title: "Not the 'grim reaper service'": an assessment of provider knowledge, attitudes, and perceptions regarding palliative care referral barriers in heart failure.
abstract: BACKGROUND
  Although similar to cancer patients regarding symptom burden and prognosis, patients with heart failure (HF) tend to receive palliative care far less frequently. We sought to explore factors perceived by cardiology, primary care, and palliative care providers to impede palliative care referral for HF patients.
  
  
  RESULTS
  We conducted semistructured interviews regarding (1) perceived needs of patients with advanced HF; (2) knowledge, attitudes, and experiences with specialist palliative care; (3) perceived indications for and optimal timing of palliative care referral in HF; and (4) perceived barriers to palliative care referral. Two investigators analyzed data using template analysis, a qualitative technique. We interviewed 18 physician, nurse practitioner, and physician assistant providers from 3 specialties: cardiology, primary care, and palliative care. Providers had limited knowledge regarding what palliative care is, and how it can complement traditional HF therapy to decrease HF-related suffering. Interviews identified several potential barriers: the unpredictable course of HF; lack of clear referral triggers across the HF trajectory; and ambiguity regarding what differentiates standard HF therapy from palliative care. Nevertheless, providers expressed interest for integrating palliative care into traditional HF care, but were unsure of how to initiate collaboration.
  
  
  CONCLUSIONS
  Palliative care referral for HF patients may be suboptimal due to limited provider knowledge and misperceptions of palliative care as a service reserved for those near death. These factors represent potentially modifiable targets for provider education, which may help to improve palliative care referral for HF patients with unresolved disease-related burden.
authors.affiliation: Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Dio
authors.initials: D
authors.lastname: Kavalieratos
authors.forename: Emma M
authors.initials: EM
authors.lastname: Mitchell
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Carey
authors.forename: Sandesh
authors.initials: S
authors.lastname: Dev
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Biddle
authors.forename: Bryce B
authors.initials: BB
authors.lastname: Reeve
authors.forename: Amy P
authors.initials: AP
authors.lastname: Abernethy
authors.forename: Morris
authors.initials: M
authors.lastname: Weinberger
mesh_terms: D000368:Aged; D000488:Allied Health Personnel / Q000523:psychology*; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D019033:Delivery of Health Care, Integrated; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006302:Health Services Research; D054625:Healthcare Disparities; D006333:Heart Failure / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D008297:Male; D009722:Nurse Practitioners / Q000523:psychology; D010166:Palliative Care; D010465:Perception; D010823:Physician Assistants / Q000523:psychology; D010820:Physicians / Q000523:psychology; D011320:Primary Health Care; D012017:Referral and Consultation; D061665:Time-to-Treatment
keywords: health care; health disparities; health services research; healthcare access; heart failure