Most patients with acute decompensated heart failure (ADHF), with or without kidney disease, would prioritize a care plan focused on comfort rather than longevity if they were too sick to speak for themselves, but only a minority have taken part in advance care planning (ACP) discussions, according to an analysis presented at the National Kidney Foundation’s Spring Clinical Meetings.
There were also discordant results when it came to use of intensive therapies like dialysis and heart pumps or predicted prognosis, with the presence of acute kidney injury (AKI), chronic kidney disease (CKD), or both not having a major impact on responses.
“These findings highlight major gaps that exist between patient values, prognostic understanding, and their real-world clinical outcomes,” said presenter Sydney Wong, a medical student at the University of Washington School of Medicine in Seattle.
Ms. Wong presented a substudy of the Kidney Injury in Heart Failure (KIND-HF) study, which included 400 adults hospitalized with ADHF and receiving IV diuretics at three hospitals affiliated with the University of Washington between August 2020 and January 2024.
The analysis focused on 297 patients who completed a survey during the initial hospitalization. The prevalence of kidney disease was high, with 40% having CKD, 16% AKI, and 8% both.
The survey assessed four major domains: patient values regarding the type of care plan they’d prefer if they were too sick to speak for themselves; ACP engagement; preferences for and discussions around intensive therapies; and prognostic expectations.
Overall, 60.6% of respondents said they would prefer comfort-oriented care, whereas 20.9% would choose a plan to extend life even at the expense of increased pain and discomfort and 18.5% said they were unsure or preferred not to answer.
Yet, in terms of ACP, only 38.7% of patients had signed papers and discussed their preferences with a durable power of attorney. In addition, even though most patients supported use of temporary or permanent dialysis or heart pumps if needed, the majority had not had prior discussions about it with a health care provider.
As for prognosis, only 3.4% of respondents predicted that they had less than 12 months to live, although the actual mortality rate during the first year was 26.9%. Only four of the 80 patients (5%) who died at any point correctly predicted their prognosis.
Kidney disease did not have a strong influence on any of these domains, and when looking at surveys completed in the outpatient setting, there was little change in how patients responded.
“There’s a need to fill a major gap in physician-patient communication, as well as a need to better align care with patient goals and values,” Ms. Wong said. “Our study’s findings suggest opportunities to improve patient education and improve patients’ understanding of their heart failure severity and kidney dysfunction.”
She highlighted the need to integrate prognosis into shared decision-making and to start ACP discussions before critical illness develops.
“Hospitalization for acute decompensated heart failure thus may represent a particularly important opportunity to initiate or revisit these goals of care discussions,” Ms. Wong said, adding that “kidney dysfunction itself may serve as an invitation for clinicians to engage in these discussions as well.”
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