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Palliative Care Use in Patients With Acute Myocardial Infarction and Do-Not-Resuscitate Status From a Nationwide Inpatient Cohort

Open AccessPublished:November 10, 2022DOI:https://doi.org/10.1016/j.mayocp.2022.08.018

      Abstract

      Objective

      To examine the predictors, treatments, and outcomes of the use of palliative care in patients hospitalized with acute myocardial infarction (AMI) who had a do-not-resuscitate (DNR) order.

      Patients and Methods

      Using the National (Nationwide) Inpatient Sampling database for 2015-2018, we examined the predictors, in-hospital procedures, and outcomes of palliative care recipients among patients with AMI who had a DNR order.

      Results

      We identified 339,270 admissions with AMI that had a DNR order, including patients who received palliative care (n=113,215 [33.4%]). Compared with patients who did not receive palliative care, these patients were more frequently younger (median age, 81 vs 83 years; P<.001), were less likely to be female (50.9% [57,626 of 113,215] vs 54.7% [123,652 of 226,055]; P<.001), and were more likely to present with cardiac arrest (11.6% [13,133 of 113,215] vs 6.9% [15,598 of 226,055]; P<.001). Patients were more likely to receive palliative care at a large (odds ratio [OR], 1.47; 95% CI, 1.44 to 1.50) or teaching (OR, 2.10; 95% CI, 2.04 to 2.16) hospitals compared with small or rural ones. Patients receiving palliative care were less likely to be treated invasively, with reduced rates of invasive coronary angiography (OR, 0.46; 95% CI, 0.45 to 0.47) and percutaneous coronary intervention (OR, 0.47; 95% CI, 0.45 to 0.48), and were more likely to die in the hospital (52.4% [59,325 of 113,215] vs 22.9% [51,766 of 226,055]).

      Conclusion

      In patients who had a DNR status and were hospitalized and received a diagnosis of AMI, only one-third received palliative care.

      Abbreviations and Acronyms:

      AMI (acute myocardial infarction), CABG (coronary artery bypass grafting), CVA (cerebrovascular accident), DNR (do-not-resuscitate), ICA (invasive coronary angiography), ICU (intensive care unit), MACCE (major adverse cardiovascular and cerebrovascular event), MI (myocardial infarction), NIS (National (Nationwide) Inpatient Sample), OR (odds ratio), PCI (percutaneous coronary intervention), STEMI (ST-elevation myocardial infarction)
      Despite advances in pharmacological treatments and timely revascularization, acute myocardial infarction (AMI) remains one of the leading causes of death in the United States.
      • Menees D.S.
      • Peterson E.D.
      • Wang Y.
      • et al.
      Door-to-balloon time and mortality among patients undergoing primary PCI.
      Documentation of a do-not-resuscitate (DNR) order is part of end-of-life care that allows patients to forgo cardiopulmonary resuscitation in the event of a cardiac arrest.
      • Loertscher L.
      • Reed D.A.
      • Bannon M.P.
      • Mueller P.S.
      Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians.
      Hospitalized patients with AMI who have a DNR order represent a heterogeneous group of patients who are generally older, have multiple comorbidities, are less likely to receive invasive management, and have a significantly greater mortality burden.
      • Kobo O.
      • Moledina S.M.
      • Slawnych M.
      • et al.
      Predictors, treatments, and outcomes of do-not-resuscitate status in acute myocardial infarction patients (from a nationwide inpatient cohort study).
      Integration of palliative care services in the care of patients with advanced illnesses has been found to have numerous benefits, including, but not limited to, helping alleviate the physical and psychological discomfort of patients and their families in addition to assisting in the transition of care after an intensive care unit (ICU) stay.
      • Jneid H.
      • Addison D.
      • Bhatt D.L.
      • et al.
      2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.
      ,
      • Elgendy I.Y.
      • Elbadawi A.
      • Sardar P.
      • el al
      Palliative care use in patients with acute myocardial infarction.
      Although the use of both DNR orders
      • Kobo O.
      • Moledina S.M.
      • Slawnych M.
      • et al.
      Predictors, treatments, and outcomes of do-not-resuscitate status in acute myocardial infarction patients (from a nationwide inpatient cohort study).
      ,
      • Pollock B.D.
      • Herrin J.
      • Neville M.R.
      • et al.
      Association of do-not-resuscitate patient case mix with publicly reported risk-standardized hospital mortality and readmission rates.
      and palliative care
      • Elgendy I.Y.
      • Elbadawi A.
      • Sardar P.
      • el al
      Palliative care use in patients with acute myocardial infarction.
      has been investigated independently previously in patients with AMI, little is known about the use of palliative care in patients hospitalized with AMI and a concomitant DNR order.
      Thus, using data from a large nationwide database, we examined the predictors, treatments, and outcomes of the use of palliative care in patients hospitalized with AMI who had a DNR order.

      Patients and Methods

      The National (Nationwide) Inpatient Sample (NIS), the largest all-payer inpatient health care database in the United States, was developed by the Healthcare Cost and Utilization Project and sponsored by the Agency for Healthcare Research and Quality.

      HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2011. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/nisoverview.jsp

      Since 2012, the NIS samples discharge from all hospitals participating in the Healthcare Cost and Utilization Project, approximating a 20% stratified sample of all discharges from US community hospitals.
      We analyzed all adult (≥18 years) patients hospitalized with a principal diagnosis of AMI who also had a DNR status from October 1, 2015, through December 31, 2018. Patient and procedural characteristics were extracted using the International Classification of Diseases, Tenth Revision codes provided in Supplemental Table 1 (available online at http://www.mayoclinicproceedings.org). Information on patient demographic characteristics were recorded for each hospital discharge, including age, sex, race, admission day (weekday or weekend), expected primary payer, and median household income according to zip code. Patients with missing data for age, sex, elective admission, weekend admission, and mortality status were excluded from the analysis. Patients with type 2 myocardial infarction (MI) or elective admissions were also excluded from the analysis (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org). Each discharge record had information on up to 30 diagnoses. A full list of International Classification of Diseases, Tenth Revision, Clinical Modification codes used to identify receipt of palliative care as well as other patient characteristics and complications is provided in Supplemental Table 1. We also used International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify procedural information during hospitalization.
      The main outcome measured was in-hospital all-cause mortality. Other outcomes included in-hospital major adverse cardiovascular and cerebrovascular events (MACCEs), acute ischemic cerebrovascular accident (CVA), and major bleeding. We defined MACCE as a composite of all-cause mortality and acute ischemic CVA or transient ischemic attack. Major bleeding events were defined as a composite of gastrointestinal, retroperitoneal, intracranial, and intracerebral hemorrhage; periprocedural hemorrhage; unspecified hemorrhage; or need for a blood transfusion. Destination of discharge and receipts of invasive procedures such as invasive coronary angiography (ICA), percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), mechanical ventilation, and circulatory support were also measured.
      Continuous variables are presented as median and interquartile range due to skewed data, and categorical data are presented as frequencies and percentages. Categorical variables were compared using the Pearson χ2 test, while continuous variables were compared using the Student t test or the Mann-Whitney U test, as appropriate. Sampling weights were used to calculate the estimated total discharges as specified by the Agency for Healthcare Research and Quality. Multivariable logistic regression models were used to examine the association between demographic characteristics and comorbidities and receipt of palliative care, as well as the association between receipt of palliative care and in-hospital outcomes and procedures among patients with DNR status, all expressed as odds ratios (ORs) with corresponding 95% CIs. The models were adjusted for baseline differences between the groups, controlling for the following covariates: age; sex; weekend admission; hospital size (number of beds); region and location/teaching status; ST-elevation MI (STEMI); cardiogenic shock; use of intra-aortic balloon pump, CABG, PCI, or ICA; ventricular fibrillation; ventricular tachycardia; atrial fibrillation; heart failure; hypertension; dyslipidemia; diabetes mellitus; valvular heart disease; smoking status; chronic lung disease; chronic liver disease; chronic renal failure; anemia; obesity; thrombocytopenia; coagulopathies; and malignancies.
      All statistical analyses were performed with IBM SPSS statistical software, version 26. Statistical significance was set at the 2-tailed P=.05 level, without multiplicity adjustment.

      Results

      Between October 2015 and December 2018, 2,959,244 patients were admitted to US hospitals and during the hospitalization received a principal diagnosis of AMI. Application of relevant inclusion and exclusion criteria (Supplemental Figure 1) produced a study cohort of 339,270 patients, 113,215 (33.4%) of whom received palliative care. Differences in clinical characteristics between the 2 groups (those with and without palliative care) at admission are presented in Table 1. Recipients of palliative care were younger (median age, 81 vs 83 years; P<.001), less likely to be female (57,626 of 113,215 [50.9%] vs 123,652 of 226,055 [54.7%]; P<.001), less often White (89,664 of 113,215 [79.2%] vs 185,366 of 226,055 [82.0%]; P<.001), and less likely to have Medicare insurance (92,096 of 113,215 [81.4%] vs 197,701 of 226,055 [87.7%]; P<.001), while the highest proportion of patients receiving palliative care were admitted to large (61,703 of 113,215 [54.5%] vs 110,541 of 226,055 [48.9%]; P<.001) and teaching (81,062 of 113,215 [71.6%] vs 142,640 of 226,055 [63.1%]; P<.001) hospitals. Patients who received palliative care were more likely to be admitted with STEMI (23,090 of 113,215 [20.4%] vs 33,004 of 226,055 [14.6%]; P<.001) and to experience cardiac arrest (13,133 of 113,215 [11.6%] vs 15,598 of 226,055 [6.9%]; P<.001), cardiogenic shock (19,248 of 113,215 [17.0%] vs 19,441 of 226,055 [8.6%]; P<.001), or ventricular arrhythmias (ventricular fibrillation, 5,887 of 113,215 [5.2%] vs 6,556 of 226,055 [2.9%]; ventricular tachycardia, 9,855 of 113,215 [8.7%] vs 14,015 of 226,055 [6.2%]; both P<.001).
      Table 1Characteristics of 339,270 Study Patients With DNR Orders, Stratified by Receipt of Palliative Care
      CABG, coronary artery bypass grafting; DNR, do-not-resuscitate; IQR, interquartile range; MI, myocardial infarction; NA, not applicable; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation MI.
      ,
      Data are presented as No. (percentage) of patients unless indicated otherwise.
      VariableNo palliative carePalliative careP value
      No. of weighted records226,055 (66.6)113,215 (33.4)NA
      Age (y), median (IQR)83 (74-90)81 (71-89)<.001
      Female123,652 (54.7)57,626 (50.9)<.001
      Race<.001
       White185,366 (82.0)89,664 (79.2)
       Black16,728 (7.4)10,982 (9.7)
       Hispanic13,111 (5.8)6,340 (5.6)
       Asian/Pacific Islander5,651 (2.5)3,283 (2.9)
       Native American904 (0.4)453 (0.4)
       Other4,295 (1.9)2,493 (2.2)
      Hospital location<.001
       Northeast51,315 (22.7)22,545 (19.9)
       Midwest60,131 (26.6)30,723 (27.1)
       South75,728 (33.5)41,368 (36.5)
       West38,881 (17.2)18,579 (16.4)
      Hospital size<.001
       Small47,019 (20.8)18,114 (16.0)
       Medium68,495 (30.3)33,398 (29.5)
       Large110,541 (48.9)61,703 (54.5)
      Hospital location/teaching status<.001
       Rural27,353 (12.1)7,585 (6.7)
       Urban nonteaching56,062 (24.8)24,568 (21.7)
       Teaching142,640 (63.1)81,062 (71.6)
      Weekend admission61,939 (27.4)30,790 (27.2).16
      Median zip code income<.001
       1st quartile61,919 (27.4)31,134 (27.5)
       2nd quartile63,190 (28.0)30,565 (27.0)
       3rd quartile55,835 (24.7)27,851 (24.6)
       4th quartile45,111 (20.0)23,665 (20.9)
      Expected primary payer<.001
       Medicare197,701 (87.5)92,096 (81.4)
       Medicaid7,380 (3.3)5,492 (4.9)
       Private14,920 (6.6)10,805 (9.5)
       Uninsured2,713 (1.2)1,801 (1.6)
       No charge226 (0.1)105 (0.1)
       Other3,115 (1.4)2,916 (2.6)
      Record characteristics
       STEMI33,004 (14.6)23,090 (20.4)<.001
       Cardiac arrest15,598 (6.9)13,133 (11.6)<.001
       Ventricular fibrillation6,556 (2.9)5,887 (5.2)<.001
       Ventricular tachycardia14,015 (6.2)9,855 (8.7)<.001
       Cardiogenic shock19,441 (8.6)19,248 (17.0)<.001
      Comorbidities
       Previous MI33,682 (14.9)13,925 (12.3)<.001
       Cerebrovascular disease19,989 (8.4)9,398 (8.3).71
       Heart failure127,721 (56.5)64,080 (56.6).5
       Valvular disease48,602 (21.5)20,718 (18.3)<.001
       Atrial fibrillation/flutter83,414 (36.9)42,342 (37.4)<.001
       Hypertension186,948 (82.7)87,170 (77.0)<.001
       Dyslipidemia118,452 (52.4)48,342 (42.7)<.001
       Diabetes85,448 (37.8)28,070 (24.8)<.001
       Smoking80,928 (35.8)38,708 (34.2)<.001
       Peripheral vascular disease26,222 (11.6)12,230 (10.8)<.001
       Chronic lung disease66,913 (29.6)32,275 (28.5)<.001
       Chronic renal failure90,189 (39.9)43,020 (38.0)<.001
       Obesity20,334 (9.0)8,945 (7.9)<.001
       Anemia84,994 (37.6)44,275 (39.1)<.001
       Thrombocytopenia19,2107 (8.5)12,785 (11.3)<.001
       Coagulopathy7,911 (3.5)7,360 (6.5)<.001
       Dementia55,603 (24.6)28,525 (25.2)<.001
       Chronic liver disease2,476 (1.1)1,590 (1.4)<.001
       Homelessness385 (0.2)232 (0.2).03
       Solid malignancy13,770 (6.1)11,770 (10.4)<.001
       Hematologic malignancies5,185 (2.3)3,857 (3.4)<.001
       Metastatic cancer7,469 (3.3)8,040 (7.1)<.001
      In-hospital procedures
       Coronary angiography47,026 (20.8)16,650 (14.7)<.001
       PCI25,989 (11.5)9,175 (8.1)<.001
       CABG2,476 (1.1)915 (0.8)<.001
       Thrombolysis206 (0.1)42 (0.04)<.001
      a CABG, coronary artery bypass grafting; DNR, do-not-resuscitate; IQR, interquartile range; MI, myocardial infarction; NA, not applicable; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation MI.
      b Data are presented as No. (percentage) of patients unless indicated otherwise.
      Patients who received palliative care had a lower prevalence of previous MI (13,925 of 113,215 [12.3%] vs 33,682 of 226,055 [14.9%]; P<.001), valvular heart disease (20,718 of 113,215 [18.3%] vs 48,602of 226,055 [21.5%]; P<.001), and cardiovascular risk factors including hypertension (87,170 of 113,215 [77.0%] vs 186,948 of 226,055 [82.7%]; P<.001), dyslipidemia (48,342 of 113,215 [42.7%] vs 118,452 of 226,055 [52.4%]; P<.001), and diabetes mellitus (28,070 of 113,215 [24.8%] vs 85,448 of 226,055 [37.8%]; P<.001). Conversely, they had a higher prevalence of thrombocytopenia (12,785 of 113,215 [11.3%] vs 19,2107 of 226,055 [8.5%]; P<.001), coagulopathy (7,360 of 113,215 [6.5%] vs 7,911 of 226,055 [3.5%]; P<.001), and malignancies (solid, 11,770 of 113,215 [10.4%] vs 13,770 of 226,055 [6.1%]; hematologic, 3,857 of 113,215 [3.4%] vs 5,185 of 226,055 [2.3%]; metastatic, 8,040 of 113,215 [7.1%] vs 7,469 of 226,055 [3.3%]; all P<.001) compared with those who did not receive palliative care.
      The destination of discharge for patients is shown in Supplemental Figure 2 (available online at http://www.mayoclinicproceedings.org). Recipients of palliative care were less likely to be discharged home (3,290 of 113,215 [2.9%] vs 42,510 of 226,055 [18.8%]) and to receive home health care (16,417of 113,215 [14.5%] vs 38,437 of 226,055 [17.0%]) and were more likely to die in the hospital (59,325 of 113,215 [52.4%] vs 51, 766 of 226,055 [22.9%]).
      Factors independently associated with receipt of palliative care are summarized in Supplemental Table 2 (available online at http://www.mayoclinicproceedings.org). Positive predictors included Black (OR,1.12; 95% CI, 1.09 to 1.15) or Asian/Pacific Islander (OR, 1.17; 95% CI, 1.11 to 1.22) race and medium (OR,1.26; 95% CI, 1.23 to 1.29), large (OR, 1.47; 95% CI, 1.44 to 1.50), urban (OR, 1.59; 95% CI, 1.54 to 1.64), and teaching (OR, 2.10; 95% CI, 2.04 to 2.16) hospitals. Comorbidities including thrombocytopenia (OR, 1.19; 95% CI, 1.16 to 1.22), dementia (OR, 1.22; 95% CI, 1.20 to 1.24), malignancies (solid—OR,1.32; 95% CI, 1.28 to 1.36; hematologic—OR, 1.32; 95% CI, 1.26 to 1.38), and metastases (OR, 1.62; 95% CI, 1.55 to 1.69) were positive predictors of palliative care receipt. Female sex was a negative predictor for receipt of palliative care (OR, 0.93; 95% CI, 0.91 to 0.95), as were traditional cardiovascular risk factors (hypertension—OR, 0.83; 95% CI, 0.81 to 0.95; dyslipidemia—OR, 0.75; 95% CI, 0.74 to 0.76; diabetes—OR, 0.92; 95% CI, 0.91 to 0.94; smoking—OR, 0.88; 95% CI, 0.87 to 0.90; and obesity—OR, 0.86; 95% CI, 0.84 to 0.88).
      Differences in the management strategy and outcomes between the 2 groups are presented in Table 2. Patients who received palliative care were less likely to undergo ICA (16,670 of 113,215 [14.7%] vs 47,026 of 226,055 [20.8%]; P<.001), PCI (9,230 of 113,215 [8.1%] vs 25,989 of 226,055 [11.5%]; P<.001), or CABG (915of 113,215 [0.8%] vs 2,476 of 226,055 [1.1%]; P<.001). They were more likely to receive circulatory support (5,890 of 113,215 [5.2%] vs 7,230 of 226,055 [3.2%]; P<.001) or undergo mechanical ventilation during admission (37,140 of 113,215 [32.8%] vs 37,980 of 226,055 [16.8%]; P<.001).
      Table 2In-Hospital Procedures and Outcomes Among 339,270 Study Patients With DNR Status, Stratified by Receipt of Palliative Care
      CABG, coronary artery bypass grafting; CVA, cerebrovascular accident; DNR, do-not-resuscitate; ECMO, extracorporeal membrane oxygenation; GI, gastrointestinal; IABP, intra-aortic balloon pump; LV, left ventricle; MACCE, major adverse cardiovascular and cerebrovascular event; NA, not applicable; PCI, percutaneous coronary intervention.
      ,
      MACCE is defined as a composite of all-cause mortality, acute ischemic CVA or transient ischemic attack, and cardiac complications.
      VariableNo palliative care, No. (%)Palliative care, No. (%)P value
      No. of weighted records226,055 (66.6)113,215 (33.4)NA
      In-hospital procedures
       Coronary angiography47,026 (20.8%)16,670 (14.7%)<.001
       PCI25,989 (11.5%)9,230 (8.1%)<.001
       CABG2,476 (1.1%)915 (0.8%)<.001
       Thrombolysis206 (0.1%)42 (0.04)<.001
       Circulatory support (including IABP, LV assist device, and ECMO)7,230 (3.2%)5,890 (5.2%)<.001
       Mechanical ventilation37,980 (16.8%)37,140 (32.8%)<.001
      In-hospital outcomes
       MACCE
      MACCE is defined as a composite of all-cause mortality, acute ischemic CVA or transient ischemic attack, and cardiac complications.
      61, 045 (27.0%)64, 775 (57.2%)<.001
       Mortality51,766 (22.9%)59,325 (52.4%)<.001
       Acute ischemic CVA10,178 (4.5%)10,313 (9.1%)<.001
       Major bleeding16,720 (7.4%)12 ,230 (10.8%)<.001
      GI bleed13,150 (5.8%)8,270 (7.3%)<.001
      Procedure-related bleeding930 (0.4%)455 (0.4%).07
      Retroperitoneal bleed460 (0.2%)448 (0.4%)<.001
      Intracranial hemorrhage2,490 (1.1%)3405 (3.0%)<.001
      a CABG, coronary artery bypass grafting; CVA, cerebrovascular accident; DNR, do-not-resuscitate; ECMO, extracorporeal membrane oxygenation; GI, gastrointestinal; IABP, intra-aortic balloon pump; LV, left ventricle; MACCE, major adverse cardiovascular and cerebrovascular event; NA, not applicable; PCI, percutaneous coronary intervention.
      b MACCE is defined as a composite of all-cause mortality, acute ischemic CVA or transient ischemic attack, and cardiac complications.
      In-hospital mortality (59,325 of 113,215 [52.4%] vs 51,766 of 226,055 [22.9%]; P<.001), acute ischemic CVA (10,313 of 113,215 [9.1%] vs 10,178 of 226,055 [4.5%]; P<.001), major bleeding (12,230 of 113,215 [10.8%] vs 16,720 of 226,055 [7.4%]; P<.001), and MACCE (64,772 of 113,215 [57.2%] vs 61,045 of 226,055 [27.0%]; P<.001) were all significantly more frequent in the palliative care group.
      When adjusted for important baseline characteristics and comorbidities (Table 3), patients receiving palliative care had lower odds of ICA (OR, 0.46; 95% CI, 0.45 to 0.47) and PCI (OR, 0.47; 95% CI, 0.45 to 0.48) and higher odds of adverse in-hospital clinical outcomes such as mortality (OR, 3.18; 95% CI, 3.13 to 3.23), acute ischemic CVA (OR, 2.01; 95% CI, 1.95 to 2.06), MACCE (OR, 3.08; 95% CI, 3.03 to 3.13), and major bleeding (OR, 1.30; 95% CI, 1.26 to 1.33).
      Table 3Adjusted OR of Patients With DNR Orders and Receipt of Palliative Care for In-Hospital Procedures and Outcomes During Hospitalization for AMI
      AF, atrial fibrillation; AMI, acute myocardial infarction; CVA, cerebrovascular accident; DNR, do-not-resuscitate; ECMO, extracorporeal membrane oxygenation; HF, heart failure; IABP, intra-aortic balloon pump; LV, left ventricle; MACCE, major adverse cardiovascular and cerebrovascular event; MI, myocardial infarction; OR, odds ratio; PVD, peripheral vascular disease; STEMI, ST-elevation MI; VF, ventricular fibrillation; VT, ventricular tachycardia.
      ,
      Reference: DNR with no palliative care.
      VariableOR (95% CI)P value
      In-hospital procedures
       Invasive coronary angiography
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, and malignancies.
      0.46 (0.45-0.47)<.001
       PCI
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, and malignancies.
      0.47 (0.45-0.48)<.001
       Circulatory support (including IABP, LV assist device, and ECMO)
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, and malignancies.
      0.90 (0.86-0.94)<.001
       Mechanical ventilation
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, and malignancies.
      1.95 (1.91-1.99)<.001
      In-hospital outcomes
       MACCE
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, malignancies, and in-hospital procedures.
      3.08 (3.03-3.13)<.001
       Mortality
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, malignancies, and in-hospital procedures.
      3.18 (3.13-3.23)<.001
       Acute ischemic CVA
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, malignancies, and in-hospital procedures.
      2.01 (1.95-2.06)<.001
       Major bleeding
      Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, malignancies, and in-hospital procedures.
      1.30 (1.26-1.33)<.001
      a AF, atrial fibrillation; AMI, acute myocardial infarction; CVA, cerebrovascular accident; DNR, do-not-resuscitate; ECMO, extracorporeal membrane oxygenation; HF, heart failure; IABP, intra-aortic balloon pump; LV, left ventricle; MACCE, major adverse cardiovascular and cerebrovascular event; MI, myocardial infarction; OR, odds ratio; PVD, peripheral vascular disease; STEMI, ST-elevation MI; VF, ventricular fibrillation; VT, ventricular tachycardia.
      b Reference: DNR with no palliative care.
      c Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, and malignancies.
      d Adjusted for age, sex, weekend admission, hospital size (number of beds), region and location/teaching status, STEMI, cardiogenic shock, VF, VT, AF, previous MI, HF, hypertension, dyslipidemias, diabetes mellitus, valvular heart disease, smoking status, chronic lung disease, chronic liver disease, chronic renal failure, PVD, obesity, anemia, thrombocytopenia, coagulopathies, malignancies, and in-hospital procedures.
      Our key study findings are summarized in the Figure.
      Figure thumbnail gr1
      FigureKey study findings. AMI, acute myocardial infarction; CVA, cerebrovascular accident; DNR, do-not-resuscitate; ICA, invasive coronary angiogram; MACCE, major adverse cardiovascular and cerebrovascular event; PCI, percutaneous coronary intervention.

      Discussion

      The results of this analysis of more than 300,000 patients with a DNR status who were admitted to US hospitals between 2015 and 2018 and during the hospitalization received a diagnosis of AMI revealed several important findings. First, only 1 of 3 patients in this heterogeneous group received palliative care. Second, patients less frequently received palliative care if they were female or presented with cardiovascular risk factors including previous MI, hypertension, dyslipidemia, diabetes, or smoking, whereas they were more likely to receive palliative care if they had comorbidities including heart failure, malignancy (solid or hematologic), or metastatic cancer. Third, they were less likely to obtain palliative care if they presented at a small hospital compared with a medium or large hospital or presented to a rural hospital compared with a suburban or teaching hospital. Fourth, patients who were in receipt of palliative care were less likely to receive in-hospital procedures including ICA and PCI. Finally, patients with a DNR status who obtained palliative care had increased adjusted odds of in-hospital mortality, acute ischemic CVA, major bleeding, and MACCE.
      Our study identified several patient-related characteristics that were associated with palliative care use, including ventricular arrhythmias, cardiogenic shock or arrest, STEMI, and malignancy. It is likely that physicians recognize these high-risk factors and subsequently provide palliative care to these patients. Importantly, the frequency of patients receiving circulatory support or mechanical ventilation was significantly higher in the cohort that received palliative care. This is an unexpected finding because one of the key principles of palliative care is de-escalation of treatments. Thus, it is possible that this finding is a reflection of treatment failures. This finding raises questions about the appropriateness of such interventions when it may have been more appropriate to get early involvement with palliative care.
      Our analysis, like that of others,
      • Elgendy I.Y.
      • Elbadawi A.
      • Sardar P.
      • el al
      Palliative care use in patients with acute myocardial infarction.
      revealed that both the size and type of hospital played an important role in which patients received palliative care. Patients in teaching and urban hospitals were more likely to receive palliative care than those in rural ones. Access to palliative care has been found to be an important proxy outcome measure to determine the quality of care patients receive prior to death, such that in 2014 the World Health Organization made a global resolution to improve palliative care access as a core component of health care.
      • Carrasco J.M.
      • Inbadas H.
      • Whitelaw A.
      • Clark D.
      Early impact of the 2014 World Health Assembly resolution on palliative care: a qualitative study using semistructured interviews with key experts.
      ,
      • Chukwusa E.
      • Verne J.
      • Polato G.
      • Taylor R.
      • Higginson I.J.
      • Gao W.
      Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK.
      Although access to health care is both a complex and multidimensional concept,
      • Gulliford M.
      • Figueroa-Munoz J.
      • Morgan M.
      • et al.
      What does 'access to health care' mean?.
      it is likely that institutional factors and geography are implicated in less frequent palliative care in patients who were treated in rural and small hospitals. Chukwusa et al
      • Chukwusa E.
      • Verne J.
      • Polato G.
      • Taylor R.
      • Higginson I.J.
      • Gao W.
      Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK.
      found considerable variations in geographic access to inpatient hospice, with evidence that patients who lived further away from hospice locations were less likely to die in a hospice facility. There may be both a lack of availability of palliative care and awareness of the need for this care in the AMI population. Observations that this disparity of care exists for this heterogeneous group of patients with AMI are an important step forward because better access to palliative care is likely to reduce this disparity gap.
      Our analysis demonstrates that sex disparities exist, with women who have a DNR status being less likely than their male counterparts to receive a palliative care consultation. This finding is surprising because another recent study in an unselected cohort of patients with AMI reported that females were more likely to receive palliative care.
      • Elgendy I.Y.
      • Elbadawi A.
      • Sardar P.
      • el al
      Palliative care use in patients with acute myocardial infarction.
      Similarly, Saeed et al
      • Saeed F.
      • Hoerger M.
      • Norton S.A.
      • Guancial E.
      • Epstein R.M.
      • Duberstein P.R.
      Preference for palliative care in cancer patients: are men and women alike?.
      reported that in patients diagnosed with cancer, women were significantly more likely to prefer palliative care than men, whereas a multisite prospective cohort study by Sharma et al
      • Sharma R.K.
      • Prigerson H.G.
      • Penedo F.J.
      • Maciejewski P.K.
      Male-female patient differences in the association between end-of-life discussions and receipt of intensive care near death.
      found that men with cancer were more likely to receive aggressive nonbeneficial intensive care near the end of their life. We previously reported that females who were diagnosed with AMI were more likely than men to have a DNR order.
      • Kobo O.
      • Moledina S.M.
      • Slawnych M.
      • et al.
      Predictors, treatments, and outcomes of do-not-resuscitate status in acute myocardial infarction patients (from a nationwide inpatient cohort study).
      In this high-risk cohort of patients, it is likely that there is a complex interplay between a person’s own wishes and priorities toward the end of their life. Given that the presentation and perception of the symptoms of AMI differ between the sexes, it is possible that this may also be a factor in the differences of management.
      • Lichtman J.H.
      • Leifheit E.C.
      • Safdar B.
      • et al.
      Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients).
      ,
      • Zucker D.R.
      • Griffith J.L.
      • Beshansky J.R.
      • Selker H.P.
      Presentations of acute myocardial infarction in men and women.
      It is important to recognize that there are differences in the use of palliative care in this cohort based on race. In our study, patients who were Black and Asian/Pacific Islander were more likely to receive palliative care consultation than White patients, whereas Hispanic patients were less likely to receive such care than White patients. In a previous population-based study of 1212 patients, Ornstein et al
      • Ornstein K.A.
      • Roth D.L.
      • Huang J.
      • et al.
      Evaluation of racial disparities in hospice use and end-of-life treatment intensity in the REGARDS cohort.
      found that Black individuals were significantly less likely to use hospice and more likely to undergo intensive treatment in the last 6 months of their lives than White individuals regardless of cause of death. Although patient preference and cultural differences are a key factor in differences in the use of palliative care, it is reassuring to see that in this high-risk cohort of patients, Black individuals are not disadvantaged in the receipt of palliative care.
      Although the AMI cohort of patients who have a DNR order represents a group that generally has poor outcomes and is less likely to receive invasive management compared with those without a DNR order,
      • Kobo O.
      • Moledina S.M.
      • Slawnych M.
      • et al.
      Predictors, treatments, and outcomes of do-not-resuscitate status in acute myocardial infarction patients (from a nationwide inpatient cohort study).
      our analysis revealed that patients who receive palliative care are even less likely to undergo invasive management. One of the key facets of palliative care is “active listening,” in which equal importance is placed on patients’ attitude regarding their condition and understanding their fears, concerns, and priorities.
      • Wittenberg-Lyles E.
      • Goldsmith J.
      • Platt C.S.
      Palliative care communication.
      • Wentlandt K.
      • Seccareccia D.
      • Kevork N.
      • et al.
      Quality of care and satisfaction with care on palliative care units.
      • Shaw M.
      • Shaw J.
      • Simon J.
      Listening to patients' own goals: a key to goals of care decisions in cardiac care.
      In conditions such as heart failure and cancer, patients with advanced disease often have a preference to not be treated aggressively, with the focus on prioritizing their quality of life.
      • Duberstein P.R.
      • Kravitz R.L.
      • Fenton J.J.
      • et al.
      Physician and patient characteristics associated with more intensive end-of-life care.
      Our results suggest a similar pattern in this high-risk cohort of patients with AMI in which the focus of management is likely to be patient-centered and less focused on interventions that prolong life. The clinical outcomes for patients with AMI including mortality, acute ischemic CVA, major bleeding, and MACCE were significantly worse in patients who received palliative care. This finding is likely multifactorial and in part may be that the patients receiving palliative care are likely to represent a more unwell group of patients who would generally have worse clinical outcomes and may thus be less likely to be offered life-prolonging–focused interventions.
      Importantly, our study does not have temporal data on the timing of the DNR order, receipt of palliative care, or its relationship with the timing of the AMI. Thus, it is important to recognize that the group of patients who received palliative care in this cohort reflects a highly heterogeneous group of patients. For instance, patients may range from those who had a multimorbidity burden and a preexisting DNR order who were subsequently hospitalized with a noncardiac cause and had an AMI in the hospital to those who were previously well, were admitted to the hospital with an AMI, and initiated a DNR order and palliative care in the hospital following a catastrophic complication. Thus, there exists a highly complex interplay of the receipt of palliative care and its timing in relationship to both a DNR order and the timing of the AMI. For many conditions such as cancer, the initiation of a DNR order has become synonymous with the involvement of palliative care and recognition that the priority of care for the patient and their families should be switched to prioritizing comfort.

      Espeli VG, Fusi-Schimdhauser T, Mangan D, Gamondi C. The role of palliative care in relapsed and metastatic head and neck cancer patients in a single ESMO integrated oncology and palliative care centre [published online ahead of print July 12, 2022; correction published online August 5, 2022 (https://doi.org/10.1007/s00405-022-07583-5)]. Eur Arch Otorhinolaryngol. https://doi.org/10.1007/s00405-022-07535-z

      Importantly, this relationship has not been well defined for AMI, and differences are likely given the varied patient populations and treatments in comparison to patients who have cancer.
      • Kobo O.
      • Moledina S.M.
      • Raisi-Estabragh Z.
      • et al.
      Emergency department cardiovascular disease encounters and associated mortality in patients with cancer: a study of 20.6 million records from the USA.
      Thus, our study raises questions about the timing of palliative care within the realms of AMI in view of the immediate lifesaving treatments available, particularly PCI for patients with STEMI. In the past decade, both DNR orders and palliative care have been used increasingly in an ICU setting, both for patients who are expected to die in the ICU and for those discharged either to home or to another department within the hospital, where early involvement has been found to be beneficial.
      • Aslakson R.A.
      • Curtis J.R.
      • Nelson J.E.
      The changing role of palliative care in the ICU.
      ,
      • Cook D.
      • Rocker G.
      Dying with dignity in the intensive care unit.
      Given the parallels between ICU care and cardiac diseases, it is likely there are lessons to be learned on the timing of involvement of palliative care for patients with AMI by looking at successful use in the ICU.
      Our analysis has important clinical implications for practice. Cardiology as a specialty has often been criticized for its reluctance to utilize palliative care, largely attributed to advances in cardiovascular sciences over the past 20 years that allow patients with advanced heart disease to survive events that previously would have been fatal.
      • Warraich H.J.
      • Hernandez A.F.
      • Allen L.A.
      How medicine has changed the end of life for patients with cardiovascular disease.
      • Hanratty B.
      • Hibbert D.
      • Mair F.
      • et al.
      Doctors' understanding of palliative care.
      • Ecarnot F.
      • Meunier-Beillard N.
      • Seronde M.-F.
      • et al.
      End-of-life situations in cardiology: a qualitative study of physicians' and nurses' experience in a large university hospital.
      It is important to recognize that a DNR order only reflects the desires of a patient once they experience a full cardiopulmonary arrest and does not reflect their preferences about other forms of life-sustaining treatment. Thus, in this high-risk cohort of patients with poor outcomes, it is likely that increased use of palliative care will have significant benefits for patients and their families in deciding which treatments they would be willing to accept and focusing on their key priorities.
      • Hoare S.
      • Morris Z.S.
      • Kelly M.P.
      • Kuhn I.
      • Barclay S.
      Do patients want to die at home? a systematic review of the UK literature, focused on missing preferences for place of death.
      Of concern, the lower rates of discharge to home with home health care or to a nursing home suggests that in this cohort, palliative care was mostly being reserved as end-of-life care for those identified as at high risk of dying during that hospitalization. “Late” use of palliative care has been reported similarly by others,
      • Warraich H.J.
      • Wolf S.P.
      • Mentz R.J.
      • Rogers J.G.
      • Samsa G.
      • Kamal A.H.
      Characteristics and trends among patients with cardiovascular disease referred to palliative care.
      and cardiologists are increasingly being asked to reframe palliative care as a useful added layer of support for those with advanced illness, not just in the final weeks of life but potentially over months and years.
      • Klinedinst R.
      • Kornfield Z.N.
      • Hadler R.A.
      Palliative care for patients with advanced heart disease.
      ,
      • Braun L.T.
      • Grady K.L.
      • Kutner J.S.
      • et al.
      American Heart Association Advocacy Coordinating Committee. Palliative care and cardiovascular disease and stroke: a policy statement from the American Heart Association/American Stroke Association.
      There are several barriers to earlier referral,
      • Bonares M.J.
      • Mah K.
      • MacIver J.
      • et al.
      Referral practices of cardiologists to specialist palliative care in Canada.
      but greater education for physicians and integrated-care pathways with palliative care teams are likely to facilitate a more timely patient-centered approach.
      This study has several strengths. Our analysis represents the largest study to date that examined the use of palliative care in a heterogeneous high-risk group of patients with a diagnosis of AMI who had a DNR status. The NIS database gives insight into the real-world in-hospital outcomes in a large and unselected cohort of patients with AMI, including those who are at high risk and have multiple comorbid illnesses, such that they are underrepresented in clinical trials. The size of the database provides sufficient power to detect differences in adverse outcomes between the 2 cohorts of interest.
      Our study also has several important limitations. Despite the NIS using International Classification of Diseases, Tenth Revision codes and being a validated data set for the purposes of cardiovascular research,
      • Birman-Deych E.
      • Waterman A.D.
      • Yan Y.
      • Nilasena D.S.
      • Radford M.J.
      • Gage B.F.
      Accuracy of ICD-9-CM codes for identifying cardiovascular and stroke risk factors.
      ,
      • DeShazo J.P.
      • Hoffman M.A.
      A comparison of a multistate inpatient EHR database to the HCUP Nationwide Inpatient Sample.
      it is an administrative data set, and coding error may be a source of bias. The identification of AMI, DNR status, palliative care, comorbidities, and procedural data was based on the use of administrative codes. Second, the NIS data set only records in-hospital outcomes, and therefore, longer-term follow-up of mortality or other adverse outcomes is missing from our analysis. Third, because the database does not include pharmacotherapy, we were unable to determine if there was a significant disparity in care between the 2 groups regarding pharmacotherapy or to see if the use of pharmacotherapy altered clinical outcomes for those patients with palliative care. Furthermore, the NIS does not capture when the DNR order was instituted, whether it was in place prior to admission,
      • Saczynski J.S.
      • Gabbay E.
      • McManus D.D.
      • et al.
      Increase in the proportion of patients hospitalized with acute myocardial infarction with do-not-resuscitate orders already in place between 2001 and 2007: a nonconcurrent prospective study.
      at the point of admission, or during the inpatient episode following a complication/adverse outcome. Thus, the intention of the palliative care is unknown. Similarly, we do not know the timing of the palliative care in relationship to the diagnosis of AMI (even though there is a suggestion that it might be late) or to the DNR status. Importantly, we also don’t know whether receipt of palliative care means that patients received high-quality palliative care, nor that they received specialist palliative care consultation. It is also possible that unmeasured confounders such as frailty or malnutrition may contribute to the adverse association that we report in patients referred for palliative treatment. Finally, the process by which the palliative care was established and how patients’ preferences were elicited in decision making is unknown.

      Conclusion

      Our study found that in hospitalized patients who had a DNR status and received a diagnosis of AMI, only one-third received palliative care. Females, patients presenting at small or rural hospitals, and those with cardiovascular comorbidities were less likely to receive palliative care, whereas patients who had multiple comorbidities with heart failure or malignancy were more likely to receive palliative care. Patients who received palliative care had increased adjusted odds of in-hospital mortality, acute ischemic CVA, major bleeding, and MACCE. Further evaluation of the use of palliative care, particularly in patients who had a DNR order in place prior to admission with an AMI, is required to determine its appropriateness and to facilitate greater use in this high-risk cohort of patients.

      Potential Competing Interests

      The authors report no competing interests.

      Acknowledgments

      Drs Kobo and Moledina are joint first authors of this article.
      Authors contributions: Dr Kobo—Data curation, formal analysis, writing/original draft; Dr Moledina—Writing/original draft; Dr Mohamed—Writing, review editing; Dr Sinnarajah—Writing, review editing; Dr Simon—Writing, review editing; Dr Sun—Writing, review editing; Dr Slawnych—Writing, review editing; Dr Fischman—Writing, review editing; Dr Roguin—Writing, review editing; Dr Mamas—Conceptualization, project administration, supervision, writing, review editing.

      Supplemental Online Material

      References

        • Menees D.S.
        • Peterson E.D.
        • Wang Y.
        • et al.
        Door-to-balloon time and mortality among patients undergoing primary PCI.
        N Engl J Med. 2013; 369: 901-909
        • Loertscher L.
        • Reed D.A.
        • Bannon M.P.
        • Mueller P.S.
        Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians.
        Am J Med. 2010; 123: 4-9
        • Kobo O.
        • Moledina S.M.
        • Slawnych M.
        • et al.
        Predictors, treatments, and outcomes of do-not-resuscitate status in acute myocardial infarction patients (from a nationwide inpatient cohort study).
        Am J Cardiol. 2021; 159: 8-18
        • Jneid H.
        • Addison D.
        • Bhatt D.L.
        • et al.
        2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.
        J Am Coll Cardiol. 2017; 70: 2048-2090
        • Elgendy I.Y.
        • Elbadawi A.
        • Sardar P.
        • el al
        Palliative care use in patients with acute myocardial infarction.
        J Am Coll Cardiol. 2020; 75: 113-117
        • Pollock B.D.
        • Herrin J.
        • Neville M.R.
        • et al.
        Association of do-not-resuscitate patient case mix with publicly reported risk-standardized hospital mortality and readmission rates.
        JAMA Netw Open. 2020; 3e2010383
      1. HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2011. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/nisoverview.jsp

        • Carrasco J.M.
        • Inbadas H.
        • Whitelaw A.
        • Clark D.
        Early impact of the 2014 World Health Assembly resolution on palliative care: a qualitative study using semistructured interviews with key experts.
        J Palliat Med. 2021; 24: 103-106
        • Chukwusa E.
        • Verne J.
        • Polato G.
        • Taylor R.
        • Higginson I.J.
        • Gao W.
        Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK.
        Int J Health Geogr. 2019; 18: 8
        • Gulliford M.
        • Figueroa-Munoz J.
        • Morgan M.
        • et al.
        What does 'access to health care' mean?.
        J Health Serv Res Policy. 2002; 7: 186-188
        • Saeed F.
        • Hoerger M.
        • Norton S.A.
        • Guancial E.
        • Epstein R.M.
        • Duberstein P.R.
        Preference for palliative care in cancer patients: are men and women alike?.
        J Pain Symptom Manage. 2018; 56: 1-6.e1
        • Sharma R.K.
        • Prigerson H.G.
        • Penedo F.J.
        • Maciejewski P.K.
        Male-female patient differences in the association between end-of-life discussions and receipt of intensive care near death.
        Cancer. 2015; 121: 2814-2820
        • Lichtman J.H.
        • Leifheit E.C.
        • Safdar B.
        • et al.
        Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients).
        Circulation. 2018; 137: 781-790
        • Zucker D.R.
        • Griffith J.L.
        • Beshansky J.R.
        • Selker H.P.
        Presentations of acute myocardial infarction in men and women.
        J Gen Intern Med. 1997; 12: 79-87
        • Ornstein K.A.
        • Roth D.L.
        • Huang J.
        • et al.
        Evaluation of racial disparities in hospice use and end-of-life treatment intensity in the REGARDS cohort.
        JAMA Netw Open. 2020; 3e2014639
        • Wittenberg-Lyles E.
        • Goldsmith J.
        • Platt C.S.
        Palliative care communication.
        Semin Oncol Nurs. 2014; 30: 280-286
        • Wentlandt K.
        • Seccareccia D.
        • Kevork N.
        • et al.
        Quality of care and satisfaction with care on palliative care units.
        J Pain Symptom Manage. 2016; 51: 184-192
        • Shaw M.
        • Shaw J.
        • Simon J.
        Listening to patients' own goals: a key to goals of care decisions in cardiac care.
        Can J Cardiol. 2020; 36: 1135-1138
        • Duberstein P.R.
        • Kravitz R.L.
        • Fenton J.J.
        • et al.
        Physician and patient characteristics associated with more intensive end-of-life care.
        J Pain Symptom Manage. 2019; 58: 208-215.e1
      2. Espeli VG, Fusi-Schimdhauser T, Mangan D, Gamondi C. The role of palliative care in relapsed and metastatic head and neck cancer patients in a single ESMO integrated oncology and palliative care centre [published online ahead of print July 12, 2022; correction published online August 5, 2022 (https://doi.org/10.1007/s00405-022-07583-5)]. Eur Arch Otorhinolaryngol. https://doi.org/10.1007/s00405-022-07535-z

        • Kobo O.
        • Moledina S.M.
        • Raisi-Estabragh Z.
        • et al.
        Emergency department cardiovascular disease encounters and associated mortality in patients with cancer: a study of 20.6 million records from the USA.
        Int J Cardiol. 2022; 363: 210-217
        • Aslakson R.A.
        • Curtis J.R.
        • Nelson J.E.
        The changing role of palliative care in the ICU.
        Crit Care Med. 2014; 42: 2418-2428
        • Cook D.
        • Rocker G.
        Dying with dignity in the intensive care unit.
        N Engl J Med. 2014; 370: 2506-2514
        • Warraich H.J.
        • Hernandez A.F.
        • Allen L.A.
        How medicine has changed the end of life for patients with cardiovascular disease.
        J Am Coll Cardiol. 2017; 70: 1276-1289
        • Hanratty B.
        • Hibbert D.
        • Mair F.
        • et al.
        Doctors' understanding of palliative care.
        Palliat Med. 2006; 20: 493-497
        • Ecarnot F.
        • Meunier-Beillard N.
        • Seronde M.-F.
        • et al.
        End-of-life situations in cardiology: a qualitative study of physicians' and nurses' experience in a large university hospital.
        BMC Palliat Care. 2018; 17: 112
        • Hoare S.
        • Morris Z.S.
        • Kelly M.P.
        • Kuhn I.
        • Barclay S.
        Do patients want to die at home? a systematic review of the UK literature, focused on missing preferences for place of death.
        PLoS One. 2015; 10e0142723
        • Warraich H.J.
        • Wolf S.P.
        • Mentz R.J.
        • Rogers J.G.
        • Samsa G.
        • Kamal A.H.
        Characteristics and trends among patients with cardiovascular disease referred to palliative care.
        JAMA Netw Open. 2019; 2e192375
        • Klinedinst R.
        • Kornfield Z.N.
        • Hadler R.A.
        Palliative care for patients with advanced heart disease.
        J Cardiothorac Vasc Anesth. 2019; 33: 833-843
        • Braun L.T.
        • Grady K.L.
        • Kutner J.S.
        • et al.
        American Heart Association Advocacy Coordinating Committee. Palliative care and cardiovascular disease and stroke: a policy statement from the American Heart Association/American Stroke Association.
        Circulation. 2016; 134: e198-e225
        • Bonares M.J.
        • Mah K.
        • MacIver J.
        • et al.
        Referral practices of cardiologists to specialist palliative care in Canada.
        CJC Open. 2020; 3: 460-469
        • Birman-Deych E.
        • Waterman A.D.
        • Yan Y.
        • Nilasena D.S.
        • Radford M.J.
        • Gage B.F.
        Accuracy of ICD-9-CM codes for identifying cardiovascular and stroke risk factors.
        Med Care. 2005; 43: 480-485
        • DeShazo J.P.
        • Hoffman M.A.
        A comparison of a multistate inpatient EHR database to the HCUP Nationwide Inpatient Sample.
        BMC Health Serv Res. 2015; 15: 384
        • Saczynski J.S.
        • Gabbay E.
        • McManus D.D.
        • et al.
        Increase in the proportion of patients hospitalized with acute myocardial infarction with do-not-resuscitate orders already in place between 2001 and 2007: a nonconcurrent prospective study.
        Clin Epidemiol. 2012; 4: 267-274