HeartFull: Feasibility of an Integrated Program of Care for Patients with Advanced Stage of Heart Failure

Components of home-based palliative and supportive care for adults with heart failure: A scoping review

BACKGROUND

Palliative care and supportive care provided in the home for people with heart failure can improve quality of life, caregiver wellbeing and reduce healthcare costs. Identifying components of home-based palliative and supportive care in heart failure is useful to inform tailored care to people with heart failure.

AIM

To identify and describe components of home-based palliative and supportive care in adults with heart failure.

DESIGN

A scoping review was undertaken in accordance with Joanna Briggs Institute guidelines. The protocol was registered prospectively with the Open Science Framework (https://doi.org/10.17605/OSF.IO/GHCME).

DATA SOURCES

Embase, PubMed, CINAHL and Cochrane databases were searched from inception in May 2023 and re-run in January 2024. Original research focussed on palliative and supportive care in the home setting that included adults diagnosed with heart failure who have not undergone nor awaiting a heart transplant was included.

RESULTS

Results were extracted from 13 papers based on eight studies. The findings highlight that nurses supported by a multidisciplinary team, providing symptom management, patient and carer education and discussion of goals of care and advance care planning, facilitates home-based palliative and supportive care for people with heart failure.

CONCLUSION

Ensuring patient and caregiver-centred care supported by a multidisciplinary team is essential to delivering home-based palliative and supportive care for people with heart failure. Further research focussed on the role of digital interventions in home-based palliative and supportive care, the composition of the multidisciplinary team and research which includes individuals across all stages of heart failure is needed.

Supporting the Heterogeneous and Evolving Treatment Preferences of Patients With Heart Failure Through Collaborative Home-Based Palliative Care

Background We characterized the treatment preferences, care setting, and end-of-life outcomes among patients with advanced heart failure supported by a collaborative home-based model of palliative care. Methods and results This decedent cohort study included 250 patients with advanced heart failure who received collaborative home-based palliative care for a median duration of 1.9 months of follow-up in Ontario, Canada, from April 2013 to July 2019. Patients were categorized into 1 of 4 groups according to their initial treatment preferences. Outcomes included location of death (out of hospital versus in hospital), changes in treatment preferences, and health service use. Among patients who initially prioritized quantity of life, 21 of 43 (48.8%) changed their treatment preferences during follow-up (mean 0.28 changes per month). The majority of these patients changed their preferences to avoid hospitalization and focus on comfort at home (19 of 24 changes, 79%). A total of 207 of 250 (82.8%) patients experienced an out-of-hospital death. Patients who initially prioritized quantity of life had decreased odds of out-of-hospital death (versus in-hospital death; adjusted odds ratio, 0.259 [95% CI, 0.097-0.693]) and more frequent hospitalizations (mean 0.45 hospitalizations per person-month) compared with patients who initially prioritized quality of life at home. Conclusions Our results yield a more detailed understanding of the interaction of advanced care planning and patient preferences. Shared decision making for personalized treatment is dynamic and can be enacted earlier than at the very end of life.

Modification of Cardiovascular Drugs in Advanced Heart Failure: A Narrative Review

Advanced heart failure (HF) is a complex entity with a clinical course difficult to predict. However, most patients have a poor prognosis. This document addresses the modification of cardiovascular drugs in patients with advanced HF that are not candidates to heart transplantation or ventricular assist device and are in need of palliative care. The adjustment of cardiovascular drugs is frequently needed in these patients. The shift in emphasis from life-prolonging to symptomatic treatments should be a progressive one. We establish a series of recommendations with the aim of adjusting drugs in these patients, in order to adapt treatment to the needs and wishes of each patient. This is frequently a difficult process for patients and professionals, as drug discontinuing needs to balance treatment benefit with the psychological adaption to having a terminal illness. We encourage the use of validated assessment tools to assess prognosis and to use this information to take clinical decisions regarding drug withdrawal and therapeutic changes. The golden rule is to stop drugs that are harmful or non-essential and to continue the ones that provide symptomatic improvement.