Frequency of Comfort Care and Palliative Care Consultation after ST-Elevation Myocardial Infarction
Madeline Abrams1, Matthew R Carey1, Shunichi Nakagawa2
1Department of Medicine (M.A., M.R.C.), Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, New York, New York, USA.
Insights
Comfort-focused care is common for patients dying from ST-elevation myocardial infarction (STEMI), especially those with cardiogenic shock. Palliative care consultation for STEMI patients remains rare and is often delayed.
Area of Science:
- Cardiology
- Palliative Care
- Medical Ethics
Background:
- ST-elevation myocardial infarction (STEMI) is a significant cause of mortality despite advancements in treatment.
- Patients with poor prognosis after STEMI increasingly require comfort-focused care strategies.
Purpose of the Study:
- To investigate the frequency of comfort-focused care approaches in STEMI patients.
- To determine the utilization and timing of palliative care consultations in STEMI patients.
Main Methods:
- Retrospective cohort study at a tertiary care academic medical center.
- Analysis of patient data, causes of death, and palliative care consultations for STEMI patients.
- Data abstracted from medical records for patients from January 2010 to July 2018.
Main Results:
- 11.4% of 536 STEMI patients died during hospitalization; 41% transitioned to comfort-focused care.
- Mechanical circulatory support (MCS) use was higher in patients transitioned to comfort care.
- Palliative care was consulted in only 9.8% of deceased STEMI patients, often late in hospitalization.
Conclusions:
- Transition to comfort-focused care is frequent in STEMI deaths, particularly with cardiogenic shock or MCS.
- Palliative care consults are underutilized and delayed in STEMI patients nearing end-of-life.
- These findings highlight the need for earlier integration of palliative care in STEMI management.
Introduction:
ST-elevation myocardial infarction (STEMI) remains a leading cause of death despite advances in revascularization and post-STEMI care. Especially for patients with a poor prognosis, there is increasing emphasis on comfort-focused care.
Methods:
We conducted a single-center retrospective cohort study of patients with STEMI at a large tertiary care academic medical center, abstracting patient-level data, causes of death, and use of palliative care consultation from the medical records. We sought to investigate the frequency of comfort-focused approaches and palliative care consultation after STEMI.
Results:
A total of 536 patients presented with or were transferred with STEMI from January 2010 to July 2018, of whom 61/536 (11.4%) died during index hospitalization. Among those who underwent percutaneous intervention (PCI), the in-hospital mortality rate was 6.8%. Median (IQR) and time to death was two (0-6) days. Among those who died, 25/61 (41%) were treated with mechanical circulatory support (MCS). A total of 25/61 (41%) patients died following transition to a comfort-focused approach. Rate of MCS utilization during hospitalization was higher in the group that was ultimately transitioned to comfort-focused measures than the group who received full treatment measures. Palliative care was consulted in the case of 6/61 (9.8%) patients. Median time to consultation was 5 (1-7) days and time to death was 6.5 (2-28) days.
Discussion:
Transition to comfort-focused care before death after STEMI is common, particularly in those with cardiogenic shock and/or treated with MCS, highlighting the critical status of such patients. Although increasingly employed in recent years, palliative care consults remain rare and are often employed late in the hospitalization.
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