop a palliative care plan that aligns interventions with patient goals.

Dr. Barsness, what is palliative care, and what do palliative care specialists do?

Gregory Barsness, M.D.

The practice of palliative care aligns what is possible with what is desired. In modern medicine, there are a great many more treatment options available to patients and these treatments carry different potential benefits and risks. The health care decisions that patients and their families make are directly related to how patients understand these risks and benefits and how the results might align with their overall life goals. 

Palliative care specialists provide insight and guidance to help patients and their families understand and integrate advanced diagnostics and treatments therapeutics with their social, emotional and spiritual needs.

Palliative care specialists play a crucial role in the care of patients with acute or chronic conditions. In particular, in the acute cardiac ICU setting, they can assist patients and families faced with choices that include treatments that prolong life but do not cure. For example, there are a number of different machines that help the heart pump, breathe for the patient or filter a patient’s blood when their kidneys stop working.

Many of these patients may also experience significant changes in their health and needs during their time in the hospital, leading to later decisions that could be inconsistent with their overall goals of care.

Dr. Barsness: Why is it important to make palliative care an integral offering in the cardiac ICU?

A team-based approach incorporating palliative care specialists to care for patients with cardiogenic shock following a heart attack is crucial to individualizing care based on each patient’s specific goals and desires. This is actually an ideal approach for patients with any acute or chronic condition that has substantial implications for quality and longevity of life.

The cardiac ICU, in particular, is a fast-paced environment where crucial decisions often revolve around technical feasibility with an emphasis on the science of medicine. Involving team members with special skills in palliative medicine assures that we place appropriate emphasis on individual values and choices.

At Mayo Clinic, we do that routinely via scheduled family conferences and open visitation schedules and health care providers present and available around-the-clock. Use of palliative care is an extension of the same philosophy wherein we value the patients’ and families’ emotional, spiritual and social concerns along with the science of care delivery. So incorporating palliative care specialists is like getting a different set of eyes, i.e. different perspective, on the same core issue – the needs of the patient.

Dr. Vallabhajosyula, while at Mayo Clinic including palliative care support may be more the norm, your study showed that in general, across the U.S., palliative care is not provided to these patients. Do you have any thoughts as to why?

I think it is a combination of factors that largely have to do with the perception of palliative care. Hospice care, end-of-life care and palliative care are presumed to be interchangeable, potentially resulting in late referrals of ‘actively dying’ patients.

As Dr. Barsness and I previously noted, the philosophy of palliative care is compatible with continued medical care and does not mean ‘giving up,’ or the cessation of care. That being said, we all can do better.

Only 4.5% of the nearly 450,000 patients (admitted to hospital) in our national study were offered palliative care. Other research has shown that the national rates for palliative care use in a range of critical care settings, 7%-13%, are still very low.

Dr. Barsness: Your study showed that people receiving palliative care support were more likely to die in hospital or not return home. Were there any things about this finding that concerned you?

As noted in the study, patients with palliative care visits were sicker, had higher acute organ failure and were likely offered palliative care too late in their hospital course.

Our results might suggest that patients with palliative care support received futile care less often and adopted life limiting decisions more frequently – that is, they perhaps chose to reduce or decline use of equipment and technologies that prolonged life. They also may have sought non-hospitalization care during end-of-life.

However, to draw firm conclusions, more data are needed on the timing of palliative care consultation, as well as any changes care in management plans that result from palliative care consultation.

Dr. Vallabhajosyula continues:

The major findings of our study are the strikingly low use of palliative care specialists in a patient population that has nearly 30% in-hospital mortality.

Though the time trends analyses show higher use in more recent years, there still remain multiple barriers. Perceptions of palliative care and other barriers to incorporation are common as we noted previously. Additionally, we found geographic, racial, sex and age-related disparities.

These factors indicate the need for more qualitative research to understand these barriers to implementing high-quality care.

Dr. Barsness: Do you expect Mayo Clinic practice to change as a result of these findings?

These national results are certainly eye-opening and would make many of us working in the cardiac ICU reflect on our practice. Given Mayo’s emphasis on multidisciplinary care, the high spirit of collaboration and prioritizing the needs of our patients, our numbers are significantly better than these national statistics. However, in our relentless efforts to provide the best possible care for our patients, we seek to continually improve on this aspect and many others relating to health care delivery in the CICU.

When asked if there was anything else they’d like to add, both doctors chimed in with thanks to that same multidisciplinary team they mentioned – the nurses, therapists, pharmacists and technicians of the cardiac ICU that make it possible to deliver high quality care to critically ill patients, while providing hope and healing to these patients and their families. They went on to credit other groups without which they would not have been able to conduct this research, the Divisions of Pulmonary and Critical Care Medicine and General Internal Medicine, Mayo Clinic Center for Palliative Medicine, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic Center for Clinical and Translational Science and the Mayo Clinic School of Graduate Medical Education.


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Tags: cardiology, cardiovascular medicine, Center for Clinical and Translational Science, Center for the Science of Health Care Delivery, Findings, Gregory Barsness, ICU, intensive care unit, Mayo Clinic College of Medicine and Science, News, palliative care, Saraschandra Vallabhajosyula

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