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Jones CD, Moss A, Sevick C, Roczen M, Sterling MR, Portz J, Lum HD, Yu A, Urban JA, Khazanie P. Factors Associated With Mortality and Hospice Use Among Medicare Beneficiaries With Heart Failure Who Received Home Health Services. J Card Fail 2024; 30:788-799. [PMID: 38142043 DOI: 10.1016/j.cardfail.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Although many Medicare beneficiaries with heart failure (HF) are discharged with home health services, little is known about mortality rates and hospice use in this group. OBJECTIVES To identify risk factors for 6-month mortality and hospice use among patients hospitalized due to HF who receive home health care, which could inform efforts to improve palliative and hospice use for these patients. METHODS A retrospective cohort analysis was conducted in a 100% national sample of Medicare fee-for-service beneficiaries with HF who were discharged to home health care between 2017 and 2018. Multivariable Cox regression models examined factors associated with 6-month mortality, and multivariable logistic regression models examined factors associated with hospice use at the time of death. RESULTS A total of 285,359 Medicare beneficiaries were hospitalized with HF and discharged with home health care; 15.5% (44,174) died within 6 months. Variables most strongly associated with mortality included: age > 85 years (hazard ratio [HR] 1.66, 95% CI 1.61-1.71), urgent/emergency hospital admission (HR 1.68, 1.61-1.76), and "serious" condition compared to "stable" condition (HR 1.64, CI 1.52-1.78). Among 44,174 decedents, 48.2% (21,284) received hospice care at the time of death. Those with lower odds of hospice use at death included patients who were: < 65 years (odds ratio [OR] 0.65, CI 0.59-0.72); of Black (OR 0.64, CI 0.59-0.68) or Hispanic race/ethnicity (OR 0.79, CI 0.72-0.88); and Medicaid-eligible (OR 0.80, CI 0.76-0.85). CONCLUSIONS Although many patients hospitalized for HF are at risk of 6-month mortality and may benefit from palliative and/or hospice services, our findings indicate under-use of hospice care and important disparities in hospice use by race/ethnicity and socioeconomic status.
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Affiliation(s)
- Christine D Jones
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO; Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of Geriatrics, Department of Medicine, University of Colorado, Aurora, CO.
| | - Angela Moss
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Carter Sevick
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Madeline R Sterling
- Division of General Internal Medicine, Department of Medicine at Weill Cornell Medicine, New York, NY
| | - Jennifer Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Hillary D Lum
- Division of Geriatrics, Department of Medicine, University of Colorado, Aurora, CO
| | - Amy Yu
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Jacqueline A Urban
- Division of General Internal Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Prateeti Khazanie
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO
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Chou PL, Lin PC, Lin CC, Lee HC, Huang YT. Trends and Changes in Intensive Care Use for Patients With Heart Failure in the Last Month of Life. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241239143. [PMID: 38506439 PMCID: PMC10956157 DOI: 10.1177/00469580241239143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
A good death is a human right. Unfortunately, patients with chronic heart failure (CHF) in the terminal stage still receive inappropriate life-sustaining treatment before death. There is limited understanding of the status of intensive care unit (ICU) admission, mechanical ventilation (MV), cardiopulmonary resuscitation (CPR), and even extracorporeal membrane oxygenation (ECMO) for patients with CHF before death, as well as their use of hospice-related services. This study investigated the trends and trend changes in intensive procedures and hospice-related services for patients with CHF in the last month of life. This population-based retrospective observational study included 25 375 patients with CHF from the National Health Insurance research database in Taiwan and collected information on their intensive treatments during the last month of life. We computed intensive treatment utilization rates and analyzed the trends and trend changes via joinpoint regression. The average percentage of patients with CHF admitted to ICUs was 53.27% (n = 13 516). A total of 327 (1.29%) patients with CHF received ECMO. The percentages of patients receiving MV (54.3%'41.5%) and CPR (41.5%'17%) decreased over time. Conversely, the percentage of ECMO use (0.52%'1.78%) increased. However, only 222 (0.87%) patients with CHF received hospice care in the last month of life between 2001 and 2013. The rates of ICU admission and life-sustaining treatment among patients with CHF in the month before death remain high, and hospice-related services remain inadequate. This study highlights the need for research and training in providing palliative and hospice care for patients with CHF.
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Affiliation(s)
- Pi-Ling Chou
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Chao Lin
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Hsiang-Chun Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan
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3
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Graham C, Schonnop R, Killackey T, Kavalieratos D, Bush SH, Steinberg L, Mak S, Quinn K, Isenberg SR. Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study. J Am Heart Assoc 2022; 11:e024628. [PMID: 35730640 PMCID: PMC9333360 DOI: 10.1161/jaha.121.024628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home-based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home. Methods and Results We conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi-structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on-going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours). Conclusions Our results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.
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Affiliation(s)
- Cassandra Graham
- Division of Palliative Medicine, Department of Medicine University of Toronto Toronto Canada.,Division of Palliative Care University Health Network Toronto Canada
| | - Rebecca Schonnop
- Department of Emergency Medicine University of Alberta Edmonton Canada.,Department of Emergency Medicine Royal Alexandra Hospital Edmonton Canada
| | - Tieghan Killackey
- Child Health Evaluative Sciences The Hospital for Sick Children Toronto Canada
| | - Dio Kavalieratos
- Division of Palliative Medicine Emory University Atlanta Georgia
| | - Shirley H Bush
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Canada.,Bruyere Continuing Care Ottawa Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada.,Division of Palliative Care SinaiHealth Toronto Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine University of Toronto Toronto Canada.,Division of Cardiology Department of Medicine SinaiHealth Toronto Canada
| | - Kieran Quinn
- Department of Medicine University of Toronto Toronto Canada.,ICES Toronto and Ottawa Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada.,Department of Medicine SinaiHealth Toronto Canada
| | - Sarina R Isenberg
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada
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Yi S, Chen M. Decreased albumin is associated with elevated N-terminal pro-brain natriuretic peptide and poor long-term prognosis in patients with chronic heart failure. Medicine (Baltimore) 2020; 99:e23872. [PMID: 33371174 PMCID: PMC7748339 DOI: 10.1097/md.0000000000023872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 11/23/2020] [Indexed: 12/28/2022] Open
Abstract
At present, the association between albumin, N-terminal pro-brain natriuretic peptide (NT-proBNP) and long-term prognosis in patients with chronic heart failure (CHF) is unclear. Therefore, the purpose of this study is to explore the relationship between albumin, NT-proBNP and all-cause mortality in CHF patients.Three hundred fifty two CHF patients were recruited in our study, and patients were divided into 2 groups according to the mean (37.16 g/L) of albumin concentration [low group (albumin < 37.16 g/L) and high group (albumin≥37.16 g/L)]. Differences between groups was compared by odds ratio (OR) and 95% confidence interval (CI).NT-proBNP in the high group was significantly lower than that in the low group at baseline [1811.50 (698.75-4037.00) vs 3479.50 (1538.50-7824.25), P < .001]. Spearman correlation analysis showed that there was a negative correlation between albumin and NT-pro BNP log10 transform (ρ= -0.217, P < .001). Furthermore, curve fitting further confirmed that albumin was negatively correlated with NT-proBNP. After a median follow-up of 1726 days, 90 patients in the high group occur all-cause mortality, and 98 patients in the low group occur all-cause mortality (46.88% vs 61.25%, OR = 0.29, 95% CI: 0.08-0.50). After adjusting for the selected confounding covariates by multivariate regression analysis, decreased albumin was still associated with increased all-cause mortality (high group vs low group: OR = 0.62, 95% CI: 0.39-0.97).Decreased albumin is associated with elevated NT-ProBNP and poor long-term prognosis in CHF patients. Clinicians need to pay enough attention to the nutritional status of CHF patients.
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Affiliation(s)
- Sheng Yi
- Intensive Care Unit, Central Hospital of Hengyang, Hengyang, Hunan
- Guangxi Medical University
| | - Menghua Chen
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Jones CD, Jones J, Bowles KH, Schroeder S, Masoudi FA, Coleman EA, Falvey J, Levy CR, Boxer RS. Patient, Caregiver, and Clinician Perspectives on Expectations for Home Healthcare after Discharge: A Qualitative Case Study. J Hosp Med 2019; 14:90-95. [PMID: 30785416 PMCID: PMC6574082 DOI: 10.12788/jhm.3140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients discharged from the hospital with skilled home healthcare (HHC) services have multiple comorbidities, high readmission rates, and multiple care needs. In prior work, HHC nurses described that patients often express expectations for services beyond the scope of skilled HHC. OBJECTIVE The objective of this study is to evaluate and compare expectations for HHC from the patient, caregiver, and HHC perspectives after hospital discharge. DESIGN/PARTICIPANTS This was a descriptive qualitative case study including HHC patients, caregivers, and clinicians. Patients were discharged from an academic medical center between July 2017 and February 2018. RESULTS The sample (N = 27) included 11 HHC patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). Patient mean age was 66 years and the majority were female, white, and had Medicare. We observed main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC aligned with the services received. Unclear expectations occur when the patient and/or caregiver expectations are uncertain or misaligned with the services received. Patients and caregivers with clear expectations for HHC frequently described prior experiences with skilled HHC or work experience within the healthcare field. In most cases with unclear expectations, the patient and caregiver did not have prior experience with HHC. CONCLUSIONS To improve HHC transitions, we recommend actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services, and assess and address additional care needs.
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Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Corresponding Author: Christine D. Jones, MD, MS; E-mail: ; Telephone: 720-848-4289; Twitter: @jones_delong
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kathryn H Bowles
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York
| | - Shara Schroeder
- College of Liberal Arts and Sciences, Department of Sociology, University of Colorado, Denver, Colorado
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jason Falvey
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Medical Center, Denver, Colorado
- Yale School of Medicine, New Haven, Connecticut
| | - Cari R Levy
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Medical Center, Denver, Colorado
| | - Rebecca S Boxer
- Veterans Affairs Medical Center, Denver, Colorado
- Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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6
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Khoshab H, Nouhi E, Tirgari B, Ahmadi F. A survey on teamwork status in caring for patients with heart failure: A cross-sectional study. J Interprof Care 2018; 33:8-14. [DOI: 10.1080/13561820.2018.1512959] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Hadi Khoshab
- Nursing Research Center, Razi School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Esmat Nouhi
- Physiologic Research Center & Nursing Research Center, Razi School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Batool Tirgari
- Nursing Research Center, Razi School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Fazlollah Ahmadi
- Nursing Department, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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7
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Groninger H, Gilhuly D, Walker KA. Getting to the Heart of the Matter: A Regional Survey of Current Hospice Practices Caring for Patients With Heart Failure Receiving Advanced Therapies. Am J Hosp Palliat Care 2018; 36:55-59. [DOI: 10.1177/1049909118789338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: No guidelines exist regarding care for patients with advanced heart failure (HF) receiving hospice care while continuing advanced HF therapies such as left ventricular assist devices (LVADs) or continuous inotropes. Objective: We surveyed hospice providers in our tristate region to determine hospice demographics, current practices for care of patients with advanced HF, and perceived challenges of providing advanced HF therapies. Design: Cross-sectional survey of hospice clinical and administrative leaders. Results: Forty-six respondents representing 23 hospices completed the survey. Over half (27/46) held leadership administrative roles, and most (37/46) had more than 5 years of hospice experience. Although lack of experience and cost were cited as primary barriers to providing inotrope therapy in home hospice, about half of respondents (24/46) said they would manage inotropes. All participants said their respective hospices accept patients with implantable cardioverter-defibrillators; over half (28/46) said they accept patients with LVADs into hospice care. Lack of experience with LVADs was the most frequently cited barrier. Most participants were interested in training and support by an advanced HF program to facilitate hospice care of patients receiving these advanced therapies. General access to hospice services for patients with HF at their organization was considered adequate by 30 of 46 participants. Most (32/46) reported that referrals are made too late. Conclusions: Hospice specialists reported widely varied practice experiences caring for patients with HF receiving advanced therapies, noted specific challenges for care of these patients, and expressed a desire for targeted HF education.
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Affiliation(s)
- Hunter Groninger
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Devin Gilhuly
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Kathryn A. Walker
- MedStar Health, Columbia, MD, USA
- University of Maryland School of Pharmacy, Baltimore, MD, USA
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8
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Abstract
Hospice is a model of care for patients nearing the end of their lives that emphasizes symptom management, quality of life (QOL), and support of the patient and caregiving family through the death of the patient and the family's bereavement. It is associated with high patient and caregiver satisfaction and appears to not shorten lifespan for appropriately referred patients. Patients with advanced heart failure are being referred to hospice care more often than in the past, but the majority of deaths occur without this benefit. Hospice care in the USA is defined by the Medicare Hospice Benefit and associated regulations. Hospice is appropriate for patients with an expected survival prognosis of 6 months or less, and multiple predictive factors and tools are available to assist in prognostication. Management of symptoms and specific drug therapy options are discussed. For many patients, deactivation of electronic cardiac devices is appropriate when the goals of care are comfort and QOL. Ongoing collaboration of the referring physician with the hospice agency and staff offers opportunities for seamless and quality care.
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9
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Piamjariyakul U, Smith CE, Werkowitch M, Thompson N, Fox M, Williamson KP, Olson L. Designing and Testing an End-of-Life Discussion Intervention for African American Patients With Heart Failure and Their Families. J Hosp Palliat Nurs 2016; 18:528-535. [PMID: 29081717 PMCID: PMC5656294 DOI: 10.1097/njh.0000000000000290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is an escalating prevalence of heart failure (HF) with high mortality. Compared with other races, African Americans face a higher incidence of HF at earlier age of onset, with more rapid progression, and with increased family care burden and greater care costs and disparity in health care services at the end of life (EOL). Concomitant out-of-pocket HF costs and care demands indicate the need for early discussion of palliative and EOL care needs. We therefore developed and pilot tested a culturally sensitive intervention specific to the needs of African American HF patients and their families at the EOL. Our pilot study findings encompass patient and caregiver perspectives and align with the state of EOL science. The ultimate long-term goal of this intervention strategy is to translate into practice the preferred, culturally sensitive, and most cost-efficient EOL care recommendations for HF patients and families.
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Affiliation(s)
- Ubolrat Piamjariyakul
- Research associate professor, School of Nursing, University of Kansas Medical Center
| | - Carol E Smith
- Professor, School of Nursing and PreventiveMedicine & Public Health, University of KansasMedical Center
| | - Marilyn Werkowitch
- Research assistant, School of Nursing, University of Kansas Medical Center
| | - Noreen Thompson
- Psychiatric nurse specialist, Department of Nursing Clinical Excellence, University of Kansas Medical Center
| | - Maria Fox
- Director, Advanced Practice Professionals, University of Kansas Health System
| | - Karin Porter Williamson
- Associate professor and senior scientist, Palliative Medicine, University of Kansas Medical Center
| | - Lori Olson
- Assistant professor and senior scientist, Internal Medicine, University of Kansas Medical Center
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10
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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