Withdrawal of Care Common in STEMI, but Palliative Care Is Not

PHOENIX -- Withdrawal of care was a common cause of death for ST-elevation myocardial infarction (STEMI) patients, with only rare use of palliative care, a single-center study showed.

Overall, 24.6% of STEMI patients who died at a large tertiary care hospital had withdrawal of life-sustaining measures and 11.5% were transitioned to receive only comfort care before their death.

However, just six of the 61 -- 9.0% -- had any palliative care consultation before their death, Madeline Abrams, MD, of Columbia University Medical Center in New York City, reported at the Society for Cardiovascular Angiography and Interventions meeting here.

"When you think of post-STEMI mortality, you think of cardiac causes, there's obviously neurologic causes, there's multi-organ failure -- but what's really not in the literature is withdrawal of care and comfort measures as a 'cause of death,'" Abrams told MedPage Today.

"It's actually probably higher than expected," commented Arnold Seto, MD, MPA, of the Long Beach VA Healthcare System in California, who was not involved in the study.

While there's no way to say what the palliative care consultation rate should have been, Abrams called the 9% rate seen in the study "certainly too low."

"There's some component of the primary team being able to sort of handle these conversations on their own without the need for palliative care support," she said. "But I think palliative care support is always beneficial, both for the primary team themselves, for the patient, for the family."

Seto agreed that ideally all such patients who are critically ill with shock should get a palliative care consultant on admission. Whether in the intensive care unit (ICU), oncology, or cardiology, research has shown "palliative care is a winner," he said. "It's cost saving, et cetera. We should use it more often."

Barriers, Seto said, are the culture for medicine in general, lack of availability of palliative care off-hours, and that "many hospitals feel like they only need to call palliative care when their initial efforts fail of communicating outcomes to the family."

Abrams added that misconstruing the purpose of palliative care can also play a role: "Palliative care, I feel like oftentimes people think of it as sort of the equivalent of hospice, right? ... But it's really more about focus on comfort measures. And so even someone who is not necessarily on their way toward dying can still benefit from palliative care."

One potential solution is automating palliative care consultation for anyone who needs ICU or oncology or anyone with mechanical circulatory support (MCS), said Seto, since "in the midst of battling to save someone's life, people don't reach out to them."

The retrospective cohort study included STEMI cases seen at Columbia from January 2010 through July 2018. Of 536 patients, 61 (11.4%) died during the index hospitalization. Median time to palliative care consultation was 5 days, while median time to death was 6.5 days.

Abrams noted that all the palliative care consultations occurred after 2014, suggesting some increase over time.

Of the 41% of decedents who required MCS (25 of 61), the rate of withdrawal of care was 44.0% compared with 11.5% among other cases (P=0.006).

Who should get MCS and when is care futile "is a very active area of research and need, where we have to decide to focus this high-intensity, high-effort, high-expense treatment on patients who are most likely to benefit from it," Abrams said.

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