aginghearts Acute Myocardial Infarction, Coronary Intervention, Latest, Shared Decision Making

NSTEMI Decide: A Decision Aid for Older Adults

Many patients hospitalized with non ST-elevation myocardial infarction (NSTEMI) are over age 75. This condition requires major management decisions – most importantly, whether to pursue invasive coronary angiography. However there is limited evidence about the absolute benefits of this procedure for NSTEMI in older adults; available data indicate certain advantages (reduced risk of another MI) but also risks (bleeding, acute kidney injury). Until ongoing trials provide better evidence, patients and clinicians are left with uncertainty around whether invasive coronary angiography is worth pursuing.

Our previous qualitative research revealed that for many older adults hospitalized with NSTEMI, they expressed a desire to be better informed about their options. In the same study, cardiologists asked for a tool that would help them facilitate discussions with these patients. And both groups endorsed the process of shared decision making, which involves the active participation of patients in health care decisions that have multiple acceptable choices.

In this context, we undertook an iterative process to develop a decision aid for invasive coronary angiography in older adults with NSTEMI. We convened both clinical experts (cardiologists, geriatricians, internists, nurses) and patients, in order to review serial drafts of this decision aid for accuracy and comprehension. Our development methods are now published and freely available on medRxiv.

We adapted the final decision aid, NSTEMI Decide, to a mobile health app to maximize ease of use in clinical settings. This can currently be found in Apple’s App Store and downloaded for use on iPhone or iPad (an Android version is also under development). The app is eleven pages long and can be used in English or Spanish. We used data from available trials to provide estimates of the benefits and risks of cardiac catheterization, and created visual representations (with patient input) to help make the provided estimates understandable.

Sample screenshots from NSTEMI Decide.

To our knowledge, this is the first decision aid developed for NSTEMI in older adults. We are currently studying this decision aid prospectively to evaluate feasibility of use in practice, and how it influences patients’ medical knowledge and feelings of self-efficacy. Our hope is that NSTEMI Decide may eventually be widely disseminated to help patients and clinicians better navigate care decisions together.

Sophie Montgomery is a 2nd year medical student at NYU Grossman School of Medicine.

John Dodson is a Cardiologist and Associate Professor at NYU Grossman School of Medicine.

 

aginghearts Emergency Medicine, palliative care, Patient Priorities Care, Research, Shared Decision Making

Palliative Care in the Emergency Department

Ask any older adult about their preferences foUNC Headshotr end-of-life care, and the majority of them will tell you that they would prefer to die at home rather than in a hospital. Unfortunately, this desire is often not fulfilled.

The population in the United States is aging; by 2030, 1 in 5 Americans will be over age 65. This shift in demographics has already had a significant impact on healthcare utilization, particularly in regard to emergency medical services. Not only do older adults visit the emergency department (ED) at higher rates than younger patients, but they are also more likely to be admitted and experience longer stays.

These trends are especially prominent near the end of life, with half of older adults visiting the ED within the last month of life. For those older patients who are discharged home from the ED, repeat visits are common. This often results in a vicious cycle in which older patients are repeatedly discharged home from the ED, only to return within a few months, often for the same diagnosis that brought them to the ED in the first place. Notably, there are few safeguards in place to reduce recurrent ED visits.

With the passage of the Affordable Care Act in 2010 came the Hospital Readmission Reduction Program, which allowed Medicare to reduce payments to hospitals with excessive readmission rates. As a result, hospitals created programs to reduce readmissions, such as arranging for outpatient follow-up before discharge. However, such initiatives are only available to patients who are admitted to inpatient services and do not exist for patients who are discharged home from the ED. Thus, the ED represents a pivotal point in which clinicians can intervene to improve end-of-life care and reduce recurrent ED visits among older adult patients with advanced illnesses. The question then becomes: what should those interventions be?

Utilizing the ED as a means to enroll patients in palliative care programs represents a paradigm shift that may support older adults with advanced illness and repeat ED presentations. Palliative care is a rapidly growing field that is designed to provide supplementary care to patients with serious, life-limiting illnesses by providing medical, social, and emotional support to patients and their caregivers. Importantly, palliative care does not depend on prognosis and may be delivered in conjunction with life-prolonging treatment.

Multiple studies have shown that palliative care improves quality of life among patients and their families, lessens symptom burden, reduces future ED visits, and helps patients achieve their end-of-life goals (as evidenced here and here). Further, when the American Board of Emergency Medicine officially recognized palliative medicine as a subspecialty in 2006, palliative care found a new role within the ED. As a result, there has been a surge of research regarding the benefits and feasibility of palliative care in the ED, as well as the best ways to design programs and educate providers.

Although the benefits have been well established, there are also significant barriers to implementing palliative care in the ED. Patients in the ED, particularly those in need of palliative care services, are often distressed and may not be receptive to discussions regarding end-of-life care. Additionally, some ED physicians may feel that palliative care is outside the scope of their practice. Others worry that the chaotic environment in the ED is not conducive to meaningful end-of-life care discussions, and that implementing palliative care in the ED may significantly impact wait times.

In spite of these barriers, frequent repeated ED visits are likely to become more common with the aging U.S. population, and initiating palliative care in the ED has the potential to improve care for older adults in several ways: by decreasing repeat ED visits, improving quality of life, and helping patients achieve their end-of-life goals. Future implementation science efforts may help to identify optimal strategies to deliver palliative care in the fast-moving and often disruptive ED environment.

 

By: Julia Allison Brickey
Julia Allison Brickey is a medical student at the University of North Carolina School of Medicine.

 

 

aginghearts Acute Myocardial Infarction, Coronary Intervention, Patient Priorities Care, Shared Decision Making

“I Had No Choice”: Perspectives from Heart Attack Patients on Coronary Interventional Procedures

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Photo taken at Boston Public Garden

Last week, I had the privilege of attending the Gerontological Society of America (GSA) 2018 Annual Scientific Meeting that was held in Boston, MA this year with the theme centralized around “The Purpose of Longer Lives.” GSA is one of the oldest and largest interdisciplinary organizations that is well-attended nationally by scientists, clinicians, and students who all have one thing in common: a passion for gerontology research.

Aside from connecting with many respectable researchers in the field, I also had the opportunity to present findings from our qualitative research focusing on decisional needs among older adults with cardiovascular disease. Specifically, our study sought to investigate the perspectives of older adults on coronary interventional procedures after their hospitalization for acute myocardial infarction (otherwise known as AMI, or heart attack). In recent decades, older adults have been undergoing more coronary revascularization procedures for AMI (stent placements and coronary artery bypass surgery (CABG)); consequently, procedure-related risks are more common. Moreover, time-sensitive settings during AMI at times do not allow for easy shared decision-making (SDM) discussions with their clinicians to detail these risks. Our study therefore was interested in probing further into AMI patients’ decision-making process – and to identify what factors, exactly, that led them to decide on whether or not to undergo a coronary revascularization procedure.

Based on our preliminary research from 15 patients who had been hospitalized with AMI and discharged home, the main themes that emerged were as follows:

  1. Procedural risks are perceived to be minimal when compared to perceived benefits.

Perceived procedural risks – which were generally described to be stroke, bleeding, and death – were viewed minimally when compared to the benefits. When asked to list the perceived benefits, patients mentioned “living a healthy life,” “no pains,” and “prevention of future heart attacks.”

  1. Some respondents reported that the alternative to a procedure was death.

“I would not have come to the hospital if I wanted to commit suicide,” stated one respondent. While this may be seemingly viewed as a more extreme perception of the alternative to the procedure, this theme was seen across several respondents. For example, another said, “That [turning down the procedure] didn’t enter my mind at all. In fact, I would’ve been dead at this point.” Most participants viewed that they “had no choice,” stating that they would not have been alive without the interventional procedure, and as a result, viewed the procedure was an absolute necessity.

  1. Participants place a high level of trust in their cardiologists when making decisions.

A majority of respondents revealed that faith in the physician was also a major factor contributing to their decision-making process—regardless of how long they have known their cardiologist. While one participant was loyal to their outpatient cardiologist of 28 years, others put an equal amount of trust in the interventional cardiologist whom they met on the same day of the procedure. One respondent, who was unconscious during her episode, stated: “I wasn’t thinking straight, but I had total belief that the doctors were going to take care of me.”

  1. Receiving procedural information, before or after the procedure, could aid in a better overall satisfaction of the experience.

All participants expressed that it was very important for them to understand their heart disease and associated procedures – even if it is after the procedure was completed. This was especially predominant among participants who had an ST-elevation MI (STEMI) who underwent their procedure rapidly. Some suggestions on how this could be achieved include providing a copy of the angiogram results, providing pamphlets and brochures, and sending medical personnel to explain the procedure more in-depth immediately pre-procedure, or during early recovery.

  1. All participants highly value what is perceived to be SDM.

All of our respondents, regardless of whether or not they have received a procedure, expressed a desire to have a discussion with their clinicians regarding their treatment options and the risks and benefits of a procedure.

Based on our findings, SDM has the potential to better overall patient knowledge and satisfaction with care. SDM is probably most applicable in the setting of non-ST segment AMI (NSTEMI) where there is time for more informed discussions. Notably, NSTEMI is the most common AMI presentation among older adults. We believe our work supports the future utilization of SDM in clinical practice, and perhaps, a future tool designed to better expedite the SDM process in the inpatient setting.

 

By: Jenny Summapund, MA

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aginghearts Acute Myocardial Infarction, Patient Priorities Care, Shared Decision Making

Shared Decision-Making in Acute Myocardial Infarction

Headshot_Grant_2018Several weeks ago I had the pleasure of presenting our findings from a qualitative research study we conducted at the AGS 2018 annual meeting, investigating cardiologists’ perspectives and familiarity with shared decision-making (SDM) in older adults after hospitalization for acute myocardial infarction (AMI). SDM has emerged in the literature as a way to move towards patient-centered care and has significant potential to enhance patient adherence, reduce undesired treatments, and improve overall satisfaction with care. In our study, we sought to discover the degree to which practicing cardiologists understood SDM, and whether it was applicable to their practice with older adult patients – particularly in the setting of cardiac catheterization and percutaneous coronary intervention. Five major themes emerged from these interviews:

  1. Age alone is not a major contraindication to intervention.

Our respondents consistently stated that age would not deter them from sending a patient to cardiac catheterization. Instead, they generally brought up “what kind of 80,” distinguishing chronological and biological age. Further, cardiologists generally reported treating older adults similarly to how they would treat their younger counterparts.

  1. SDM is important in the setting of NSTEMI, and not practical in STEMI:

Respondents felt that SDM was useful among patients hospitalized for NSTEMI (who represent the largest proportion of older adults with AMI). Conversely, due to the acuity of STEMI (with system-wide pressures on prompt reperfusion therapy), there was near-universal agreement that SDM was not practical in this setting.

  1. Dementia and functional status emerged as the major contraindications to intervention:

While age was not itself a major contraindication to intervention, age-related impairments such as dementia and functional status were consistently noted as reasons cardiologists would adopt a more conservative approach to care.

  1. There was some variation in cardiologists’ interpretation of SDM:

While most cardiologists saw SDM as a move away from paternalism towards patient-centered care, there was some variation in what the meaning of “shared” was among our respondents. While some respondents felt it was shared between the cardiologist and her patient, others thought it was between the patient and family members, and still others thought it was between the provider and her colleagues.

  1. A personalized (and geriatric-informed) risk calculator may help to facilitate SDM in this population for cardiologists:

Cardiologists continually highlighted the paucity of data to guide their care in the older adult population, and emphasized that a risk calculator tailored to these patients would allow them to give more specific and personalized information in order to promote SDM with accurate calculations of risk and benefit.

Our findings have several implications. The take-home message was that cardiologists generally accepted SDM as an optimal model of care, particularly in settings where the risk/benefit ratio was uncertain, but experienced some challenges with accurate prognostication. Future efforts at personalized risk calculators, tailored to older patients’ phenotypes, may help to promote SDM in practice.

 

By: Eleonore Grant, BA

Eleonore Grant was an Associate Research Coordinator at NYU Langone Health and coordinated studies on shared decision-making. She will be matriculating at medical school this Fall. 

aginghearts Patient Caregiver, Shared Decision Making

Decision Making at the End of Life

RuthMr. M was an 89- year- old male with congestive heart failure. Over the past few weeks his dyspnea had worsened such that he could no longer lay flat and had to sleep in a chair on 6L of oxygen. He also suffered from a persistent cough that was exacerbated every time he tried to speak.

Mr. M was living at home with his wife of 67 years. They had married at 21 years of age, graduated from college, had six children and built a very successful business which they co-owned and operated for over three decades. Mrs. M faced her own physical limitations, including being primarily wheelchair-bound due to a progressive myositis. Through the challenges of life, including losing two children and the more recent physical limitations of their respective illnesses, they had become inseparable.

Mr. and Mrs. M had a nearly two-decade long relationship with their primary care doctor. He attended to them with care and compassion, even occasionally doing home-visits. On this occasion, the primary care doctor found Mr. M sitting in a chair at rest with severe exertional dyspnea. After a brief physical exam he recommended admitting him to the local community hospital for further evaluation.

While his primary care doctor was focusing on the immediate differential diagnosis—was his congestive heart failure complicated by possible pneumonia? — he did not step back and look at the big picture. Mr. M had been diagnosed with congestive heart failure eight years prior and it was clear that he was nearing the end of life. The American Heart Association has published a Scientific Statement about decision making in advanced heart failure, which includes referral to hospice in patients approaching the end of life who are not deemed eligible for mechanical circulatory support or a transplant.

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“Decision Making in Advanced Heart Failure,” Circulation, American Heart Association

As Mr. M’s granddaughter, I asked if the primary care doctor would consider hospice instead of a hospitalization. I knew that my grandparents wanted to spend their last days and hours together praying, sharing from their rich stores of memories and holding hands while sleeping. After an open conversation that took into account not just Mr. M’s physical status, but his values and wishes—primarily of which was to be with his wife and surrounded by family—Mr. M was referred to hospice. A week later he passed away peacefully, without distress and surrounded by family members who were able to come to his bedside and share meaningful last words. His last words were instructions to care for his “Queen” and to make sure that she would be given an exquisite bouquet of roses after he died.

In some of our recent work of an analysis of over 1,000 patients with heart failure in hospice, we found that the Palliative Performance Scale was able to provide an accurate prediction of death for patients with heart failure in hospice up to 90 days. This tool and others can be used to support primary care healthcare providers with making a referral to hospice and discussing end-of-life options with patients and families.

We need to shift to allowing patient values to drive the decision making at the end of life. Healthcare providers need to be more open with patients and families about palliative care and hospice services, and patients and families need to be educated to ask.

 

By: Ruth Masterson Creber, PhD, MSc, RN

For additional information on Palliative Care for Heart Failure patients, please visit American College of Cardiology’s blog post: Palliative Care for Patients with Heart Failure