An Extension of Ethical Principles: The Significance of Incorporating Patient-Centered Care into Clinical Cardiovascular Medicine

Text summarizing the key points and clinical implications:

Medicine has long rooted its practice in a series of ethical principles to guide and advance decision-making and clinical care. The Hippocratic Oath first articulated the ethos and responsibility of medical professionals. Building upon that ancient declaration, ideal modern-day medicine has evolved to center around four major tenets:

1. Autonomy- respect for an individual's right to self-determination
2. Beneficence- the duty to "do good"
3. Non-Maleficence- the duty to "not do bad/harm" and
4. Justice- to treat all people equally and equitably.¹

Through this lens, the AHA scientific statement entitled "Patient-Centered Adult Cardiovascular Care" could be seen as an extension of established ethical principles of autonomy and beneficence to ultimately advance healthcare planning, decision-making, delivery, and outcomes within cardiovascular disease. This statement provides an overview of the significance of patient-centered care, defines its utility within the practice of cardiovascular medicine, and explores opportunities for its implementation into the management of cardiovascular disease.

What is Patient-centered care and why does it matter?

In 2001 the Institute of Medicine released its landmark report, Crossing the Quality Chasm, that delineated six goals for high-quality care systems in the coming 21^st Century.² Among them was patient-centered care, defined as "care that is respectful of and responsive to individual patient preferences, needs, and values".² Here patient-centered care can be viewed as a philosophy that not only considers but incorporates patients' beliefs, preferences, and values into all aspects of healthcare decision-making. Patient-centered care calls for a collaborative team approach that emphasizes patient engagement for shared decision-making that ensures management that is line with patients' priorities and goals. Coordinated care across specialty and disciplines is required to achieve outcomes that are of value to patients. These outcomes may not necessarily coincide with more traditional measures of mortality and hospitalizations, but rather focus on quality of life and functional capacity among others. When patients define goals, therapeutic strategies are tailored accordingly.³ The importance of such an approach cannot be overemphasized as the entire basis of medical care to is to care for patients – to make them feel better and/or live longer. As a collective society, far more weight is placed on the latter, when the former is really just as or in some cases more important.

Why is Patient-centered care important in cardiovascular diseases?

Cardiovascular disease is major cause of morbidity and mortality worldwide. Scientific discovery has and continues to be rampant as a result. Therapies to combat the spectrum of cardiovascular disease range from pharmacologic regimens to device implantation, surgical intervention to hospice care.⁴ Approval and payment for these therapies are largely contingent upon the demonstration of either reduction in mortality or hospitalization. Patient-centered outcomes may however be of the utmost importance depending on the individual and circumstance. These may include symptoms, quality of life, mood, functional capacity, independence, days at home (as opposed to facility) among others. Patient reported outcomes (PROs) are an important consideration in clinical management as they provide a broader and more personalized perspective of well-being by considering multiple dimensions of health including global health, physical health, mental health, and social health.^5,6

The utility of patient-centered care and principles of shared decision-making can be seen across cardiovascular medicine. For example, in the management of patients with severe aortic stenosis, some patients may prioritize the risks of surgery when favoring an approach like transcatheter aortic valve replacement compared to surgical aortic valve replacement.⁷ On the other hand, some patients with end stage heart failure who are ineligible for heart transplantation may not opt for life-prolonging left ventricular assist devices (LVADs) therapy due to the concerns of associated lifestyle changes, preferring a more palliative approach.⁸ These examples emphasize the importance of respecting the diversity of individuals' preferences and beliefs and ultimately understanding that patient-centered care may carry different meanings to different individuals. While one patient may emphasize the prolongation of life above all when rationalizing through a decision, another may see that any risks and lifestyle changes that come with a procedure (or medication) significantly outweigh any benefit. Ultimately, the practice of patient-centered care involves seeing and validating each patient as a unique individual and recognizing that there is no such thing as a "one size fits all" philosophy. Recent data has shown that the implementation of patient-centered care within these two aforementioned examples in cardiovascular medicine may lead to improved PROs. One study showed that the use of shared decision-making tools in the management of severe aortic stenosis led to improved patient medical knowledge, patient satisfaction, and patient-reported outcomes.⁹ An additional study demonstrated that a shared decision-making tool for LVADs improved patient knowledge and the concordance between patients stated values and their reported preferred treatment choice.¹⁰ Scientific advancements in cardiovascular care will only continue to provide patients with a greater number of treatment options thus necessitating the tailoring of personalized care to incorporate patient's beliefs, values, and goals into treatment plans.

How can we improve the integration of patient-centered care into the management of cardiovascular diseases?

The integration of patient-centered care across the practice of cardiovascular medicine requires an investment from healthcare systems to develop relationships between patients, clinicians, health systems, and larger communities. Prior work has established three distinct dimensions of patient-centered care that can be found within healthcare systems.¹¹

1. The first involves the interpersonal dimension or relationship between a patient and members of a healthcare team. This feature centers on the trust that exists between patients and their health care team and an organizational commitment to active communication and listening from those within a healthcare system.¹¹ Further investment in understanding the social determinants of health and the roots of mistrust among historically underrepresented and marginalized communities is critical towards building this interpersonal dimension with the greater goal of addressing disparities in cardiovascular care and outcomes.¹²
2. The second feature of patient-centered systems is the clinical dimension which features the coordination of care management.¹¹ Patient-centered care systems are to be designed to allow patients to access healthcare in some capacity outside of a traditional clinic visit. An example of this is the use of electronic telecommunication apps that allow patients to communicate with healthcare staff without having to physically visit an office or hospital. Patients with heart failure may be encouraged to utilize such technology to report on their symptom burden that may allow healthcare staff to up titrate medication with the hope that such management can reduce urgent care and emergency department visits while also improving PROs.¹³
3. The third and final characteristic of high-level patient-centered care is the structural dimension which entails the "built environment" of a healthcare system.¹¹ System wide structuring can promote patient-centered care by fundamentally designing environments to be centered around the patient. This may include structuring cardiology clinical experiences with the patient experience in mind through reducing wait times, integrating clinical appointments, lab draws, and imaging into one clinic visit, and including patient related goals as objective metrics that can be followed up each visit similar to how physiologic parameters are regularly assessed. An example of improving on the structural dimension in cardiovascular medicine is allowing patients to obtain imaging such as echocardiograms and stress tests the same day as routine visits instead of patients to first be referred for imaging at a visit, then to go for testing on a separate day, and finally to have those results communicated at an even later date.

Conclusion

Patient-centered care reorients cardiovascular healthcare delivery to meet its purpose, rooted in core ethical values – to serve patients in the ways they value most. Investment in models that acknowledge its importance will be essential to advance its prioritization across cardiovascular medicine.