Video may help heart failure patients choose level of end-of-life care

A picture may be worth a thousand words. Patients with advanced heart failure who watched a short video depicting different levels of end-of-life care were more likely to choose comfort care over invasive care that could prolong their life, according to new research in the American Heart Association's journal Circulation.

Researchers said patients who watched the video were also more knowledgeable about care levels and likely to discuss end-of-life care with their doctor—evidence that the video's goal of supporting, rather than replacing, doctor/patient communication was being achieved.

"Because the course of heart failure is uncertain, in part because of improved therapies, doctors may be reluctant to initiate a conversation with their patients about advance care planning," said Areej El-Jawahri, M.D., study lead author, director of the bone marrow transplant survivorship program at Massachusetts General Hospital Cancer Center and a member of the Video Images of Disease for Ethical Outcomes (VIDEO) Consortium. "We found that when patients were better informed, it's easier for them and their doctors to discuss end-of-life issues."

Heart failure is a chronic condition in which the heart struggles to supply the body with enough blood to remain healthy. Those with advanced heart failure typically experience shortness of breath and fatigue with little or no activity, and their care often requires hospitalization.

In this study, 246 advanced heart failure patients (average age 81) from seven U.S. hospitals were given a verbal description of three levels of care they could receive at the end of their life:

• life-prolonging care, including CPR and having a tube inserted into their windpipe and being placed on a breathing machine;
• limited care, including intravenous therapy and hospitalization, but not CPR or a breathing machine; and
• comfort care, typically delivered at home with a focus on quality of life, but including hospitalization if required for symptom relief.

Half of the participants were then randomly assigned to watch a six-minute video narrated by a physician with images depicting the three levels of care. These participants also received a checklist that encouraged them to discuss end-of-life care with their doctor.

Researchers found:

• 51 percent those who watch the end-of-life care video preferred comfort care, compared to 37 percent of who did not see it;
• 68 percent of video viewers wanted to forgo CPR, compared to 35 percent of non-viewers;
• 77 percent of video viewers wanted to forgo a breathing machine, compared to 48 percent of non-viewers;
• 25 percent of video viewers chose limited care, compared to 22 percent of non-viewers;
• 2 percent of video viewers were uncertain of their preference, compared to 7 percent of non-viewers; and
• 61 percent of video viewers discussed their end-of-life choices with their physicians within 3 months, compared to 15 percent of non-viewers.

In addition, those who watched the video scored significantly higher on a test of their knowledge of care levels.

"In this case, a picture is worth a thousand words," El-Jawahri said, "After watching the video, patients have a much better sense of what procedures and therapies align with their own preferences and values."

Authors were aware that the video might unintentionally sway patient decisions, so the video's development had extensive review by healthcare professionals and heart failure patients to ensure an accurate, neutral presentation of the levels of care. El-Jawahri noted that 96 percent of participants who viewed the video said they would recommend it to others and that only 1 percent said they were "not comfortable" watching the video.

An important study limitation was the disproportionate number of white participants. "We know from multiple studies across different medical areas that racial and ethnic minorities tend to desire more aggressive care at the end of life, so these results may not generalizable," El-Jawahri said.

Researchers believe that their approach to supporting patient's end-of-life decisions through informative videos can be inexpensively offered to patients everywhere.