|Year : 2021 | Volume
| Issue : 2 | Page : 118-123
End-of-life care in advanced heart failure during cardiology training in India: A survey
Muzaffar Ali1, Deepak Padmanabhan2, Bharatraj Banavalikar2, R Praveen Raja2, Anunay Gupta3, Sanjeev Kathuria4
1 Department of Cardiac Electrophysiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore; Department of Cardiology, Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India
2 Department of Cardiac Electrophysiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
3 Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
4 Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
|Date of Submission||12-Feb-2021|
|Date of Decision||11-Mar-2021|
|Date of Acceptance||12-May-2021|
|Date of Web Publication||25-Aug-2021|
Dr. Muzaffar Ali
Department of Cardiology, Sher-e-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir
Source of Support: None, Conflict of Interest: None
Background: The incidence of heart failure (HF) is likely to increase in future in India. As a result, India's health-care system has to care for an increased number of patients with advanced HF (AHF) in future. The objectives of this survey were as follows: (a) to assess cardiology trainees' approach toward treating HF patients and end-of-life (EOL) care, and (b) to review cardiology training curricula and HF management guidelines regarding the approach to EOL care issues in AHF.
Methods: We surveyed cardiology fellows undergoing training. The survey questions aimed to assess cardiology fellows' approach in treating patients with different severities of HF and at EOL. We reviewed the cardiology training curricula of various Indian institutions and HF management guidelines from Indian professional bodies.
Results: Ninety-nine fellows took part in the survey. 93%–100% reported that they were likely to prescribe recommended drug therapy and Cardiac resynchronization therapy-D implantation to all the patients. The number of likely responses for various EOL interventions was consistently lower when fellows had to rate interventions for themselves as patients. Sixty-four percent of fellows were unfamiliar or uncertain about the idea of hospice care. Eighty-four percent of fellows reported that their training was inadequate, or they were uncertain about the adequacy of their training regarding EOL care issues. None of the training curricula has mentioned “EOL care,” “palliative care,” or “hospice care,” and none of the HF management guidelines discussed such topics.
Conclusion: There is an urgent need for sensitizing and training Indian cardiology fellows regarding different aspects of AHF and EOL care.
Keywords: Advanced heart failure, cardiology training, end-of-life, palliative care, quality-of-life
|How to cite this article:|
Ali M, Padmanabhan D, Banavalikar B, Raja R P, Gupta A, Kathuria S. End-of-life care in advanced heart failure during cardiology training in India: A survey. Heart India 2021;9:118-23
|How to cite this URL:|
Ali M, Padmanabhan D, Banavalikar B, Raja R P, Gupta A, Kathuria S. End-of-life care in advanced heart failure during cardiology training in India: A survey. Heart India [serial online] 2021 [cited 2021 Dec 4];9:118-23. Available from: https://www.heartindia.net/text.asp?2021/9/2/118/324610
| Introduction|| |
Heart failure (HF) is a major global health issue, with an estimated worldwide prevalence of 63 million. The prevalence of HF in the US is expected to increase by 46% by the year 2030. The prevalence of HF increases with age and doubles for each decade of life, and HF is one of the leading causes of hospitalization and represents approximately 5% of total hospital admissions in most countries.
Across the globe, 17%–45% of patients admitted to a hospital with HF die within 1 year of admission, and the mortality rates for HF remain approximately 50% within 5 years of diagnosis., Patients who survive have a high rate of rehospitalization and poor quality-of-life (QoL).
In India, the estimated prevalence of HF is 22.7 million. The overall incidence is expected to increase further because of (a) aging population, (b) increased prevalence of coronary artery disease, (c) epidemic rise of risk factors such as hypertension and diabetes mellitus, (d) persistence of diseases such as rheumatic heart diseases and untreated congenital heart diseases.
Data regarding advanced HF (AHF) are scarce, but because of the increased burden of HF globally, the proportion of patients with AHF is bound to increase. As a result, India's health-care system will have to care for an increased number of patients with AHF and at end-of-life (EOL).
We devised a survey study with the objectives of (a) assessing the approach of cardiology trainees toward the treatment of HF and EOL care and (b) to review cardiology training curricula of various Indian institutions and HF management guidelines regarding the approach to EOL care issues.
| Methods|| |
We surveyed cardiology fellows undergoing training at different institutions of India from January 2020 to August 2020. Two-hundred and fifty questionnaires [Supplementary Material 1] were distributed electronically (E-mail and WhatsApp messaging application) to different institutions in India.
The HF management covered by the survey included drug therapy, cardiac resynchronization therapy-D (CRT-D) implantation, ventricular tachycardia (VT) ablation, heart transplantation, and other EOL care interventions in AHF. The three sets of the questionnaire had similar questions, but the patient under consideration was different for each set: (a) the first set was based on an unknown patient (patient Group 1), (b) the second set was regarding the trainee himself/herself as the patient (patient Group 2), and (c) the third set was based on a close relative/friend of the trainee as the patient (patient Group 3). There were three more questions based on whether the trainee has had an EOL care discussion with any patient, familiarity with hospice care, and adequacy of cardiology training vis-a-viz EOL care issues.
The trainees had to grade each treatment/intervention option based on how likely they were to prescribe or recommend that intervention. The fellows rated the responses on a scale of 1–5, 1 being not at all likely and 5 being very likely.
Freidman nonparametric test was used to compare the responses between the three patient groups.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), software version 20 (IBM Corp. USA).
All the trainees signed an informed consent form.
We reviewed the cardiology training curricula of the following institutions: (1) All India Institute of Medical Sciences (AIIMS), New Delhi, (2) Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, (3) Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry (4) Baba Farid University of Health Sciences, Faridkot (5) The Tamil Nadu Dr. MGR Medical University, Chennai (6) Rajiv Gandhi University of Health Sciences, Bangalore (7) Diplomate of National Board Cardiology (8) Amrita Vishwa Vidyapeetham, Coimbatore.
HF management guidelines published from India were also reviewed.,,,
A descriptive analysis was performed for all responses.
| Results|| |
Ninety-nine cardiology trainees (91 males and 8 females; mean age: 32 ± 1.7 years) took part in the survey. Fellows from the following institutions participated in the survey:
- Sher-e-Kashmir Institute of Medical Sciences, Srinagar
- AIIMS, New Delhi
- Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi
- Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi
- LPS Institute of Cardiology and Cardiac Surgery, Kanpur
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore
- Nizam's Institute of Medical Sciences, Hyderabad
- Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow
- Lokmanya Tilak Municipal Medical College, Mumbai.
Interventions in heart failure
Ninety-eight fellows (99%) reported that they were likely to prescribe recommended drug therapy in all patient groups.(P ≥ 0.4) One fellow reported that he/she was unlikely to prescribe renin-angiotensin system blockers and aldosterone antagonists to himself/herself, and another fellow was unlikely to recommend beta-blockers in all three patient groups.
Responses for CRT implantation, VT ablation, and heart transplantation are mentioned in [Table 1].
|Table 1: Likely and unlikely responses of the trainees regarding various treatment options in advanced heart failure|
Click here to view
Sixty-six percent of fellows were likely to recommend the continuation of intensive care unit care to themselves. The corresponding percentage for patient Groups 1 and 3 was 81% and 80%, respectively.
A similar trend was seen for continuous iv inotrope administration, direct current cardioversion (DCCV), intubation/mechanical ventilation, chest compressions, and hospital-based care [Table 2].
|Table 2: Likely and unlikely responses of the trainees regarding various interventions at end-of-life in advanced heart failure|
Click here to view
Thirty-three (33%) fellows reported not being involved or unsure about being involved in EOL care discussions in AHF patients during cardiology training.
Sixty-three (64%) fellows were unfamiliar or uncertain about the idea of hospice care.
Most of the fellows (84%) reported that compared to core cardiology principles, their training was inadequate, or they were uncertain about the adequacy of their training regarding EOL care issues.
Cardiology training curricula and heart failure management guidelines
Cardiology training curricula
None of the cardiology training curricula has covered the health-care issues particular to end-stage heart disease. None of the documents has the following words/phrases in their text: “Palliative therapy/care,” “EOL care,” and “hospice care.” None of the documents has discussed ethical issues involved at EOL.
One curriculum has a chapter on medical ethics that has an objective, among others, to achieve ethical sensitization by “lectures or discussion on ethical issues, clinical case discussion of cases with an important ethical component and by including ethical aspects in discussion in all case presentation, bedside rounds, and academic postgraduate programs.” Some of the topics to be covered are as follows:
- Prolongation of life
- Advanced life directives – The living will
- Cancer and terminal care.
Heart failure management guidelines
None of the HF management guidelines reviewed had a dedicated section dealing with palliative care (PC) or EOL care in AHF.
One document did not have any mention of palliation, PC, EOL care, or hospice care. The other three documents have mentioned “palliative therapy” vis-a-viz the long-term use of inotropic agents in AHF.,,
Two thousand eighteen consensus document mentions EOL care and hospice once, and as a part of “advanced and special treatment strategies in AHF.”
Cardiological Society of India (CSI) position statement on the management of HF in India, the most detailed of the four, also mentions atrial septostomy in severe RV failure as a part of palliation, but there is no mention of EOL care or hospice care in the document.
| Discussion|| |
AHF is associated with significant morbidity and mortality.,,
Patients with AHF also experience debilitating physical and emotional symptoms, loss of independence, and disruptions to social roles, all of which severely degrade the QoL.,, There is a growing body of evidence that shows that integration of PC with the usual HF care in patients with AHF improves QOL.,
Given the increasing prevalence of AHF and the substantial associated morbidity and mortality, it is no longer appropriate to assume that PC should be initiated only as a treatment of last resort when traditional HF management fails to fulfill a patient's goals. American and European professional societies have endorsed the introduction of PC early in the HF disease trajectory,, but <10% of patients with HF in the US receive PC.
To ensure access to PC for all HF patients, particularly patients with AHF, it is paramount that cardiology training also encompasses the sensitization and training regarding PC.
Two studies have analyzed PC education during cardiology training in the US., Both the studies found that cardiology training offers incomplete education and training in PC.
In the survey by Crousillat et al., <10% of fellows and no faculty reported required or elective training in PC during cardiology fellowship. Among faculty, 62% reported minimal exposure to PC education, and only 31% cited clinical collaboration with a PC specialty service during their fellowship training. By contrast, 71% of fellows reported clinical collaboration with PC specialists during the fellowship.
In the survey done by Dabbouseh et al., 41.8% reported explicit teaching in the management of a patient who is dying, and in terms of reported quality of teaching, 67.7% of fellows rated teaching of general cardiology principles as excellent. At the same time, this number was lower in the domains of EOL care, end-stage HF options, end-stage coronary disease options, and symptom control for a terminal or a dying patient.
Our study, to the best of our knowledge, is the first study that has looked at EOL care in HF during cardiology training from an Indian perspective.
In this survey, almost all the trainees (94%–100%) reported that they were likely to prescribe guideline-directed medical therapy and CRT-D implantation in all the patients. Uncertain responses increased regarding VT ablation (21%–24%) and heart transplantation (13%–17%), as did the number of trainees who were unlikely to recommend heart transplantation to themselves (12%).
Various interventions in AHF showed a similar trend where the number of trainees likely to recommend an intervention for patient Group 2, i.e., for themselves, was lower than for the patient Groups 1 and 3, except for home-based care.
Most trainees (83%–93%) responded that they were likely to recommend EOL care discussions in AHF, but only 67% of trainees reported being involved in such discussions.
This survey also highlights the inadequacy of cardiology training regarding PC and EOL issues in AHF as more than half of the trainees (64%) were unfamiliar with the idea of hospice care, and 84% of trainees reported about the inadequacy of their training regarding issues at EOL.
The review of different cardiology training curricula and HF management guidelines published from India also points to the fact that EOL care issues have not received the attention that they deserve.
| Conclusion|| |
Thus, there is an urgent need for sensitizing and training Indian cardiology fellows and cardiologists regarding different aspects of EOL care in AHF.
We recommend the following actions:
- Inclusion of EOL care issues in the cardiology curriculum
- Inclusion of PC cardiology in HF management guidelines
- Establishment of cardiology subspecialty of HF and PC cardiology in India.
The issues that the introduction of such discourse in doctor–patient conversation is going to face are, as also highlighted in this manuscript, readiness on the part of doctors to start such discussions and the acceptance of such discussions from the patients and their caregivers, for example, the percentage of trainees who were likely to recommend EOL care discussions fell from 93% for an unknown patient to 83% for a family member.
There is a common misconception that PC is synonymous with hospice care and dying, and some physicians perceive a transition to PC as a defeat. This misconception leads to the initiation of PC referrals after life-prolonging treatments have been exhausted or become too burdensome, and death is imminent, limiting the benefits patients receive from these referrals. As a result, the cardiac patient population remains underserved from a PC perspective.
The most important limitation of this survey is that it reduces some of the most complicated and complex issues related to EOL care to a Likert scale of 1–5. Such decisions are usually taken at a time when the patients and their caregivers are most vulnerable, and there is not any way to know that when faced with such a situation, the trainees will respond the same way as they have responded in this survey.
Another limitation of this survey is the number of cardiology trainees who participated in the survey. A survey which includes most of the trainees would be a better representation of the trainees' attitudes. However, we believe that our sample size adequately represents the length and breadth of the country's cardiology trainees to give us a reliable idea about their attitudes.
The scope of the survey is minimal. It does not cover some of the other pressing issues pertaining to AHF, for example, switching off ICD therapies. Those aspects of EOL care issues were included in the survey, which the trainees are directly involved with, to draw any meaningful deductions.
MA planned the study. MA, DP, BB, RPR, AG, and SK were involved in collecting the data. MA was involved in preparing the first draft. DP and BB were involved in revising the manuscript. All the authors have read and approved the manuscript.
Ethical committee approval was not applied for this survey.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Supplementary Material 1: Questionnaire used in the survey|| |
Name: Age: Sex:
| Year of Cardiology Training|| |
A 50-year-old male comes to your clinic with the diagnosis of nonischemic cardiomyopathy with an LVEF of 20%, LBBB, and NYHA class III symptoms. There are no other comorbidities.
What follows is a list of medications/interventions which are indicated in such patients.
Let's assume that every treatment option is indicated in this patient. Please rate each treatment option based on your perception of the benefit or your preference of the respective treatment option.
Please rated the responses on a scale of 1 to 5:
- Not at all likely
- Very likely.
1-1. Drug therapy
1-1a. Beta-Blockers 1 2 3 4 5
1-1b. ACEI/ARB/ARNI 1 2 3 4 5
1-1c. Spironolactone/Eplerenone 1 2 3 4 5
1-2 Device therapy
The patient remains symptomatic despite all these drugs. Please grade the following treatment option.
1-2a: CRT-D 1 2 3 4 5
1-3 VT Ablation
The patient develops recurrent appropriate ICD shocks, please grade the following treatment option:
1-3a. VT ablation 1 2 3 4 5
1-4 Heart Transplantation
The patient continues to deteriorate and develops refractory heart failure. Please grade the following treatment options:
1-4a. Heart Transplant 1 2 3 4 5
1-5 ICU Care
After employing all these treatment options, the patient presents with decompensated “end-stage” heart failure and is admitted to an ICU. Please grade the following treatment options:
1-5a. Continuation of ICU Care 1 2 3 4 5
1-5b. Continuous IV Inotropes 1 2 3 4 5
1-5c. DCCV (for VT) 1 2 3 4 5
1-5d. Intubation/Mech ventilation 1 2 3 4 5
1-5e. Chest Compressions 1 2 3 4 5
1-5f. Home-based 1 2 3 4 5
1-5g. Hospital-based 1 2 3 4 5
1-5h. End-of-life care discussion 1 2 3 4 5
1-6. Have you ever started a conversation with a patient about end-of-life care? Yes/No/Not sure
1-7. Are you familiar with the idea of hospice care? Yes/No/Not sure
1-8. Compared to core cardiology principles, how would you rate training regarding end-of-life care issues: Inadequate/Uncertain/Adequate.
You are the patient we have been talking about. Please grade the treatment recommendations for yourself.
2-1 Drug therapy
2-1a. Beta-Blockers 1 2 3 4 5
2-1b. ACEI/ARB/ARNI 1 2 3 4 5
2-1c. Spironolactone/Eplerenone 1 2 3 4 5
2-2 Device therapy
You remain symptomatic despite all these drugs. Please grade the following treatment option.
2-2a. CRT 1 2 3 4 5
2-3 VT Ablation
You develop recurrent appropriate ICD shocks even on AAD, please grade the following treatment option:
2-3a. VT ablation 1 2 3 4 5
2-4 Heart transplant
You continue to deteriorate and develop refractory heart failure. Please grade the following treatment options for yourself:
2-4a. Heart Transplant 1 2 3 4 5
2-5 ICU Care
After employing all these treatment options, you develop decompensated “end-stage” heart failure and you are admitted to an ICU. Please grade the following treatment options for yourself:
2-5a. Continuation of ICU Care 1 2 3 4 5
2-5b. Continuous IV Inotropes 1 2 3 4 5
2-5c. DCCV (for VT) 1 2 3 4 5
2-5d. Intubation/Mech ventilation 1 2 3 4 5
2-5e. Chest Compressions 1 2 3 4 5
2-5g. Hospital-based 1 2 3 4 5
2-5h. End-of-life care discussion 1 2 3 4 5
The patient is one of your close relatives/friends. Please grade the treatment options.
3-1 Drug therapy
3-1a. Beta-Blockers 1 2 3 4 5
3-1b. ACEI/ARB/ARNI 1 2 3 4 5
3-1c. Spironolactone/Eplerenone 1 2 3 4 5
3-2 Device therapy
The patient remains symptomatic despite all these drugs. Please grade the following treatment option.
3-2a. CRT-D 1 2 3 4 5
3-3 VT Ablation
The patient continues to have recurrent appropriate ICD shocks even on AAD, please grade the following treatment option:
3-3a. VT ablation 1 2 3 4 5
3-4 Heart Transplantation
The patient continues to deteriorate and develops refractory heart failure. Please grade the following treatment options:
3-4a. Heart Transplant 1 2 3 4 5
3-5 ICU Care
After employing all these treatment options your relative presents with decompensated “end-stage” heart failure and is admitted to an ICU. Please grade the following treatment options:
3-5a. Continuation of ICU Care 1 2 3 4 5
3-5b. Continuous IV Inotropes 1 2 3 4 5
3-5c. DCCV (for VT) 1 2 3 4 5
3-5d. Intubation/Mech ventilation 1 2 3 4 5
3-5e. Chest Compressions 1 2 3 4 5
3-5f. Home-based 1 2 3 4 5
3-5g. Hospital-based 1 2 3 4 5
3-5h. End-of-life care discussion 1 2 3 4 5
| References|| |
GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1211-59.
Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, et al
. Forecasting the impact of heart failure in the United States: A policy statement from the American Heart Association. Circ Heart Fail 2013;6:606-19.
Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol 2016;13:368-78.
McMurray JJ, Stewart S. The burden of heart failure. Eur Heart J Suppl 2004;6:50-8.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al.
2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation 2013;128:240-327.
Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S, et al
. Heart failure: Preventing disease and death worldwide. ESC Heart Fail 2014;1:4-25.
Joyce E, Chung C, Badloe S, Odutayo K, Desai A, Givertz MM, et al
. Variable contribution of heart failure to quality of life in ambulatory heart failure with reduced, better, or preserved ejection fraction. JACC Heart Fail 2016;4:184-93.
Pillai HS, Ganapathi S. Heart failure in South Asia. Curr Cardiol Rev 2013;9:102-11.
Mishra S, Mohan JC, Nair T, Chopra VK, Harikrishnan S, Guha S, et al
. Management protocols for chronic heart failure in India. Indian Heart J 2018;70:105-27.
Seth S, Bhargava B, Maulik S, McDonagh T, Saxena A, Airan B, et al
. Consensus statement on management of chronic heart failure in India. J Pract Cardiovasc Sci 2015;1:105. [Full text]
Seth S, Ramakrishnan S, Parekh N, Karthikeyan G, Singh S, Sharma G. Heart failure guidelines for India: Update 2017. J Pract Cardiovasc Sci 2017;3:133. [Full text]
Guha S, Harikrishnan S, Ray S, Sethi R, Ramakrishnan S, Banerjee S, et al
. CSI position statement on management of heart failure in India. Indian Heart J 2018;70 Suppl 1:S1-72.
Afzal AK, Steven JJ, Douglas WM, Jan AK, Margaret MR, John CB, et al.
Prevalence and prognostic significance of heart failure stages. Circulation 2007;115:1563-70.
Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al
. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435-43.
Costanzo MR, Mills RM, Wynne J. Characteristics of “Stage D” heart failure: Insights from the acute decompensated heart failure national registry longitudinal module (ADHERE LM). Am Heart J 2008;155:339-47.
Bekelman DB, Havranek EP, Becker DM, Kutner JS, Peterson PN, Wittstein IS, et al
. Symptoms, depression, and quality of life in patients with heart failure. J Card Fail 2007;13:643-8.
Kavalieratos D, Gelfman LP, Tycon LE, Riegel B, Bekelman DB, Ikejiani DZ, et al
. Palliative care in heart failure: Rationale, evidence, and future priorities. J Am Coll Cardiol 2017;70:1919-30.
O'Donnell AE, Schaefer KG, Stevenson LW, DeVoe K, Walsh K, Mehra MR, et al
. Social worker-aided palliative care intervention in high-risk patients with heart failure (SWAP-HF): A pilot randomized clinical trial. JAMA Cardiol 2018;3:516-9.
Rogers JG, Patel CB, Mentz RJ, Granger BB, Steinhauser KE, Fiuzat M, et al
. Palliative care in heart failure: The PAL-HF randomized, controlled clinical trial. J Am Coll Cardiol 2017;70:331-41.
Braun Lynne T, Grady Kathleen L, Kutner Jean S, Eric A, Nancy B, Renee B, et al
. Palliative care and cardiovascular disease and stroke: A policy statement from the American Heart Association/American Stroke Association. Circulation 2016;134:e198-225.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129-200.
Gelfman LP, Kalman J, Goldstein NE. Engaging heart failure clinicians to increase palliative care referrals: Overcoming barriers, improving techniques. J Palliat Med 2014;17:753-60.
Crousillat DR, Keeley BR, Buss MK, Zheng H, Polk DM, Schaefer KG. Palliative care education in cardiology. J Am Coll Cardiol 2018;71:1391-4.
Dabbouseh NM, Kaushal S, Peltier W, Johnston FM. Palliative care training in cardiology fellowship: A national survey of the fellows. Am J Hosp Palliat Care 2018;35:284-92.
Slawnych M. New dimensions in palliative care cardiology. Can J Cardiol 2018;34:914-24.
[Table 1], [Table 2]