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Li Y, Li J, Fu MR, Martín Payo R, Tian X, Sun Y, Sun L, Fang J. Effectiveness of palliative care interventions on patient-reported outcomes and all-cause mortality in community-dwelling adults with heart failure: A systematic review and meta-analysis. Int J Nurs Stud 2024; 160:104887. [PMID: 39278195 DOI: 10.1016/j.ijnurstu.2024.104887] [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: 01/28/2024] [Revised: 08/15/2024] [Accepted: 08/24/2024] [Indexed: 09/18/2024]
Abstract
BACKGROUND Current evidence that supports palliative care interventions predominantly focuses on individuals with cancer or hospitalized patients. However, the effectiveness of palliative care on patient-reported outcomes and mortality in community-dwelling adults with heart failure has not been evaluated. OBJECTIVE We aimed to evaluate the effectiveness of palliative care interventions on patient-reported outcomes and all-cause mortality in community-dwelling adults with heart failure. DESIGN A systematic review and meta-analysis of randomized controlled trials. METHODS MEDLINE, Embase, Cochrane Library, and CINAHL databases were searched from inception to October 2023. Randomized controlled trials were considered if they compared palliative care interventions with usual care, attention control, or waiting-list control primarily in a community-dwelling heart failure patient population. The primary outcome was patient-reported generic health-related or heart failure-specific quality of life. Secondary outcomes were patient-reported symptom burden, psychological health (anxiety and depression), spiritual well-being, and all-cause mortality. Two independent reviewers screened the retrieved articles and extracted data from the included studies. A random-effects meta-analysis was performed to pool the data, followed by sensitivity analysis, subgroup analysis, and meta-regression. All analyses were performed using R version 4.2.2. RESULTS Eleven eligible studies were included in this review with a total of 1535 patients. Compared to usual care, palliative care interventions demonstrated statistically significant effects on improving generic health-related quality of life (SMD, 0.30 [95 % CI, 0.12 to 0.48]) and heart failure-specific quality of life (SMD, 0.17 [95 % CI, 0.03 to 0.31]). Palliative care interventions also reduced anxiety (SMD, -0.22 [95 % CI, -0.40 to -0.05]) and depression (SMD, -0.18 [95 % CI, -0.33 to -0.03]), and enhanced spiritual well-being (SMD, 0.43 [95 % CI, 0.05 to 0.81]), without adversely affecting all-cause mortality (RR, 1.00 [95 % CI, 0.76 to 1.33]). Yet, the interventions had no significant effects on symptom burden (SMD, -0.09 [95 % CI, -0.40 to 0.21]). The certainty of evidence across the outcomes ranged from very low to moderate based on the GRADE approach. CONCLUSIONS Palliative care interventions are beneficial for community-dwelling adults with heart failure in that the interventions improved patient-reported quality of life, psychological health, and spiritual well-being, and importantly, did not lead to higher mortality rates. Findings of this review support the implementation of palliative care for adults with heart failure in community settings. REGISTRATION CRD42023482495.
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Affiliation(s)
- Yuan Li
- Department of Nursing, West China Second University Hospital/West China School of Nursing, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China; Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, China.
| | - Jie Li
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China; West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Mei R Fu
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, United States.
| | | | - Xiaomeng Tian
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yidan Sun
- Department of Toxicology/Nephrology, West China Fourth Hospital of Sichuan University, Chengdu, China
| | - Lisha Sun
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Jinbo Fang
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China.
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Balata M, Radbruch L, Hesse M, Westenfeld R, Neukirchen M, Pfister R, Batzler YN, Öztürk C, Kavsur R, Tiyerili V, Weltermann B, Pölsler R, Standl T, Nickenig G, Becher MU. Early integration of palliative care versus standard cardiac care for patients with heart failure (EPCHF): a multicentre, parallel, two-arm, open-label, randomised controlled trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:100637. [PMID: 39366392 DOI: 10.1016/j.lanhl.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/06/2024] [Accepted: 08/13/2024] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND Heart failure is a substantial global health concern that severely affects patients' quality of life. We aimed to compare the effects of early integration of palliative care (EIPC) and standard cardiac care on health status and mood of patients with non-terminal heart failure. METHODS EPCHF was a multicentre, parallel, two-arm, open-label, randomised controlled trial carried out at University Hospital Bonn and University Hospital Düsseldorf in Germany. Eligible patients (aged 18 years or older) had heart failure, with New York Heart Association class II or more and NT-proBNP concentrations greater than or equal to 400 pg/mL. Patients were randomly assigned (1:1) to receive EIPC with standard cardiac care or standard cardiac care alone. Randomisation was computer-generated with allocation concealment, variable block sizes, and stratification by investigational site. The primary endpoints were health status and mood, measured every 3 months over 12 months using the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-PAL) and the Kansas City Cardiomyopathy Questionnaire (KCCQ), analysed by intention to treat. This trial is registered with DRKS.de, DRKS00013922. FINDINGS Between May 21, 2019, and Nov 15, 2021, 843 patients were assessed for eligibility, 205 of whom were enrolled (100 assigned to EIPC and 105 assigned to standard cardiac care). 143 (70%) patients were male and 62 (30%) were female. Over 12 months, both groups significantly improved in FACIT-PAL and KCCQ Overall Summary Score (OSS) with no significant differences between the groups (FACIT-PAL adjusted mean difference 0·98 points [95% CI -1·28 to 3·23]; p=0·40; KCCQ-OSS adjusted mean difference -2·06 points [-7·89 to 3·78]; p=0·49). Nine (9%) patients in the EIPC group and seven (7%) patients in the standard cardiac care group died from any cause, with no significant differences in time to death between the two groups (hazard ratio [HR] 1·32 [95% CI 0·49 to 3·54]; p=0·58). 22 (22%) patients in the EIPC group and 21 (21%) patients in the standard cardiac care group were hospitalised at least once due to heart failure, with no significant differences in time to heart-failure-related hospitalisation between the two groups (HR 1·09 [0·61 to 1·98]; p=0·77). 70 (70%) patients in the EIPC group and 62 (59%) in the standard cardiac care group had any adverse events (p=0·10). INTERPRETATION In this open-label, randomised clinical trial, standard cardiac care, featuring guideline-directed optimisation of medical therapy and regular 3-monthly follow-ups was found to be as effective as when combined with EIPC in improving health status and mood in patients with non-terminal heart failure. Future clinical practices should consider EIPC based on individual patient needs. FUNDING Federal Ministry of Education and Research.
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Affiliation(s)
- Mahmoud Balata
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany.
| | - Lukas Radbruch
- Department of Palliative Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Michaela Hesse
- Institute of General Practice Medicine, University Hospital Aachen, Aachen, Germany
| | - Ralf Westenfeld
- Heart Center, Department of Cardiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin Neukirchen
- Department of Palliative Care Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Roman Pfister
- Heart Center, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Yann-Nicolas Batzler
- Department of Palliative Care Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Vedat Tiyerili
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Birgitta Weltermann
- Institute of General Practice and Family Medicine, University Hospital Bonn, Bonn, Germany
| | - Robert Pölsler
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, Städtisches Klinikum Solingen, Solingen, Germany
| | - Thomas Standl
- Department of Anesthesia, Intensive Care and Palliative Medicine, Städtisches Klinikum Solingen, Solingen, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marc Ulrich Becher
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany; Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, Städtisches Klinikum Solingen, Solingen, Germany
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Belur AD, Mehta A, Bansal M, Wieruszewski PM, Kataria R, Saad M, Clancy A, Levine DJ, Sodha NR, Burtt DM, Rachu GS, Abbott JD, Vallabhajosyula S. Palliative care in the cardiovascular intensive care unit: A systematic review of current literature. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 66:68-73. [PMID: 38531709 DOI: 10.1016/j.carrev.2024.03.024] [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: 02/06/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice. METHODS PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions - acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism - admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity. RESULTS Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality. CONCLUSIONS Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU.
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Affiliation(s)
- Agastya D Belur
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, United States of America
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Mridul Bansal
- Department of Medicine, East Carolina University Brody School of Medicine, Greenville, NC, United States of America
| | - Patrick M Wieruszewski
- Departments of Pharmacy and Anesthesiology, Mayo Clinic, Rochester, MN, United States of America
| | - Rachna Kataria
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Marwan Saad
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Annaliese Clancy
- Department of Pharmacy, Lifespan Health System, Providence, RI, United States of America
| | - Daniel J Levine
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Neel R Sodha
- Lifespan Cardiovascular Institute, Providence, RI, United States of America; Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Douglas M Burtt
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Gregory S Rachu
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - J Dawn Abbott
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America; Lifespan Cardiovascular Institute, Providence, RI, United States of America.
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Sebastian SA, Shah Y, Arsene C. Effectiveness of integrated palliative care telehealth intervention in patients with chronic heart failure: A systematic review and meta-analysis of randomized controlled trials. Curr Probl Cardiol 2024; 49:102685. [PMID: 38821234 DOI: 10.1016/j.cpcardiol.2024.102685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Heart failure (HF) represents a substantial burden, impacting both health and financial domains. Despite the presence of evidence-based interventions for prevention and management, suboptimal care has been recognized as a critical contributor to adverse HF-related outcomes. We aim to analyze the impact of palliative care telehealth intervention compared to usual care in quality of life (QoL) and resource utilization of chronic HF patients. METHODS We conducted a systematic search across various databases, including MEDLINE (via PubMed), Google Scholar, the Cochrane Library, and ScienceDirect to identify randomized controlled trials (RCTs) examining the impact of palliative care telehealth interventions on the QoL and health outcomes of HF patients from inception until May 2024. Statistical analysis was performed using RevMan 5.4, pooling odds ratios (OR), and weighted mean differences (WMD) via a random effects model for primary and secondary outcomes. The study protocol has been registered in PROSPERO (CRD42024542371). RESULTS In our study, 16 RCTs involving 2,324 HF patients, averaging 69.2 years old, were included. Upon analyzing the primary outcome, QoL, assessed through the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) Scale, we found a statistically significant improvement in QoL among patients who received palliative care or palliative care telehealth interventions compared to those who received usual care. The WMD for KCCQ was 3.56 (95% CI: 0.43 to 6.69, p = 0.03; I2 = 46%) and for FACIT-Pal was 2.54 (95% CI: 1.00 to 4.08, p = 0.001; I2 = 14%). Furthermore, HF patients receiving palliative care experienced a notable decrease in hospitalizations (OR: 0.60; 95% CI: 0.41 to 0.86; p = 0.006; I2 = 52%). However, we did not observe a significant change in all-cause mortality, with an OR of 1.22 (95% CI: 0.77 to 1.94, p = 0.39; I2 = 37%). CONCLUSION The implementation of palliative care telehealth interventions demonstrates a notable impact, positively influencing the QoL and decreasing hospitalization rates among patients with chronic HF.
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Affiliation(s)
| | - Yash Shah
- Department of Internal Medicine, Trinity Health Oakland/Wayne State University, Pontiac, Michigan, United States
| | - Camelia Arsene
- Department of Internal Medicine, Trinity Health Oakland/Wayne State University, Pontiac, Michigan, United States
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Role of Palliative Care. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00043-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Motamedi M, Brandenburg C, Bakhit M, Michaleff ZA, Albarqouni L, Clark J, Ooi M, Bahudin D, Chróinín DN, Cardona M. Concerns and potential improvements in end-of-life care from the perspectives of older patients and informal caregivers: a scoping review. BMC Geriatr 2021; 21:729. [PMID: 34930177 PMCID: PMC8690959 DOI: 10.1186/s12877-021-02680-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements. METHODS Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis); narrative and tabulations were used to summarise quantitative data (secondary analysis). RESULTS Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers; (2) Healthcare that values patient preferences and shared decision making; (3) Models of care that support quality of life and death with dignity; (4) Healthcare services that meet patient expectations; and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework. CONCLUSION The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL.
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Affiliation(s)
- Mina Motamedi
- Australian Centre for Health Engagement Evidence and Values (ACHEEV), University of Wollongong, Wollongong, NSW Australia
| | - Caitlin Brandenburg
- Allied Health Services, Gold Coast University Hospital, Southport, QLD Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD Australia
| | - Mina Bakhit
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD Australia
| | - Zoe A. Michaleff
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD Australia
| | - Loai Albarqouni
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD Australia
| | - Justin Clark
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD Australia
| | - Meidelynn Ooi
- Faculty of Medicine, UNSW Sydney, Sydney, NSW Australia
| | - Danial Bahudin
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD Australia
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, NSW Australia
- South Western Sydney Clinical School, UNSW Sydney, Sydney, NSW Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare (IEBH), Bond University, Robina, QLD Australia
- Bond EBP Professorial Unit, Gold Coast University Hospital, QLD Southport, Australia
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Sahlollbey N, Lee CKS, Shirin A, Joseph P. The impact of palliative care on clinical and patient‐centred outcomes in patients with advanced heart failure: a systematic review of randomized controlled trials. Eur J Heart Fail 2020; 22:2340-2346. [DOI: 10.1002/ejhf.1783] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/25/2022] Open
Affiliation(s)
- Nick Sahlollbey
- McMaster University Hamilton Canada
- Population Health Research Institute (PHRI), Hamilton Health Sciences and McMaster University Hamilton Canada
| | | | | | - Philip Joseph
- McMaster University Hamilton Canada
- Population Health Research Institute (PHRI), Hamilton Health Sciences and McMaster University Hamilton Canada
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Anand A, Cudmore S, Robertson S, Stephen J, Haga K, Weir CJ, Murray SA, Boyd K, Gunn J, Iqbal J, MacLullich A, Shenkin SD, Fox KAA, Mills N, Denvir MA. Frailty assessment and risk prediction by GRACE score in older patients with acute myocardial infarction. BMC Geriatr 2020; 20:102. [PMID: 32164580 PMCID: PMC7069195 DOI: 10.1186/s12877-020-1500-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 02/28/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Risk prediction after myocardial infarction is often complex in older patients. The Global Registry of Acute Coronary Events (GRACE) model includes clinical parameters and age, but not frailty. We hypothesised that frailty would enhance the prognostic properties of GRACE. METHODS We performed a prospective observational cohort study in two independent cardiology units: the Royal Infirmary of Edinburgh, UK (primary cohort) and the South Yorkshire Cardiothoracic Centre, Sheffield, UK (external validation). The study sample included 198 patients ≥65 years old hospitalised with type 1 myocardial infarction (primary cohort) and 96 patients ≥65 years old undergoing cardiac catheterisation for myocardial infarction (external validation). Frailty was assessed using the Clinical Frailty Scale (CFS). The GRACE 2.0 estimated risk of 12-month mortality, Charlson comorbidity index and Karnofsky disability scale were also determined for each patient. RESULTS Forty (20%) patients were frail (CFS ≥5). These individuals had greater comorbidity, functional impairment and a higher risk of death at 12 months (49% vs. 9% in non-frail patients, p < 0.001). The hazard of 12-month all-cause mortality nearly doubled per point increase in CFS after adjustment for age, sex and comorbidity (Hazard Ratio [HR] 1.90, 95% CI 1.47-2.44, p < 0.001). The CFS had good discrimination for mortality by Receiver Operating Characteristic (ROC) curve analysis (Area Under the Curve [AUC] 0.81, 95% CI 0.72-0.89) and enhanced the GRACE estimate (AUC 0.86 vs. 0.80 without CFS, p = 0.04). At existing GRACE thresholds, the CFS resulted in a Net Reclassification Improvement (NRI) of 0.44 (95% CI 0.28-0.60, p < 0.001), largely through reductions in risk estimates amongst non-frail patients. Similar findings were observed in the external validation cohort (NRI 0.46, 95% CI 0.23-0.69, p < 0.001). CONCLUSIONS The GRACE score overestimated mortality risk after myocardial infarction in these cohorts of older patients. The CFS is a simple guided frailty tool that may enhance prediction in this setting. These findings merit evaluation in larger cohorts of unselected patients. TRIAL REGISTRATION Clinicaltrials.gov; NCT02302014 (November 26th 2014, retrospectively registered).
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Affiliation(s)
- Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.305 Chancellor's Building, Edinburgh, EH16 4SB, UK.
- Geriatric Medicine Research Group, University of Edinburgh, Edinburgh, UK.
| | - Sarah Cudmore
- Department of Cardiology, Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Shirley Robertson
- Department of Cardiology, Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute for Population Health Sciences and Informatics University of Edinburgh, Edinburgh, UK
| | - Kristin Haga
- Department of Cardiology, Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute for Population Health Sciences and Informatics University of Edinburgh, Edinburgh, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Julian Gunn
- South Yorkshire Cardiothoracic Centre, Northern General Hospital, Sheffield, UK
| | - Javaid Iqbal
- South Yorkshire Cardiothoracic Centre, Northern General Hospital, Sheffield, UK
| | | | - Susan D Shenkin
- Geriatric Medicine Research Group, University of Edinburgh, Edinburgh, UK
| | - Keith A A Fox
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.305 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Nicholas Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.305 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Martin A Denvir
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.305 Chancellor's Building, Edinburgh, EH16 4SB, UK
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Schichtel M, Wee B, Perera R, Onakpoya I. The Effect of Advance Care Planning on Heart Failure: a Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:874-884. [PMID: 31720968 PMCID: PMC7080664 DOI: 10.1007/s11606-019-05482-w] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/16/2019] [Accepted: 10/11/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Advance care planning is widely advocated to improve outcomes in end-of-life care for patients suffering from heart failure. But until now, there has been no systematic evaluation of the impact of advance care planning (ACP) on clinical outcomes. Our aim was to determine the effect of ACP in heart failure through a meta-analysis of randomized controlled trials (RCTs). METHODS We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO (inception to July 2018). We selected RCTs including adult patients with heart failure treated in a hospital, hospice or community setting. Three reviewers independently screened studies, extracted data, assessed the risk of bias (Cochrane risk of bias tool) and evaluated the quality of evidence (GRADE tool) and analysed interventions according to the Template for Intervention Description and Replication (TIDieR). We calculated standardized mean differences (SMD) in random effects models for pooled effects using the generic inverse variance method. RESULTS Fourteen RCTs including 2924 participants met all of the inclusion criteria. There was a moderate effect in favour of ACP for quality of life (SMD, 0.38; 95% CI [0.09 to 0.68]), patients' satisfaction with end-of-life care (SMD, 0.39; 95% CI [0.14 to 0.64]) and the quality of end-of-life communication (SMD, 0.29; 95% CI [0.17 to 0.42]) for patients suffering from heart failure. ACP seemed most effective if it was introduced at significant milestones in a patient's disease trajectory, included family members, involved follow-up appointments and considered ethnic preferences. Several sensitivity analyses confirmed the statistically significant direction of effect. Heterogeneity was mainly due to different study settings, length of follow-up periods and compositions of ACP. CONCLUSIONS ACP improved quality of life, patient satisfaction with end-of-life care and the quality of end-of-life communication for patients suffering from heart failure and could be most effective when the right timing, follow-up and involvement of important others was considered.
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Affiliation(s)
- Markus Schichtel
- Department of Public Health and Primary Care, Primary Care Unit, University of Cambridge, Cambridge, UK.
| | - Bee Wee
- Oxford Centre for Education and Research in Palliative Care, Churchill Hospital, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Nishikawa Y, Hiroyama N, Fukahori H, Ota E, Mizuno A, Miyashita M, Yoneoka D, Kwong JSW, Cochrane Heart Group. Advance care planning for adults with heart failure. Cochrane Database Syst Rev 2020; 2:CD013022. [PMID: 32104908 PMCID: PMC7045766 DOI: 10.1002/14651858.cd013022.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain. OBJECTIVES To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure. DATA COLLECTION AND ANALYSIS Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information. MAIN RESULTS We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI -0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD -0.58, 95% CI -0.82 to -0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD -0.40, 95% CI -1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment. AUTHORS' CONCLUSIONS ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.
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Affiliation(s)
- Yuri Nishikawa
- Tokyo Medical and Dental UniversityDepartment of System Management in Nursing Graduate School of Health Care SciencesTokyoJapan
| | - Natsuko Hiroyama
- Tokyo Medical and Dental UniversityDepartment of System Management in Nursing Graduate School of Health Care SciencesTokyoJapan
| | - Hiroki Fukahori
- Tokyo Medical and Dental UniversityDepartment of System Management in Nursing Graduate School of Health Care SciencesTokyoJapan
- Keio UniversityFaculty of Nursing and Medical CareFujisawaJapan
| | - Erika Ota
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
| | | | - Mitsunori Miyashita
- Tohoku University Graduate School of MedicineDepartment of Palliative Nursing, Health SciencesSendaiJapan
| | - Daisuke Yoneoka
- St. Luke’s International UniversityDivision of Biostatistics and Bioinformatics, Graduate School of Public HealthSt. Luke’s Center for Clinical Academia, 5th Floor 3‐6‐2 Tsukiji, Chuo‐KuTokyoJapan1040045
| | - Joey SW Kwong
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
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11
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Hadler RA, Curtis BR, Ikejiani DZ, Bekelman DB, Harinstein M, Bakitas MA, Hess R, Arnold RM, Kavalieratos D. "I'd Have to Basically Be on My Deathbed": Heart Failure Patients' Perceptions of and Preferences for Palliative Care. J Palliat Med 2020; 23:915-921. [PMID: 31916910 DOI: 10.1089/jpm.2019.0451] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To identify patient perceptions of how and when palliative care (PC) could complement usual heart failure (HF) management. Background: Despite guidelines calling for the integration of PC into the management of HF, PC services remain underutilized by this population. Patient preferences regarding delivery of and triggers for PC are unknown. Setting/subjects: Individuals with New York Heart Association Class II-IV disease were recruited from inpatient and outpatient settings at an academic quaternary care hospital. Measurements: Participants completed semistructured interviews discussing perceptions, knowledge, and preferences regarding PC. They also addressed barriers and facilitators to PC delivery. Two investigators independently analyzed data using template analysis. Results: We interviewed 27 adults with HF (mean age 63, 85% white, 63% male, 30% Class II, 48% Class III, and 22% Class IV). Participants frequently conflated PC with hospice; once corrected, they expressed variable preferences for primary versus specialist services. Proponents of primary PC cited continuity in care, HF-specific expertise, convenience, and cost, whereas advocates for specialist care highlighted expertise in symptom management and caregiver support, reduced time constraints, and a comprehensive approach to care. Triggers for specialist PC focused on late-stage manifestations of disease such as loss of independence and absence of disease-directed therapies. Conclusions: Patients with HF demonstrated variable conceptions of PC and its relevance to their disease management. Although preferences for delivery model were based on a variety of logistical and relational factors, triggers for initiation remained focused on late-stage disease, suggesting that patients with HF may misconceive PC is an option of last resort.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brett R Curtis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dara Z Ikejiani
- Division of Oncology, Department of Medicine, Johns Hopkins School of Medicine, Sibley Memorial Hospital, Washington, DC, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health, Aurora, Colorado, USA
| | - Matthew Harinstein
- Heart and Vascular Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marie A Bakitas
- Center for Palliative and Supportive Care, School of Nursing and Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel Hess
- Division of Health System Innovation and Research, Department of Health Sciences, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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12
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Veldhoven CMM, Nutma N, De Graaf W, Schers H, Verhagen CAHHVM, Vissers KCP, Engels Y. Screening with the double surprise question to predict deterioration and death: an explorative study. BMC Palliat Care 2019; 18:118. [PMID: 31881958 PMCID: PMC6935168 DOI: 10.1186/s12904-019-0503-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/09/2019] [Indexed: 12/25/2022] Open
Abstract
Background Early identification of palliative patients is challenging. The Surprise Question (SQ1; Would I be surprised if this patient were to die within 12 months?) is widely used to identify palliative patients. However, its predictive value is low. Therefore, we added a second question (SQ2) to SQ1: ‘Would I be surprised if this patient is still alive after 12 months?’ We studied the accuracy of this double surprise question (DSQ) in a general practice. Methods We performed a prospective cohort study with retrospective medical record review in a general practice in the eastern part of the Netherlands. Two general practitioners (GPs) answered both questions for all 292 patients aged ≥75 years (mean age 84 years). Primary outcome was 1-year death, secondary outcomes were aspects of palliative care. Results SQ1 was answered with ‘no‘ for 161/292 patients. Of these, SQ2 was answered with ‘yes’ in 22 patients. Within 12 months 26 patients died, of whom 24 had been identified with SQ1 (sensitivity: 92%, specificity: 49%). Ten of them were also identified with SQ2 (sensitivity: 42%, specificity: 91%). The latter group had more contacts with their GP and more palliative care aspects were discussed. Conclusions The DSQ appears a feasible and easy applicable screening tool in general practice. It is highly effective in predicting patients in high need for palliative care and using it helps to discriminate between patients with different life expectancies and palliative care needs. Further research is necessary to confirm the findings of this study.
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Affiliation(s)
- C M M Veldhoven
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands. .,General practice Berg en Dal, Oude Kleefsebaan 96, 6571, BJ, Berg en Dal, the Netherlands.
| | - N Nutma
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - W De Graaf
- General practice Berg en Dal, Oude Kleefsebaan 96, 6571, BJ, Berg en Dal, the Netherlands
| | - H Schers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - C A H H V M Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - K C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Y Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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13
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Skorstengaard MH, Brogaard T, Jensen AB, Andreassen P, Bendstrup E, Løkke A, Aagaard S, Wiggers H, Johnsen AT, Neergaard MA. Advance care planning for patients and their relatives. Int J Palliat Nurs 2019; 25:112-127. [PMID: 30892997 DOI: 10.12968/ijpn.2019.25.3.112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Advance care planning (ACP) has been suggested to improve the quality of life (QoL) and mental wellbeing in severely ill patients and their relatives. AIM To investigate the effects of ACP among patients with lung, heart and cancer diseases with an estimated life-span of up to 12 months. METHODS Patients and relatives were randomised into two groups: one receiving usual care and one receiving ACP and usual care. Themes from the ACP discussion were documented in patients' electronic medical file. Participants completed self-reported questionnaires four to five weeks after randomisation. FINDINGS In total, 141 patients and 127 relatives participated. No significant differences were found according to outcomes. However, patients with non-malignant diseases had the highest level of anxiety and depression; these patients seemed to benefit the most from ACP, though not showing statistically significant results. CONCLUSION No significant effects of ACP among patients with lung, heart, and cancer diseases and their relatives regarding HRQoL, anxiety, depression, and satisfaction with healthcare were found.
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Affiliation(s)
| | - Trine Brogaard
- Department of Public Health, Research Unit for General Practice, Aarhus University, Denmark
| | | | | | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Denmark
| | - Anders Løkke
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Denmark
| | - Susanne Aagaard
- Department of Cardiology, Aarhus University Hospital, Denmark
| | - Henrik Wiggers
- Department of Cardiology, Aarhus University Hospital, Denmark
| | - Anna Thit Johnsen
- Department of Palliative Medicine, the Research Unit, Bispebjerg Hospital, Copenhagen University Hospital, Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mette Asbjoern Neergaard
- Associate professor, Department of Oncology, Aarhus University Hospital, Denmark, The Palliative Care Team, Department of Oncology, Aarhus University Hospital, Denmark
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14
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Neergaard MA, Brogaard T, Vedsted P, Jensen AB. Asking terminally ill patients about their preferences concerning place of care and death. Int J Palliat Nurs 2019; 24:124-131. [PMID: 29608384 DOI: 10.12968/ijpn.2018.24.3.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Asking patients with palliative care needs about their end-of-life (EoL) preferences is widely acknowledged as an important aspect of EoL care. However, the issue of how to ask patients these questions has not been fully explored. Most prior studies in this area do not differentiate between patients' pragmatic preferences and ideal preferences, and between preferences concerning place of care (PoC) and place of death (PoD). AIM The aim of this study was to examine possible differences between pragmatic and ideal preferences of terminally ill patients, as well as differences between asking patients about preferences concerning PoC and PoD. METHODS Structured interviews were performed with terminally ill cancer patients at inclusion and a follow-up questionnaire was completed 1 month later. Answers were compared using kappa (k) statistics and Pearson's c2-test. RESULTS Among 96 cancer patients, agreement between pragmatic and ideal preferences was statistically significantly different (p=<0.001). Agreement between preferences for PoC and PoD was high (k:0.76-0.85). CONCLUSION Differences exist between pragmatic and ideal EoL preferences, whereas preferences for PoC and PoD were found to be similar. These findings highlight the importance of the phrasing of questions when uncovering patients' preferences for EoL care.
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Affiliation(s)
- Mette Asbjoern Neergaard
- Associate Professor, Consultant in Palliative Medicine, Palliative Care Team, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Trine Brogaard
- GP, Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
| | - Peter Vedsted
- Professor and Research Director, Research Centre for Cancer Diagnosis, Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
| | - Anders Bonde Jensen
- Professor, Consultant in Oncology, Department of Oncology, Aarhus University Hospital, Denmark
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15
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Sobanski PZ, Alt-Epping B, Currow DC, Goodlin SJ, Grodzicki T, Hogg K, Janssen DJA, Johnson MJ, Krajnik M, Leget C, Martínez-Sellés M, Moroni M, Mueller PS, Ryder M, Simon ST, Stowe E, Larkin PJ. Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement. Cardiovasc Res 2019; 116:12-27. [DOI: 10.1093/cvr/cvz200] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 04/19/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Abstract
Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Waldeggstrasse 10, 6430 Schwyz, Switzerland
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Medical Center Göttingen Georg August University, Robertkochstrasse 40, 37075 Göttingen, Germany
| | - David C Currow
- University of Technology Sydney, Broadway, Ultimo, Sydney, 2007 New South Wales, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Sydney, New South Wales, Australia
| | - Sarah J Goodlin
- Department of Medicine-Geriatrics, Portland Veterans Affairs Medical Center and Patient-cantered Education and Research, 3710 SW US Veterans Rd, Portland, 97239 OR, USA
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, 31-531 Kraków, Śniadeckich 10, Poland
| | | | - Daisy J A Janssen
- Department of Research and Education, CIRO, Hornerheide 1, 6085 NM Horn, The Netherlands
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Allam Medical Building University of Hull, Cottingham Road, Hull, HU6 7RX, UK
| | - Małgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Carlo Leget
- University of Humanistic Studies, Chair Care Ethics, Kromme Nieuwegracht 29, Utrecht, The Netherlands
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Matteo Moroni
- S.S.D. Cure Palliative, sede di Ravenna, AUSL Romagna, Via De Gasperi 8, 48121 Ravenna, Italy
| | - Paul S Mueller
- Mayo Clinic Health System, Mayo Clinic Collage of Medicine and Science, 700 West Avennue South, La Crosse, 54601 Wisconsin, USA
| | - Mary Ryder
- School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland St. Vincent’s University Hospital Dublin,Belfield, Dublin 4, Ireland
| | - Steffen T Simon
- Department of Palliative Medicine, Medical Faculty of the Universityof Cologne, Köln, Germany
- Centre for Integrated Oncology Cologne/Bonn (CIO), Medical Faculty ofthe University of Cologne, Kerpener Strasse 62, 50924 Köln, Germany
| | | | - Philip J Larkin
- Service des soins palliatifs Lausanne University Hospital, CHUV, Centre hospitalier univeritaire vaudois, Lausanne Switzerland
- Institut universitaire de formation et de recherche en soins – IUFRS, Faculté de viologie et de medicine – FBM, Lausanne, Switzerland
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16
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Solís García del Pozo J, Olmeda Brull C, de Arriba Méndez J, Corbí Pascual M. Palliative medicine for patients with advanced heart failure: New evidence. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Affiliation(s)
- Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, The University of Hull, Hull, UK
| | - Daisy Janssen
- Department of Research & Education, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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Abstract
PURPOSE OF REVIEW The unmet palliative care needs of patients with chronic heart failure (CHF) are well known. Palliative care needs assessment is paramount for timely provision of palliative care. The present review provides an overview of palliative care needs assessment in patients with CHF: the role of prognostic tools, the role of the surprise question, and the role of palliative care needs assessment tools. RECENT FINDINGS Multiple prognostic tools are available, but offer little guidance for individual patients. The surprise question is a simple tool to create awareness about a limited prognosis, but the reliability in CHF seems less than in oncology and further identification and assessment of palliative care needs is required. Several tools are available to identify palliative care needs. Data about the ability of these tools to facilitate timely initiation of palliative care in CHF are lacking. SUMMARY Several tools are available aiming to facilitate timely introduction of palliative care. Focus on identification of needs rather than prognosis appears to be more fitting for people with CHF. Future studies are needed to explore whether and to what extent these tools can help in addressing palliative care needs in CHF in a timely manner.
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19
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Kernick LA, Hogg KJ, Millerick Y, Murtagh FEM, Djahit A, Johnson M. Does advance care planning in addition to usual care reduce hospitalisation for patients with advanced heart failure: A systematic review and narrative synthesis. Palliat Med 2018; 32:1539-1551. [PMID: 30234421 DOI: 10.1177/0269216318801162] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND People with advanced heart failure have repeated hospital admissions. Advance care planning can support patient preferences, but studies in people with heart failure have not been assessed. AIM To evaluate the literature regarding advance care planning in heart failure. DESIGN Systematic review and narrative analysis (PROSPERO CRD42017059190). DATA SOURCES Electronic databases were searched (1990 to 23 March 2017): MEDLINE(R), Cochrane Library, CINAHL and Scopus. Four journals were hand searched. Two independent researchers screened against eligibility criteria. One reviewer extracted all data and a sample by a second. Quality was assessed by Cochrane Risk of Bias or the Critical Appraisal Skills Programme Tool for Cohort Studies. RESULTS Out of the 1713 articles, 8 were included representing 14,357 participants from in/outpatient settings from five countries. Two randomised controlled trials and one observational study assessed planning as part of a specialist palliative care intervention; one randomised controlled trial assessed planning in addition to usual cardiology care; one randomised controlled trial and one observational study assessed planning in an integrated cardiology-palliative care model; one observational study assessed evidence of planning (advance directive) as part of usual care and one observational study was a secondary analysis of trial participants coded Do Not Attempt Cardiopulmonary Resuscitation. Advance care planning: (1) reduced hospitalisation (5/7 studies); (2) increased referral/use of palliative services (4/4 studies); and (3) supported deaths in the patient-preferred place (2/2 studies). CONCLUSION Advance care planning as part of specialist palliative care reduces hospitalisation. Preliminary studies of planning integrated into generic care, accessing specialist palliative care support if needed, are promising.
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Affiliation(s)
- Lucy A Kernick
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Karen J Hogg
- 2 Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Yvonne Millerick
- 3 Glasgow Royal Infirmary, Glasgow Caledonian University, Glasgow, UK
| | - Fliss E M Murtagh
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Ayse Djahit
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam Johnson
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Solís García Del Pozo J, Olmeda Brull C, de Arriba Méndez JJ, Corbí Pascual M. Palliative medicine for patients with advanced heart failure: New evidence. Rev Clin Esp 2018; 219:332-341. [PMID: 30318247 DOI: 10.1016/j.rce.2018.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 08/14/2018] [Accepted: 09/04/2018] [Indexed: 11/19/2022]
Abstract
Although heart failure is one of the most common clinical syndromes in medicine and has a high mortality rate, few patients have access to adequate palliative care for their clinical situation. Several trials have recently been published on the usefulness of starting palliative treatment along with cardiac treatment for patients with advanced heart failure. In this review, we analyse the aspects of diagnosing and controlling the symptoms of patients with advanced heart failure and provide a collection of clinical trials that have analysed the efficacy of a palliative intervention in this patient group. Physicians need to be equipped with strategies for recognizing the need for this type of intervention without it resulting in neglecting the active treatment of the patient's heart failure.
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Affiliation(s)
- J Solís García Del Pozo
- Servicio de Medicina Interna, Hospital General de Villarrobledo, Villarrobledo, Albacete, España.
| | - C Olmeda Brull
- Servicio de Medicina Interna, Hospital General de Villarrobledo, Villarrobledo, Albacete, España
| | - J J de Arriba Méndez
- Unidad de Medicina Paliativa, Complejo Hospitalario y Universitario de Albacete, Albacete, España
| | - M Corbí Pascual
- Servicio de Cardiología, Complejo Hospitalario y Universitario de Albacete, Albacete, España
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21
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Kimbell B, Murray SA, Byrne H, Baird A, Hayes PC, MacGilchrist A, Finucane A, Brookes Young P, O’Carroll RE, Weir CJ, Kendall M, Boyd K. Palliative care for people with advanced liver disease: A feasibility trial of a supportive care liver nurse specialist. Palliat Med 2018; 32:919-929. [PMID: 29516776 PMCID: PMC5946657 DOI: 10.1177/0269216318760441] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver disease is an increasing cause of death worldwide but palliative care is largely absent for these patients. AIM We conducted a feasibility trial of a complex intervention delivered by a supportive care liver nurse specialist to improve care coordination, anticipatory care planning and quality of life for people with advanced liver disease and their carers. DESIGN Patients received a 6-month intervention (alongside usual care) from a specially trained liver nurse specialist. The nurse supported patients/carers to live as well as possible with the condition and acted as a resource to facilitate care by community professionals. A mixed-method evaluation was conducted. Case note analysis and questionnaires examined resource use, care planning processes and quality-of-life outcomes over time. Interviews with patients, carers and professionals explored acceptability, effectiveness, feasibility and the intervention. SETTING/PARTICIPANTS Patients with advanced liver disease who had an unplanned hospital admission with decompensated cirrhosis were recruited from an inpatient liver unit. The intervention was delivered to patients once they had returned home. RESULTS We recruited 47 patients, 27 family carers and 13 case-linked professionals. The intervention was acceptable to all participants. They welcomed access to additional expert advice, support and continuity of care. The intervention greatly increased the number of electronic summary care plans shared by primary care and hospitals. The Palliative care Outcome Scale and EuroQol-5D-5L questionnaire were suitable outcome measurement tools. CONCLUSION This nurse-led intervention proved acceptable and feasible. We have refined the recruitment processes and outcome measures for a future randomised controlled trial.
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Affiliation(s)
- Barbara Kimbell
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Heidi Byrne
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrea Baird
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
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McIlfatrick S, Doherty LC, Murphy M, Dixon L, Donnelly P, McDonald K, Fitzsimons D. 'The importance of planning for the future': Burden and unmet needs of caregivers' in advanced heart failure: A mixed methods study. Palliat Med 2018; 32:881-890. [PMID: 29235422 DOI: 10.1177/0269216317743958] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND While studies have evaluated caregiver outcomes in heart failure, the burden and support needs when caring for someone with advanced heart failure at the end of life have yet to be outlined. AIM To identify psychosocial factors associated with caregiver burden and evaluate the support needs of caregivers in advanced heart failure. DESIGN A sequential mixed methods study comprising two phases: (1) postal survey with advanced heart failure patients and their caregivers and (2) interviews with current and bereaved caregivers. Correlation, chi-square, t test, regression and thematic analysis were undertaken on the data. PARTICIPANTS Advanced heart failure patients ( n = 112) and their caregivers ( n = 84) were recruited from secondary care settings across the United Kingdom and Ireland. For phase 2 interviews, current caregivers ( n = 20) were purposively recruited from phase 1, and bereaved caregivers ( n = 10) were purposively recruited via voluntary organisation, social media and email. RESULTS More than half the caregivers (53%) had levels of distress associated with depression (Zarit Burden score >24). Caregiver depression score, preparedness for caregiving and patients' depression score predicted caregiver burden. Qualitative analysis identified an overarching theme of lack of future care planning and four subthemes: (1) seeking emotional support from someone who understands, (2) want information on prognostication, (3) lack of knowledge on how to and where to get support and (4) require knowledge on what to expect at the end of life. CONCLUSION Caregivers have unmet needs and feel unprepared for the future. Implementation of future care planning by clinical teams should address patient and caregiver support needs and in turn alleviate caregiver burden.
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Affiliation(s)
- Sonja McIlfatrick
- 1 Institute of Nursing and Health Research, School of Nursing, Ulster University, Newtownabbey, UK.,2 All Ireland Institute for Hospice and Palliative Care, Dublin, Ireland
| | - Leanne C Doherty
- 1 Institute of Nursing and Health Research, School of Nursing, Ulster University, Newtownabbey, UK.,2 All Ireland Institute for Hospice and Palliative Care, Dublin, Ireland
| | - Mary Murphy
- 3 Belfast Health and Social Care Trust, Belfast, UK
| | - Lana Dixon
- 3 Belfast Health and Social Care Trust, Belfast, UK
| | - Patrick Donnelly
- 4 South Eastern Health and Social Care Trust, Ulster Hospital, Dundonald, UK
| | | | - Donna Fitzsimons
- 1 Institute of Nursing and Health Research, School of Nursing, Ulster University, Newtownabbey, UK.,2 All Ireland Institute for Hospice and Palliative Care, Dublin, Ireland.,6 School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
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Finucane AM, Carduff E, Lugton J, Fenning S, Johnston B, Fallon M, Clark D, Spiller JA, Murray SA. Palliative and end-of-life care research in Scotland 2006-2015: a systematic scoping review. BMC Palliat Care 2018; 17:19. [PMID: 29373964 PMCID: PMC5787303 DOI: 10.1186/s12904-017-0266-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Scottish Government set out its 5-year vision to improve palliative care in its Strategic Framework for Action 2016-2021. This includes a commitment to strengthening research and evidence based knowledge exchange across Scotland. A comprehensive scoping review of Scottish palliative care research was considered an important first step. The aim of the review was to quantify and map palliative care research in Scotland over the ten-year period preceding the new strategy (2006-15). METHODS A systematic scoping review was undertaken. Palliative care research involving at least one co-author from a Scottish institution was eligible for inclusion. Five databases were searched with relevant MeSH terms and keywords; additional papers authored by members of the Scottish Palliative and End of Life Care Research Forum were added. RESULTS In total, 1919 papers were screened, 496 underwent full text review and 308 were retained in the final set. 73% were descriptive studies and 10% were interventions or feasibility studies. The top three areas of research focus were services and settings; experiences and/or needs; and physical symptoms. 58 papers were concerned with palliative care for people with conditions other than cancer - nearly one fifth of all papers published. Few studies focused on ehealth, health economics, out-of-hours and public health. Nearly half of all papers described unfunded research or did not acknowledge a funder (46%). CONCLUSIONS There was a steady increase in Scottish palliative care research during the decade under review. Research output was strong compared with that reported in an earlier Scottish review (1990-2005) and a similar review of Irish palliative care research (2002-2012). A large amount of descriptive evidence exists on living and dying with chronic progressive illness in Scotland; intervention studies now need to be prioritised. Areas highlighted for future research include palliative interventions for people with non-malignant illness and multi-morbidity; physical and psychological symptom assessment and management; interventions to support carers; and bereavement support. Knowledge exchange activities are required to disseminate research findings to research users and a follow-up review to examine future research progress is recommended.
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Affiliation(s)
- Anne M. Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, EH10 7DR UK
- Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Emma Carduff
- Marie Curie Hospice Glasgow, 133 Balornock Road, Glasgow, G21 3US UK
- School of Medicine, Nursing and Healthcare, University of Glasgow, 59 Oakfield Avenue, Glasgow, G12 8LL UK
| | - Jean Lugton
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, EH10 7DR UK
| | - Stephen Fenning
- Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU UK
| | - Bridget Johnston
- Florence Nightingale Foundation, Clinical Nursing Practice Research, School of Medicine, Dentistry & Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow and NHS Greater Glasgow and Clyde, 57-61 Oakfield Avenue, Glasgow, G12 8LL UK
| | - Marie Fallon
- Institute of Genetics and Palliative Medicine, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XR UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Bankend Road, Dumfries, DG1 4ZL UK
| | - Juliet A. Spiller
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, EH10 7DR UK
| | - Scott A. Murray
- Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 1135] [Impact Index Per Article: 141.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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Smith LJE, Moore E, Ali I, Smeeth L, Stone P, Quint JK. Prognostic variables and scores identifying the end of life in COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2017; 12:2239-2256. [PMID: 28814852 PMCID: PMC5546187 DOI: 10.2147/copd.s137868] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION COPD is a major cause of mortality, and the unpredictable trajectory of the disease can bring challenges to end-of-life care. We aimed to investigate known prognostic variables and scores that predict prognosis in COPD in a systematic literature review, specifically including variables that contribute to risk assessment of patients for death within 12 months. METHODS We conducted a systematic review on prognostic variables, multivariate score or models for COPD. Ovid MEDLINE, EMBASE, the Cochrane database, Cochrane CENTRAL, DARE and CINAHL were searched up to May 1, 2016. RESULTS A total of 5,276 abstracts were screened, leading to 516 full-text reviews, and 10 met the inclusion criteria. No multivariable indices were developed with the specific aim of predicting all-cause mortality in stable COPD within 12 months. Only nine indices were identified from four studies, which had been validated for this time period. Tools developed using expert knowledge were also identified, including the Gold Standards Framework Prognostic Indicator Guidance, the RADboud Indicators of Palliative Care Needs, the Supportive and Palliative Care Indicators Tool and the Necesidades Paliativas program tool. CONCLUSION A number of variables contributing to the prediction of all-cause mortality in COPD were identified. However, there are very few studies that are designed to assess, or report, the prediction of mortality at or less than 12 months. The quality of evidence remains low, such that no single variable or multivariable score can currently be recommended.
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Affiliation(s)
- Laura-Jane E Smith
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
| | - Elizabeth Moore
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
| | - Ifrah Ali
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
| | - Liam Smeeth
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Patrick Stone
- Marie Curie Palliative Care Research Unit, University College London, UK
| | - Jennifer K Quint
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
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Fruhwald S, Pollesello P, Fruhwald F. Advanced heart failure: an appraisal of the potential of levosimendan in this end-stage scenario and some related ethical considerations. Expert Rev Cardiovasc Ther 2016; 14:1335-1347. [PMID: 27778514 DOI: 10.1080/14779072.2016.1247694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The later stages of heart failure are characterized by a steady decline in quality of life. Clinical priorities should be to maintain functional capacity and quality of life. In the absence of sufficient organs for transplantation, options include left ventricular assist devices and inotropic support. Areas covered: We examined data published in the last two decades on the use of inotropes and inodilators in advanced heart failure. Expert commentary: In the literature, use of conventional inotropes, including adrenergic agonists and phosphodiesterase inhibitors, appears to be suboptimal for achieving the clinical priorities of late-stage heart failure. Evidence suggests instead that the calcium-sensitizing inodilator levosimendan, administered intermittently, delivers improvements in functional capacity and quality of life and does so with no adverse impact on life expectancy. At a terminal or near-terminal stage of heart failure, the therapeutic philosophy should shift towards meeting patients' existential priorities rather than traditional heart failure-centric targets.
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Affiliation(s)
- Sonja Fruhwald
- a Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine , Medical University of Graz , Graz , Austria
| | - Piero Pollesello
- b Critical Care Proprietary Products , Orion Pharma , Espoo , Finland
| | - Friedrich Fruhwald
- c Department of Internal Medicine, Division of Cardiology , Medical University of Graz , Graz , Austria
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