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Meng Y, Zhang T, Ge X, Zheng Q, Feng T. Physical activity changes and related factors in chronic heart failure patients during the postdischarge transition period: a longitudinal study. BMC Cardiovasc Disord 2024; 24:232. [PMID: 38684960 PMCID: PMC11059695 DOI: 10.1186/s12872-024-03881-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Physical activity (PA) is essential and effective for chronic heart failure (CHF) patients. A greater understanding of the longitudinal change in PA and its influencing factors during the postdischarge transition period may help create interventions for improving PA. The aims of this study were (1) to compare the change in PA, (2) to examine the influencing factors of PA change, and (3) to verify the mediating pathways between influencing factors and PA during the postdischarge transition period in CHF patients. METHODS A total of 209 CHF patients were recruited using a longitudinal study design. The Chinese version of the International Physical Activity Questionnaire (IPAQ), Patient-reported Outcome Measure for CHF (CHF-PRO), and the Chinese version of the Tampa Scale for Kinesiophobia Heart (TSK-Heart) were used to assess PA, CHF-related symptoms, and kinesiophobia. The IPAQ score was calculated (1) at admission, (2) two weeks after discharge, (3) two months after discharge, and (4) three months after discharge. Two additional questionnaires were collected during admission. Generalized estimating equation (GEE) models were fitted to identify variables associated with PA over time. We followed the STROBE checklist for reporting the study. RESULTS The PA scores at the four follow-up visits were 1039.50 (346.50-1953.00) (baseline/T1), 630.00 (1.00-1260.00) (T2), 693.00 (1-1323.00) (T3) and 693.00 (160.88-1386.00) (T4). The PA of CHF patients decreased unevenly, with the lowest level occurring two weeks after discharge, and gradually improving at two and three months after discharge. CHF-related symptoms and kinesiophobia were significantly associated with changes in PA over time. Compared with before hospitalization, an increase in CHF-related symptoms at two weeks and two months after discharge was significantly associated with decreased PA. According to our path analysis, CHF-related symptoms were positively and directly associated with kinesiophobia, and kinesiophobia was negatively and directly related to PA. Moreover, CHF-related symptoms are indirectly related to PA through kinesiophobia. CONCLUSION PA changed during the postdischarge transition period and was associated with CHF-related symptoms and kinesiophobia in CHF patients. Reducing CHF-related symptoms helps improve kinesiophobia in CHF patients. In addition, the reduction in CHF-related symptoms led to an increase in PA through the improvement of kinesiophobia. TRIAL REGISTRATION The study was registered in the Chinese Clinical Trial Registry (11/10/2022 ChiCTR2200064561 retrospectively registered).
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Affiliation(s)
- Yingtong Meng
- Cardiology Department II ward I, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, People's Republic of China
| | - Tingting Zhang
- Cardiology Department II ward I, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, People's Republic of China
| | - Xiaohua Ge
- Department of Nursing, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, People's Republic of China.
| | - Qingru Zheng
- Department of Intensive Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, People's Republic of China
| | - Tienan Feng
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
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Ozdemir S, Lee JJ, Yeo KK, Sim KLD, Finkelstein EA, Malhotra C. A Prospective Cohort Study of Medical Decision-Making Roles and Their Associations with Patient Characteristics and Patient-Reported Outcomes among Patients with Heart Failure. Med Decis Making 2023; 43:863-874. [PMID: 37767897 DOI: 10.1177/0272989x231201609] [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] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Among patients with heart failure (HF), we examined 1) the evolution of patient involvement in decision making over 2 y, 2) the association of patient characteristics with decision-making roles, and 3) the association of decision-making roles with distress, spiritual well-being, and quality of physician communication. METHODS We administered the survey every 4 mo over 24 mo to patients with New York Heart Association class 3/4 symptoms recruited from inpatient clinics. The decision-making roles were categorized as no patient involvement, physician/family-led, joint (with family and/or physicians), patient-led, or patient-alone decision making. The associations between patient characteristics and decision-making roles were assessed using a mixed-effects ordered logistic regression, whereas those between patient outcomes and decision-making roles were investigated using mixed-effects linear regressions. RESULTS Of the 557 patients invited, 251 participated in the study. The most common roles in decision making at baseline assessment were "no involvement" (27.53%) and "patient-alone decision making" (25.10%). The proportions of different decision-making roles did not change over 2 y (P = 0.37). Older age (odds ratio [OR] = 0.97; P = 0.003) and being married (OR = 0.63; P = 0.035) were associated with lower involvement in decision making. Chinese ethnicity (OR = 1.91; P = 0.003), higher education (OR = 1.87; P = 0.003), awareness of terminal condition (OR = 2.00; P < 0.001), and adequate self-care confidence (OR = 1.74; P < 0.001) were associated with greater involvement. Compared with no patient involvement, joint (β = -0.58; P = 0.026) and patient-led (β = -0.59; P = 0.014) decision making were associated with lower distress, while family/physician-led (β = 4.37; P = 0.001), joint (β = 3.86; P < 0.001), patient-led (β = 3.46; P < 0.001), and patient-alone (β = 3.99; P < 0.001) decision making were associated with better spiritual well-being. CONCLUSION A substantial proportion of patients was not involved in decision making. Patients should be encouraged to participate in decision making since it is associated with lower distress and better spiritual well-being. HIGHLIGHTS The level of involvement in medical decision making did not change over time among patients with heart failure. A substantial proportion of patients were not involved in decision making throughout the 24-mo study period.Patients' involvement in decision making varied by age, ethnicity, education level, marital status, awareness of the terminal condition, and confidence in self-care.Compared with no patient involvement in decision making, joint and patient-led decision making were associated with lower distress, and any level of patient involvement in decision making was associated with better spiritual well-being.
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Affiliation(s)
- Semra Ozdemir
- Signature Program in Health Services and Systems Research, Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, USA
| | - Jia Jia Lee
- Research Associate, Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | | | | | - Eric Andrew Finkelstein
- Signature Program in Health Services and Systems Research, Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Duke Global Health Institute, Duke University, USA
| | - Chetna Malhotra
- Signature Program in Health Services and Systems Research, Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Cross SH, Kavalieratos D. Public Health and Palliative Care. Clin Geriatr Med 2023; 39:395-406. [PMID: 37385691 PMCID: PMC10571066 DOI: 10.1016/j.cger.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Meeting the needs of people at the end of life (EOL) is a public health (PH) concern, yet a PH approach has not been widely applied to EOL care. The design of hospice in the United States, with its focus on cost containment, has resulted in disparities in EOL care use and quality. Individuals with non-cancer diagnoses, minoritized individuals, individuals of lower socioeconomic status, and those who do not yet qualify for hospice are particularly disadvantaged by the existing hospice policy. New models of palliative care (both hospice and non-hospice) are needed to equitably address the burden of suffering from a serious illness.
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Affiliation(s)
- Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA
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Trandel ET, Lowers J, Bannon ME, Moreines LT, Dellon EP, White P, Cross SH, Quest TE, Lagnese K, Krishnamurti T, Arnold RM, Harrison KL, Patzer RE, Wang L, Zarrabi AJ, Kavalieratos D. Barriers of Acceptance to Hospice Care: a Randomized Vignette-Based Experiment. J Gen Intern Med 2023; 38:277-284. [PMID: 35319086 PMCID: PMC9905383 DOI: 10.1007/s11606-022-07468-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The per diem financial structure of hospice care may lead agencies to consider patient-level factors when weighing admissions. OBJECTIVE To investigate if treatment cost, disease complexity, and diagnosis are associated with hospice willingness to accept patients. DESIGN In this 2019 online survey study, individuals involved in hospice admissions decisions were randomized to view one of six hypothetical patient vignettes: "high-cost, high-complexity," "low-cost, high-complexity," and "low-cost, low-complexity" within two diseases: heart failure and cystic fibrosis. Vignettes included demographics, prognoses, goals, and medications with costs. Respondents indicated their perceived likelihood of acceptance to their hospice; if likelihood was <100%, respondents were asked the barriers to acceptance. We used bivariate tests to examine associations between demographic, clinical, and organizational factors and likelihood of acceptance. PARTICIPANTS Individuals involved in hospice admissions decisions MAIN MEASURES: Likelihood of acceptance to hospice care KEY RESULTS: N=495 (76% female, 53% age 45-64). Likelihoods of acceptance in cystic fibrosis were 79.8% (high-cost, high-complexity), 92.4% (low-cost, high-complexity), and 91.5% (low-cost, low-complexity), and in heart failure were 65.9% (high-cost, high-complexity), 87.3% (low-cost, high-complexity), and 96.6% (low-cost, low-complexity). For both heart failure and cystic fibrosis, respondents were less likely to accept the high-cost, high-complexity patient than the low-cost, high-complexity patient (65.9% vs. 87.3%, 79.8% vs. 92.4%, both p<0.001). For heart failure, respondents were less likely to accept the low-cost, high-complexity patient than the low-cost, low-complexity patient (87.3% vs. 96.6%, p=0.004). Treatment cost was the most common barrier for 5 of 6 vignettes. CONCLUSIONS This study suggests that patients receiving expensive and/or complex treatments for palliation may have difficulty accessing hospice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Li Wang
- University of Pittsburgh, Pittsburgh, USA
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5
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In-Hospital Left Ventricular Assist Devices Deactivation and Death Experience: A Single-Institution Retrospective Analysis. ASAIO J 2022; 68:1339-1345. [PMID: 35943389 DOI: 10.1097/mat.0000000000001658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Best practices for left ventricular assist devices (LVADs) deactivation at end-of-life (EOL) have yet to be elucidated. We conducted a single-institution retrospective review of patients who died following LVAD deactivation between January 2017 and March 2020. Data were obtained from institutional databases and electronic health record and were analyzed using descriptive statistics. Fifty-eight patients (70% male, 70% African American, median age 62 years) were categorized by implant strategy: bridge therapy (BT, N = 22, 38%) or destination therapy (DT, N = 36, 62%). Clinical events leading to deactivation were categorized either acute ( e.g. , stroke [ N = 31, 53%]), gradual decline ( N = 12, 21%), or complications during index hospitalization ( N = 15, 26%). Implant strategy was not associated with clinical trajectory leading to EOL ( p = 0.67), hospital unit of death ( p = 0.13), or use of mechanical ventilation ( p = 0.69) or renal replacement therapy ( p = 0.81) during terminal hospitalization. Overall time from admission to code status change was mean 27.0 days (SD 30.3 days). Compared with BT patients, DT experienced earlier do-not-resuscitate (DNR) orders ( p ≤ 0.01) and shorter survival post-deactivation ( p ≤ 0.01). Deactivations after gradual decline tended to occur outside ICUs, compared with acute events or index implant-related complications ( p = 0.04). Implant strategy was not associated with differences in EOL experience except regarding timing of DNR order and survival post-deactivation.
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Ahluwalia SC, Bandini JI, Kogan AC, Bekelman DB, Olsen B, Phillips J, Sudore RL. Impact of group visits for older patients with heart failure on advance care planning outcomes: Preliminary data. J Am Geriatr Soc 2021; 69:2908-2915. [PMID: 34077563 PMCID: PMC8497395 DOI: 10.1111/jgs.17283] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource-efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP-related outcomes. METHODS We conducted a mixed-methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP-related outcomes including readiness and self-efficacy. The evidence-based PREPARE for Your Care video-based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90-min group visits led by a trained facilitator. Group visit participants completed pre-, post-, and 1-month follow-up surveys using validated 5-point ACP readiness and self-efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis. RESULTS Patient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre-to-post (+0.53; p = 0.002) but was not sustained at 1-month follow-up. Patient and caregiver self-efficacy showed some improvement pre-to-post but was also not sustained at follow-up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake-up" call to action. CONCLUSIONS Disease-focused group visits may have a short-term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow-up ACP conversations after a single group visit. Timing for follow-ups and the ideal person to follow-up ACP conversations needs to be explored.
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Affiliation(s)
- Sangeeta C. Ahluwalia
- RAND Corporation, Santa Monica, CA
- UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Alexis Coulourides Kogan
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
| | - David B. Bekelman
- Department of Medicine, Eastern Colorado VA HCS and Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus
| | - Bonnie Olsen
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
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Morgan DD, Tieman JJ, Allingham SF, Ekström MP, Connolly A, Currow DC. The trajectory of functional decline over the last 4 months of life in a palliative care population: A prospective, consecutive cohort study. Palliat Med 2019; 33:693-703. [PMID: 30916620 DOI: 10.1177/0269216319839024] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Understanding current patterns of functional decline will inform patient care and has health service and resource implications. AIM This prospective consecutive cohort study aims to map the shape of functional decline trajectories at the end of life by diagnosis. DESIGN Changes in functional status were measured using the Australia-modified Karnofsky Performance Status Scale. Segmented regression was used to identify time points prior to death associated with significant changes in the slope of functional decline for each diagnostic cohort. Sensitivity analyses explored the impact of severe symptoms and late referrals, age and sex. SETTING/PARTICIPANTS In all, 115 specialist palliative care services submit prospectively collected patient data to the national Palliative Care Outcomes Collaboration across Australia. Data on 55,954 patients who died in the care of these services between 1 January 2013 and 31 December 2015 were included. RESULTS Two simplified functional decline trajectories were identified in the last 4 months of life. Trajectory 1 has an almost uniform slow decline until the last 14 days of life when function declines more rapidly. Trajectory 2 has a flatter more stable trajectory with greater functional impairment at 120 days before death, followed by a more rapid decline in the last 2 weeks of life. The most rapid rate of decline occurs in the last 2 weeks of life for all cohorts. CONCLUSIONS Two simplified trajectories of functional decline in the last 4 months of life were identified for five patient cohorts. Both trajectories present opportunities to plan for responsive healthcare that will support patients and families.
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Affiliation(s)
- Deidre D Morgan
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Jennifer J Tieman
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Samuel F Allingham
- 2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Magnus P Ekström
- 3 Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden.,4 Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Alanna Connolly
- 2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - David C Currow
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia.,4 Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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Cross SH, Kamal AH, Taylor DH, Warraich HJ. Hospice Use Among Patients with Heart Failure. Card Fail Rev 2019; 5:93-98. [PMID: 31179019 PMCID: PMC6545999 DOI: 10.15420/cfr.2019.2.2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022] Open
Abstract
Despite its many benefits, hospice care is underused for patients with heart failure. This paper discusses the factors contributing to this underuse and offers recommendations to optimise use for patients with heart failure and proposes metrics to optimise quality of hospice care for this patient group.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University Durham, NC, US
| | - Arif H Kamal
- Duke Cancer Institute Durham, NC, US.,Duke Fuqua School of Business, Duke University Durham, NC, US
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University Durham, NC, US.,Margolis Center for Health Policy, Duke University Durham, NC, US.,Duke Clinical Research Institute Durham, NC, US
| | - Haider J Warraich
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, US
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Nakagawa S, Garan AR, Takayama H, Takeda K, Topkara VK, Yuzefpolskaya M, Lin SX, Colombo PC, Naka Y, Blinderman CD. End of Life with Left Ventricular Assist Device in Both Bridge to Transplant and Destination Therapy. J Palliat Med 2018; 21:1284-1289. [DOI: 10.1089/jpm.2018.0112] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Shunichi Nakagawa
- Adult Palliative Care Service, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Arthur R. Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Susan X. Lin
- Center for Family and Community Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C. Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Craig D. Blinderman
- Adult Palliative Care Service, Department of Medicine, Columbia University Medical Center, New York, New York
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Abstract
BACKGROUND Rehospitalization soon after discharge can be distressing for persons with heart failure (HF) and places a heavy burden on the healthcare system. OBJECTIVE We investigated and explored the association of self-care decision making variables with (1) rehospitalization within 30 days of discharge and (2) delay in seeking medical assistance (delayed decision making). METHODS A cross-sectional, explanatory sequential mixed methods design (quan > qual) was used to survey 127 hospitalized HF patients and interview 15 of these participants to explain their survey responses. The survey assessed rehospitalization within 30 days of discharge, delayed decision making, HF self-care, and psychosocial factors influencing self-care. RESULTS The likelihood of delaying the decision to be hospitalized was more than 5 times higher among those with high depressive symptoms (odds ratio, 5.33; 95% confidence interval, 2.14-13.28). Those who delayed going to the hospital were uncertain about their prognosis and did not feel their symptoms were urgent. The likelihood of being rehospitalized within 30 days was more than doubled among those with high depressive symptoms (OR, 2.31; 95% confidence interval, 1.01-5.31). Those who were rehospitalized within 30 days were less likely to consult healthcare professionals in their decision making and wanted immediate relief from their symptoms. CONCLUSIONS We recommend a patient-centered approach to help HF patients identify and adequately self-manage symptoms. The strong association between high depressive symptoms and rehospitalization within 30 days as well as delayed decision making highlights the critical need for clinicians to carefully assess and address depression among HF patients.
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Ng AYM, Wong FKY. Effects of a Home-Based Palliative Heart Failure Program on Quality of Life, Symptom Burden, Satisfaction and Caregiver Burden: A Randomized Controlled Trial. J Pain Symptom Manage 2018; 55:1-11. [PMID: 28801001 DOI: 10.1016/j.jpainsymman.2017.07.047] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/03/2017] [Accepted: 07/07/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT Provision of home-based palliative care (PC) for seriously ill patients is important, yet few home-based PC services specifically or exclusively focus on end-stage heart failure (ESHF) patients. OBJECTIVES This study aimed to examine the effect of a home-based palliative heart failure (HPHF) program on quality of life (QOL), symptoms burden, functional status, patient satisfaction, and caregiver burden among patients with ESHF. METHODS This study was a two-group randomized controlled trial undertaken in three hospitals. We recruited a total of 84 hospitalized ESHF patients who were referred to PC. They were randomized to the intervention or control group. The intervention group received a 12-week structured program with regular home visits/telephone calls provided by the nurse case managers. Data were collected at baseline (T1) and at four (T2) and 12 weeks (T3) after discharge. RESULTS A statistically significant between-group effect was found, with the HPHF group having significantly higher McGill QOL total score than the control group (P = 0.016) and there was significant group × time interaction effect (P = 0.032). There was no significant between-group effects detected for the measures of symptom distress or functional status at 12 weeks. The intervention group had higher satisfaction (P = 0.001) and lower caregiver burden (P = 0.024) than the control group at 12 weeks. CONCLUSION The HPHF program is effective in enhancing the QOL of ESHF patients, satisfaction with care, and caregiver burden. The program has potential to reduce distress for some of the symptoms.
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Affiliation(s)
- Alina Yee Man Ng
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China; The Open University of Hong Kong, Hong Kong, China
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12
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Bakitas M, Dionne-Odom JN, Pamboukian SV, Tallaj J, Kvale E, Swetz KM, Frost J, Wells R, Azuero A, Keebler K, Akyar I, Ejem D, Steinhauser K, Smith T, Durant R, Kono AT. Engaging patients and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial. BMC Palliat Care 2017; 16:45. [PMID: 28859648 PMCID: PMC5580310 DOI: 10.1186/s12904-017-0226-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/01/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Early palliative care (EPC) is recommended but rarely integrated with advanced heart failure (HF) care. We engaged patients and family caregivers to study the feasibility and site differences in a two-site EPC trial, ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers). METHODS We conducted an EPC feasibility study (4/1/14-8/31/15) for patients with NYHA Class III/IV HF and their caregivers in academic medical centers in the northeast and southeast U.S. The EPC intervention comprised: 1) an in-person outpatient palliative care consultation; and 2) telephonic nurse coach sessions and monthly calls. We collected patient- and caregiver-reported outcomes of quality of life (QOL), symptom, health, anxiety, and depression at baseline, 12- and 24-weeks. We used linear mixed-models to assess baseline to week 24 longitudinal changes. RESULTS We enrolled 61 patients and 48 caregivers; between-site demographic differences included age, race, religion, marital, and work status. Most patients (69%) and caregivers (79%) completed all intervention sessions; however, we noted large between-site differences in measurement completion (38% southeast vs. 72% northeast). Patients experienced moderate effect size improvements in QOL, symptoms, physical, and mental health; caregivers experienced moderate effect size improvements in QOL, depression, mental health, and burden. Small-to-moderate effect size improvements were noted in patients' hospital and ICU days and emergency visits. CONCLUSIONS Between-site demographic, attrition, and participant-reported outcomes highlight the importance of intervention pilot-testing in culturally diverse populations. Observations from this pilot feasibility trial allowed us to refine the methodology of an in-progress, full-scale randomized clinical efficacy trial. TRIAL REGISTRATION Clinicaltrials.gov NCT03177447 (retrospectively registered, June 2017).
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Affiliation(s)
- Marie Bakitas
- School of Nursing and Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA. .,School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA.
| | - J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA
| | - Salpy V Pamboukian
- Department of Medicine, Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth Kvale
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keith M Swetz
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer Frost
- Cardiology, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA
| | - Konda Keebler
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA
| | - Imatullah Akyar
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA.,Faculty of Health Sciences, Nursing Department, Hacettepe University, Ankara, Turkey
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA
| | - Karen Steinhauser
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Tasha Smith
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, MT 412C, Birmingham, AL, 35294, USA
| | - Raegan Durant
- Department of Medicine, Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alan T Kono
- Cardiology, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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13
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Stocker R, Close H, Hancock H, Hungin APS. Should heart failure be regarded as a terminal illness requiring palliative care? A study of heart failure patients’, carers’ and clinicians’ understanding of heart failure prognosis and its management. BMJ Support Palliat Care 2017; 7:464-469. [DOI: 10.1136/bmjspcare-2016-001286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/15/2017] [Accepted: 06/26/2017] [Indexed: 11/04/2022]
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14
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Yim CK, Barrón Y, Moore S, Murtaugh C, Lala A, Aldridge M, Goldstein N, Gelfman LP. Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003335. [PMID: 28292824 DOI: 10.1161/circheartfailure.116.003335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited. METHODS AND RESULTS We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment. CONCLUSIONS Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.
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Affiliation(s)
- Cindi K Yim
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Yolanda Barrón
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Stanley Moore
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Chris Murtaugh
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Anuradha Lala
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Melissa Aldridge
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Nathan Goldstein
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Laura P Gelfman
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA.
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15
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Abstract
Heart failure presents unique challenges to the clinician who desires to provide excellent and humane care near the end of life. Accurate prediction of mortality in the individual patient is complicated by a chronic disease that is punctuated by recurrent acute episodes and sudden death. Health care providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, all of which needs to occur earlier rather than later. This article also discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation with concurrent discussion of the ethical ramifications and pitfalls of each.
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Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA.
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16
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Abstract
BACKGROUND Persons with heart failure (HF) are required to make decisions on a daily basis related to their declining health and make urgent decisions during acute illness exacerbations. However, little is known about the types of decisions patients make. OBJECTIVE The aims of this study were to critically evaluate the current quantitative literature related to decision making among persons with HF and identify research gaps in HF decision-making research. METHODS A systematic search of literature about decisions persons with HF make was conducted using PubMed, CINAHL, and PsychINFO databases. The following inclusion criteria were used: sample composed of at least 50% HF participants, concrete decisions were made, and a quantitative study design was used. Two authors performed title, abstract, and full-text reviews independently to identify eligible articles. RESULTS Twelve quantitative articles were included. Study samples were predominately older, white, male, and married. Two-thirds of the articles focused on decisions related to the end-of-life topics (ie, resuscitation decisions, advanced care planning). The other one-third focused on decisions about care seeking, participant's involvement in treatment decisions during their last clinic visit, and self-care behaviors. CONCLUSIONS Within the HF literature, the term decision is often ill-defined or not defined. Limitations in methodological rigor limit definitive conclusions about HF decision making. Future studies should consider strengthening study rigor and examining other decision topics such as inclusion of family in making decisions as HF progresses. Research rigorously examining HF decision making is needed to develop interventions to support persons with HF.
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17
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Norvell DC, Dettori JR, Chapman JR. Success in Spine Care: The Proof Is in the Measurements, Part II. Global Spine J 2015; 5:455-6. [PMID: 26682094 PMCID: PMC4671904 DOI: 10.1055/s-0035-1566228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Daniel C. Norvell
- Spectrum Research, Inc., Tacoma, Washington, United States,Address for correspondence Daniel C. Norvell, PhD Spectrum Research, Inc.705 S. 9th Street, #203, Tacoma, WA 98405United States
| | | | - Jens R. Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States
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18
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Svanholm JR, Nielsen JC, Mortensen P, Christensen CF, Birkelund R. Refusing Implantable Cardioverter Defibrillator (ICD) Replacement in Elderly Persons-The Same as Giving Up Life: A Qualitative Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1275-86. [PMID: 26234375 DOI: 10.1111/pace.12702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 05/29/2015] [Accepted: 07/15/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND More than 20% of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices are implanted in the elderly population aged 80 years or older. In recent scientific literature it is suggested to consider termination of ICD therapy, rather than ICD replacement, in this patient group. The aim of this study was to explore the experiences of persons above 80 years of age concerning replacement of the ICD battery, and the shared communication and decision making with healthcare professionals. METHODS We performed a qualitative, explorative study, inspired by Ricoeur's narrative, with a phenomenological-hermeneutic approach, involving 11 ICD patients older than 80 years. The study period was 2011-2012. RESULTS The meaning of the patients' experiences of living with an ICD was formulated into two themes: (1) "Feeling safe with the ICD" with the subthemes: "The ICD-a life keeper," "The battery level is important," "ICD shock-no problem." (2) "The physician is an authority" with the subthemes: "Being trustful," "Feeling fine knowing nothing," "Criminal act to deactivate the ICD." CONCLUSION The elderly ICD recipients tended not to be aware of the option of declining replacement of their ICD. They tended to expect to have their ICD replaced and not to be involved actively in decision making concerning this. Healthcare professionals have an obligation to discuss options and ensure that every patient understands these. More research is needed to change practices and create more realistic, person-centered, ethically acceptable, and constructive healthcare for elderly persons with an ICD.
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Affiliation(s)
| | | | - Peter Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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19
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Xu J, Nolan MT, Heinze K, Yenokyan G, Hughes MT, Johnson J, Kub J, Tudor C, Sulmasy DP, Lehmann LS, Gallo JJ, Rockko F, Lee MC. Symptom frequency, severity, and quality of life among persons with three disease trajectories: cancer, ALS, and CHF. Appl Nurs Res 2015; 28:311-5. [PMID: 26608431 DOI: 10.1016/j.apnr.2015.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/30/2014] [Accepted: 03/05/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE National reports on end-of-life symptom management reveal a gap in the evidence regarding symptoms other than pain and studies of diseases other than cancer. This study examines the frequency and severity of symptoms and quality of life (QOL) in persons with advanced cancer, amyotrophic lateral sclerosis (ALS), and congestive heart failure (CHF). METHODS The present study is a cross-sectional examination of symptoms and QOL measured using the McGill QOL Questionnaire, among 147 participants. RESULTS Forty one percent of participants had advanced cancer, 22% had ALS, and 37% had advanced CHF. A total of 266 symptoms were reported, with the common symptom categories being discomfort/pain, weakness/fatigue/sleep, and respiratory. Participants with CHF had the highest mean symptom severity and the lowest QOL. CONCLUSION Clinicians should be aware and attentive for symptoms other than pain in patients with advanced illness. Studies on diseases other than cancer, such as CHF and ALS, are important to improve symptom management in all disease groups.
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Affiliation(s)
- Jiayun Xu
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
| | - Marie T Nolan
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
| | - Katherine Heinze
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
| | - Gayane Yenokyan
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Mark T Hughes
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Julie Johnson
- The University of Chicago Medicine, Chicago, IL 60637, USA.
| | - Joan Kub
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
| | - Carrie Tudor
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
| | | | | | - Joseph J Gallo
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Felicia Rockko
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
| | - Mei Ching Lee
- Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.
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20
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Svanholm JR, Nielsen JC, Mortensen PT, Christensen CF, Birkelund R. Normativity under change: Older persons with implantable cardioverter defibrillator. Nurs Ethics 2015; 23:328-38. [PMID: 25566813 DOI: 10.1177/0969733014564906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In modern society, death has become 'forbidden' fed by the medical technology to conquer death. The technological paradigm is challenged by a social-liberal political ideology in postmodern Western societies. The question raised in this study was as follows: Which arguments, attitudes, values and paradoxes between modern and postmodern tendencies concerning treatment and care of older persons with an implantable cardioverter defibrillator appear in the literature? AIMS The aim of this study was to describe and interpret how the field of tension concerning older persons with an implantable cardioverter defibrillator - especially end-of-life issues - has been expressed in the literature throughout the last decade. METHODS Paul Ricoeur's reflexive interpretive approach was used to extract the meaningful content of the literature involving qualitative, quantitative and normative literature. Analysis and interpretation involved naive reading, structural analysis and critical interpretation. ETHICAL CONSIDERATIONS The investigation complied with the principles outlined in the Declaration of Helsinki. FINDINGS AND DISCUSSIONS The unifying theme was 'Normativity under change'. The sub-themes were 'Death has become legitimate', 'The technological imperative is challenged' and 'Patients and healthcare professionals need to talk about end-of-life issues'. There seems to be a considerable distance between the normative approach of how practice ought to be and findings in empirical studies. CONCLUSION Modern as well as postmodern attitudes and perceptions illustrate contradictory tendencies regarding deactivation of the implantable cardioverter defibrillator and replacement of the implantable cardioverter defibrillator in older persons nearing the end of life. The tendencies challenge each other in a struggle to gain position. On the other hand, they can also complement each other because professionalism and health professional expertise cannot stand alone when the patient's life is at stake but must be unfolded in an alliance with the patient who needs to be understood and accepted in his vulnerability.
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21
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Goldstein NE, Kalman J, Kutner JS, Fromme EK, Hutchinson MD, Lipman HI, Matlock DD, Swetz KM, Lampert R, Herasme O, Morrison RS. A study to improve communication between clinicians and patients with advanced heart failure: methods and challenges behind the working to improve discussions about defibrillator management trial. J Pain Symptom Manage 2014; 48:1236-46. [PMID: 24768595 PMCID: PMC4205212 DOI: 10.1016/j.jpainsymman.2014.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
Abstract
We report the challenges of the Working to Improve Discussions About Defibrillator Management trial, our novel, multicenter trial aimed at improving communication between cardiology clinicians and their patients with advanced heart failure (HF) who have implantable cardioverter defibrillators (ICDs). The study objectives are (1) to increase ICD deactivation conversations, (2) to increase the number of ICDs deactivated, and (3) to improve psychological outcomes in bereaved caregivers. The unit of randomization is the hospital, the intervention is aimed at HF clinicians, and the patient and caregiver are the units of analysis. Three hospitals were randomized to usual care and three to intervention. The intervention consists of an interactive educational session, clinician reminders, and individualized feedback. We enroll patients with advanced HF and their caregivers, and then we regularly survey them to evaluate whether the intervention has improved communication between them and their HF providers. We encountered three implementation barriers. First, there were institutional review board concerns at two sites because of the palliative nature of the study. Second, we had difficulty in creating entry criteria that accurately identified an HF population at high risk of dying. Third, we had to adapt our entry criteria to the changing landscape of ventricular assist devices and cardiac transplant eligibility. Here we present our novel solutions to the difficulties we encountered. Our work has the ability to enhance conduct of future studies focusing on improving care for patients with advanced illness.
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Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA.
| | - Jill Kalman
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erik K Fromme
- Departments of Medicine, Radiation Medicine, and Nursing, Oregon Health Sciences University, Portland, Oregon, USA
| | - Mathew D Hutchinson
- Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hannah I Lipman
- Divisions of Geriatrics and Cardiology, Montefiore Medical Center, Bronx, New York, USA; The Montefiore-Einstein Center for Bioethics, Montefiore Medical Center, Bronx, New York, USA
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rachel Lampert
- Section of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Omarys Herasme
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
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22
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Gelfman LP, Kalman J, Goldstein NE. Engaging heart failure clinicians to increase palliative care referrals: overcoming barriers, improving techniques. J Palliat Med 2014; 17:753-60. [PMID: 24901674 DOI: 10.1089/jpm.2013.0675] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Heart failure (HF) is the most common cause of hospitalization among adults over the age of 65. Hospital readmission rates, mortality rates, and Medicare costs for patients with this disease are high. Furthermore, patients with HF experience a number of symptoms that worsen as the disease progresses. However, a small minority of patients with HF receives hospice or palliative care. One possible reason for this may be that the HF and palliative care clinicians have differing perspectives on the role of palliative care for these patients. AIM The goal of the article is to offer palliative care clinicians a roadmap for collaborating with HF clinicians by reviewing the needs of patients with HF. CONCLUSIONS This article reviews the needs of patients with HF and their families, the barriers to referral to palliative care for patients with HF, and provides suggestions for improving collaboration between palliative care and HF clinicians.
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Affiliation(s)
- Laura P Gelfman
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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23
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Jacobsen J, Kvale E, Rabow M, Rinaldi S, Cohen S, Weissman D, Jackson V. Helping patients with serious illness live well through the promotion of adaptive coping: a report from the improving outpatient palliative care (IPAL-OP) initiative. J Palliat Med 2014; 17:463-8. [PMID: 24579823 DOI: 10.1089/jpm.2013.0254] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Continuity outpatient palliative care practice is characterized by long relationships between patients, families, and palliative care clinicians and by periods of relative stability when the disease and resultant symptoms are less active. Compared to inpatient palliative care, outpatient practice requires a greater focus on encouraging healthy coping and on helping patients to live well with serious illness. This paper discusses the opportunities to promote adaptive coping in the delivery of outpatient palliative care.
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Affiliation(s)
- Juliet Jacobsen
- 1 Department of Palliative Care, Massachusets General Hospital , Boston, Massachusetts
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24
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Bruce CR, Fetter JE, Blumenthal-Barby JS. Cascade effects in critical care medicine: a call for practice changes. Am J Respir Crit Care Med 2014; 188:1384-5. [PMID: 24328766 DOI: 10.1164/rccm.201309-1606ed] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Courtenay R Bruce
- 1 Center for Medical Ethics and Health Policy Baylor College of Medicine Houston, Texas and Houston Methodist Hospital System Houston Methodist Hospital System Biomedical Ethics Program Houston, Texas
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25
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Vellone E, Chung ML, Cocchieri A, Rocco G, Alvaro R, Riegel B. Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: testing dyadic dynamics using the actor-partner interdependence model. JOURNAL OF FAMILY NURSING 2014; 20:120-141. [PMID: 24189325 DOI: 10.1177/1074840713510205] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Emotions are contagious in couples. The purpose of this study was to analyze the manner in which adults with chronic heart failure (HF) and their informal caregivers influence each other's self-care behavior and quality of life (QOL). A sample of 138 HF patients and spouses was enrolled from ambulatory centers across Italy. The Actor-Partner Interdependence Model (APIM) was used to analyze dyadic data obtained with the Self-Care of Heart Failure Index (SCHFI), the Caregivers Contribution to the SCHFI, and the Short Form 12. Both actor and partner effects were found. Higher self-care was related to lower physical QOL in patients and caregivers. Higher self-care maintenance in patients was associated with better mental QOL in caregivers. In caregivers, confidence in the ability to support patients in self-care was associated with improved caregivers' mental QOL, but worsened physical QOL in patients. Interventions that build the caregivers' confidence are needed.
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26
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Fluur C, Bolse K, Strömberg A, Thylén I. Spouses' reflections on implantable cardioverter defibrillator treatment with focus on the future and the end-of-life: a qualitative content analysis. J Adv Nurs 2013; 70:1758-69. [PMID: 24321029 DOI: 10.1111/jan.12330] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2013] [Indexed: 12/01/2022]
Abstract
AIM To explore future reflections of spouses living with an implantable cardioverter defibrillator recipient with focus on the end-of-life phase in an anticipated palliative phase. BACKGROUND A history of or risk for life-threatening arrhythmias may require an implantable cardioverter defibrillator. Despite the life-saving capacity of the device, eventually life will come to an end. As discussion about preferences of shock therapy at end-of-life phase seldom takes place in advance, the implantable cardioverter defibrillator recipients may face defibrillating shocks in the final weeks of their lives, adding to stress and anxiety in patients and their families. DESIGN Qualitative study with in-depth interviews analysed with a content analysis. METHODS Interviews were performed with 18 spouses of medically stable implantable cardioverter defibrillator recipients during 2011-2012. RESULTS The spouses described how they dealt with changes in life and an uncertain future following the implantable cardioverter defibrillator implantation. Six subcategories conceptualized the spouses' concerns: Aspiring for involvement; Managing an altered relationship; Being attentive to warning signs; Worries for deterioration in the partner's health; Waiting for the defibrillating shock; and Death is veiled in silence. CONCLUSION Despite the partner's serious state of health; terminal illness or death and the role of the device was seldom discussed with healthcare professionals or the implantable cardioverter defibrillator recipient. Open and honest communication was requested as important to support coping with an unpredictable life situation and to reduce worries and uncertainty about the future and end-of-life.
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Affiliation(s)
- Christina Fluur
- Department of Cardiology UHL, County Council of Östergötland, Linköping, Sweden
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27
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Thylén I, Moser DK, Chung ML, Miller J, Fluur C, Strömberg A. Are ICD recipients able to foresee if they want to withdraw therapy or deactivate defibrillator shocks? INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2013; 1:22-31. [PMID: 29450154 PMCID: PMC5801008 DOI: 10.1016/j.ijchv.2013.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 11/01/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Expert consensus statements on management of implantable cardioverter defibrillators (ICDs) emphasize the importance of having discussions about deactivation before and after implantation. These statements were developed with limited patient input. The purpose of this study was to identify the factors associated with patients' experiences of end-of-life discussions, attitudes towards such discussions, and attitudes towards withdrawal of therapy (i.e., generator replacement and deactivation) at end-of-life, in a large national cohort of ICD-recipients. METHODS We enrolled 3067 ICD-patients, administrating the End-of-Life-ICD-Questionnaire. RESULTS Most (86%) had not discussed ICD-deactivation with their physician. Most (69%) thought discussions were best at end-of-life, but 40% stated that they never wanted the physician to initiate a discussion. Those unwilling to discuss deactivation were younger, had experienced battery replacement, had a longer time since implantation, and had better quality-of-life. Those with psychological morbidity were more likely to desire a discussion about deactivation. Many patients (39%) were unable to foresee what to decide about deactivation in an anticipated terminal condition. Women, those without depression, and those with worse ICD-related experiences were more indecisive about withdrawal of therapy. Irrespective of shock experiences, those who could take a stand regarding deactivation chose to keep shock therapies active in many cases (39%). CONCLUSIONS Despite consensus statements recommending discussions about ICD-deactivation at the end-of-life, such discussion usually do not occur. There is substantial ambivalence and indecisiveness on the part of most ICD-patients in this nationwide survey about having these discussions and about expressing desires about deactivation in an anticipated end-of-life situation.
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Affiliation(s)
- Ingela Thylén
- Division of Nursing Sciences, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Cardiology, County Council of Östergötland, Linköping, Sweden
- Department of Cardiology, County Council of Östergötland, Linköping, Sweden
| | - Debra K. Moser
- College of Nursing, University of Kentucky, Lexington, USA
| | | | | | - Christina Fluur
- Department of Cardiology, County Council of Östergötland, Linköping, Sweden
| | - Anna Strömberg
- Division of Nursing Sciences, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Cardiology, County Council of Östergötland, Linköping, Sweden
- Department of Cardiology, County Council of Östergötland, Linköping, Sweden
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Abstract
Heart failure presents its own unique challenges to the clinician who desires to make excellent and humane care near the end of life a tangible reality. Accurate prediction of mortality in the individual patient is complicated by both the frequent occurrence of sudden death, both with and without devices, and the frequently chronic course that is punctuated by recurrent and more prominent acute episodes. A significant literature demonstrates that healthcare providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, and it is clear from the prognostic uncertainty of advanced heart failure that this kind of communication, and discussions regarding palliative care, need to occur earlier rather than later. This article discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation, with concurrent discussion of the ethical ramifications and pitfalls of each. A recent scientific statement from the American Heart Association begins to address some of the methodological issues involved in the care of patients with advanced heart failure. Above all, clinicians who wish to provide the highest quality of care to the dying patient need to confront the existential reality of death in themselves, their loved ones, and their patients so as to best serve those remanded to their care.
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Bakitas M, Macmartin M, Trzepkowski K, Robert A, Jackson L, Brown JR, Dionne-Odom JN, Kono A. Palliative care consultations for heart failure patients: how many, when, and why? J Card Fail 2013; 19:193-201. [PMID: 23482081 PMCID: PMC4564059 DOI: 10.1016/j.cardfail.2013.01.011] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/17/2013] [Accepted: 01/25/2013] [Indexed: 12/25/2022]
Abstract
OBJECTIVE In preparation for development of a palliative care intervention for patients with heart failure (HF) and their caregivers, we aimed to characterize the HF population receiving palliative care consultations (PCCs). METHODS AND RESULTS Reviewing charts from January 2006 to April 2011, we analyzed HF patient data including demographic and clinical characteristics, Seattle Heart Failure scores, and PCCs. Using Atlas qualitative software, we conducted a content analysis of PCC notes to characterize palliative care assessment and treatment recommendations. There were 132 HF patients with PCCs, of which 37% were New York Heart Association functional class III and 50% functional class IV. Retrospectively computed Seattle Heart Failure scores predicted 1-year mortality of 29% [interquartile range (IQR) 19-45] and median life expectancy of 2.8 years [IQR 1.6-4.2] years. Of the 132 HF patients, 115 (87%) had died by the time of the audit. In that cohort the actual median time from PCC to death was 21 [IQR 3-125] days. Reasons documented for PCCs included goals of care (80%), decision making (24%), hospice referral/discussion (24%), and symptom management (8%). CONCLUSIONS Despite recommendations, PCCs are not being initiated until the last month of life. Earlier referral for PCC may allow for integration of a broader array of palliative care services.
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Affiliation(s)
- Marie Bakitas
- Section of Palliative Medicine, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
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Yang YT, Mahon MM. Palliative care for the terminally ill in America: the consideration of QALYs, costs, and ethical issues. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2012; 15:411-416. [PMID: 22071573 DOI: 10.1007/s11019-011-9364-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially.
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Affiliation(s)
- Y Tony Yang
- Department of Health Administration and Policy, George Mason University, MS: 1J3, 4400 University Drive, Fairfax, VA 22030-4444, USA.
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Alter DA, Ko DT, Tu JV, Stukel TA, Lee DS, Laupacis A, Chong A, Austin PC. The average lifespan of patients discharged from hospital with heart failure. J Gen Intern Med 2012; 27:1171-9. [PMID: 22549300 PMCID: PMC3515002 DOI: 10.1007/s11606-012-2072-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 03/01/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are no life-tables quantifying the average life-spans of post-hospitalized heart failure populations across various strata of risk. OBJECTIVE To quantify the life-expectancies (i.e., average life-spans) of heart failure patients at the time of hospital discharge according to age, gender, predictive 30-day mortality heart failure risk index, and comorbidity burden. DESIGN Population-based retrospective cohort study. SETTING Ontario, Canada. PATIENTS 7,865 heart failure patients discharged from Ontario hospitals between 1999 and 2000. MEASUREMENTS Data were obtained from the Enhanced Feedback for Effective Cardiac Treatment EFFECT provincial quality improvement initiative. All patients were linked to administrative data, and tracked longitudinally until March 31, 2010. Detailed clinical variables were obtained from medical chart abstraction, and death data were obtained from vital statistics. Average life-spans were calculated using Cox Proportion Hazards models in conjunction with the Declining Exponential Approximation of Life Expectancy (D.E.A.L.E) method to extrapolate life-expectancy, adjusting for age, gender, predicted 30-day mortality, left ventricular function and comorbidity, and was reported according to key prognostic risk-strata. RESULTS The average life-span of the cohort was 5.5 years (STD +/- 10.0) ranging from 19.5 years for low-risk women of less than 50 years old to 2.9 years for high-risk octogenarian males. Average life-spans were lower by 0.13 years among patients with impaired as compared with preserved left ventricular function, and by approximately one year among patients with three or more as compared with no concomitant comorbidities. In total, 17.4 % and 27 % of patients had died within 6 months and 1 year respectively, despite having predicted life-spans exceeding one-year. LIMITATIONS Data regarding changes in patient clinical status over time were unavailable. CONCLUSIONS The development of risk-adjusted life-tables for heart failure populations is feasible and mirrored those with advanced malignant diseases. Average life span varied widely across clinical risk strata, and may be less accurate among those at or near their end of life.
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Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Ahluwalia SC, Levin JR, Lorenz KA, Gordon HS. Missed opportunities for advance care planning communication during outpatient clinic visits. J Gen Intern Med 2012; 27:445-51. [PMID: 22038469 PMCID: PMC3304032 DOI: 10.1007/s11606-011-1917-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 09/27/2011] [Accepted: 09/28/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Early provider-patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease. OBJECTIVE To identify opportunities for physicians to engage in ACP discussions and to characterize physicians' responses to these opportunities. DESIGN Qualitative study of audio-recorded outpatient clinic visits. PARTICIPANTS Fifty-two patients ≥ 65 years recently hospitalized for HF with one or more post-discharge follow-up outpatient visits, and their physicians (n = 44), at two Veterans Affairs Medical Centers. APPROACH Using content analysis methods, we analyzed and coded transcripts of outpatient follow-up visits for 1) patient statements pertaining to their future health or their future physical, psychosocial and spiritual/existential care needs, and 2) subsequent physician responses to patient statements, using an iterative consensus-based coding process. RESULTS In 13 of 71 consultations, patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient's expressed emotion, or inadequately acknowledging the sentiment underlying the patient's statement. CONCLUSIONS Physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses; in order to successfully leverage opportunities to engage in ACP discussions.
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Affiliation(s)
- Sangeeta C Ahluwalia
- Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90064, USA.
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An Exploratory Study of Sleep Quality, Daytime Function, and Quality of Life in Patients with Mechanical Circulatory Support. Int J Artif Organs 2012; 35:531-7. [DOI: 10.5301/ijao.5000109] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2012] [Indexed: 11/20/2022]
Abstract
Purpose: To identify and describe: (1) characteristics of sleep quality, daytime sleepiness, and quality of life (QOL) pre and post implantation of a left ventricular assist device (LVAD); (2) changes in sleep quality, daytime sleepiness, and QOL at baseline and 6 months post implant; and (3) relationships among the sleep quality, daytime sleepiness, and QOL variables. Methods: We employed an exploratory research design. Fifteen patients with continuous/non-pulsatile flow LVAD consented to partake in the study. However, only 12 patients completed the baseline and 6-month post-LVAD implant data. We used the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) to measure study variables. Data were analyzed using IBM SPSS 19.0 software. Results: Patients reported worse sleep quality accompanied by daytime sleepiness particularly at baseline, and persisting up to 6 months post LVAD implant. A significant improvement in QOL was observed at 6 months post implant, but remained at poor levels. Correlations among sleep disturbance and daytime dysfunction components of PSQI and global daytime sleepiness (ESS) with QOL were strong (Pearson's correlations r>.60; p values <.05). Conclusions: We report the first empirical data describing the characteristics and correlations among sleep quality, daytime sleepiness, and QOL in patients with LVADs. Our findings offer beginning evidence about the sleep-QOL connection in this population which warrants attention in clinical practice and research. Further research is required to clearly elucidate these phenomena in patients with mechanical circulatory support and other implantable artificial organs.
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Casida JM, Parker J. A preliminary investigation of symptom pattern and prevalence before and up to 6 months after implantation of a left ventricular assist device. J Artif Organs 2011; 15:211-4. [PMID: 22120165 DOI: 10.1007/s10047-011-0622-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 11/09/2011] [Indexed: 01/16/2023]
Abstract
Despite increased use of left ventricular assist devices (LVAD) in patients with advanced or end-stage heart failure; little is known about the reoccurrence of common heart failure symptoms (e.g., fatigue) after LVAD implantation. The objective of this study was to investigate the prevalence and pattern of selected heart failure symptoms and identify changes in symptom patterns before and up to 6 months after LVAD implantation. We used self-report questionnaires to collect data from patients (n = 12) and measure symptoms at baseline, 1 and 2 weeks, and 1, 3, and 6 months after LVAD. We found that high levels of fatigue, anxiety, depression, and sleep disturbance were prevalent during these periods. However, we did not find any significant changes in symptom pattern over time. The preliminary findings set the starting point for large-scale studies fundamental to advances in symptom-management research in LVAD and for other patients living with artificial organs.
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Affiliation(s)
- Jesus M Casida
- Wayne State University College of Nursing Detroit, Detroit, MI 48202, USA.
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Hwang B, Fleischmann KE, Howie-Esquivel J, Stotts NA, Dracup K. Caregiving for patients with heart failure: impact on patients' families. Am J Crit Care 2011; 20:431-41; quiz 442. [PMID: 22045140 DOI: 10.4037/ajcc2011472] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Factors that affect the impact of caregiving on patients' family members who provide care to patients with heart failure have not been adequately addressed. In addition, social support and positive aspects of caregiving have received little attention. OBJECTIVE To identify factors associated with the impact of caregiving. METHODS Self-report data were collected from 76 dyads of patients with heart failure and their family caregivers. Clinical data were obtained from medical records. RESULTS A sense of less family support for caregiving was associated with a higher New York Heart Association class of heart failure, being a nonspousal caregiver, lower caregivers' perceived control, and less social support. More disruption of caregivers' schedules was associated with higher class of heart failure, more care tasks, and less social support. Greater impact of caregiving on caregivers' health was related to more recent patient hospitalization, lower caregivers' perceived control, and less social support. Nonwhite caregivers and caregivers whose family member had fewer emergency department visits felt more positive about caregiving than did other caregivers. Social support had a moderating effect on the relationship between patients' comorbid conditions and positive aspects of caregiving. CONCLUSIONS Caregiving has both positive and negative effects on family caregivers of patients with heart failure. The findings suggest the need for interventions to increase caregivers' sense of control and social support. Family caregivers may need additional support immediately after patient hospitalizations to minimize the negative impact of caregiving.
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Affiliation(s)
- Boyoung Hwang
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Kirsten E. Fleischmann
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Jill Howie-Esquivel
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Nancy A. Stotts
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Kathleen Dracup
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
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Abstract
PURPOSE OF REVIEW Heart failure is a chronic, fatally progressive and incurable condition characterized by periods of apparent stability interspersed with acute exacerbations. Treatment models have historically emphasized management of acute exacerbations of cardiovascular disease, during which end-of-life issues figure frequently and prominently, though in a setting that is inappropriate to address the comprehensive needs of patients and their families. Consequently, in comparison to patients with malignancy, heart failure patients at the end of life are less likely to access palliative resources, and more likely to access in-patient care and cardiovascular procedures. RECENT FINDINGS Recent reports and position statements have emphasized the following critical needs for provision of optimal heart failure care: a) Cardiovascular specialists require training to obtain basic skills for provision of palliative care to management of end-of-life issues; b) Discussion of end-of-life issues should be introduced as early as feasible in patients with heart failure and should be updated with changes in clinical status; c) Provision of palliative care should be integrated into a team approach; d) Patients with heart failure frequently suffer symptoms which are not typically considered 'cardiovascular', such as pain, social/functional and psychological. Patients should be assessed for these symptoms, which should be treated. SUMMARY This report summarizes many of these suggestions and outlines future directions for the expansion and improvement of this critical need for heart failure patients.
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Abstract
The purpose of this study is to illustrate variations in caregiving trajectories as described by informal family caregivers providing end-of-life care. Instrumental case study methodology is used to contrast the nature, course, and duration of the phases of caregiving across three distinct end-of-life trajectories: expected death trajectory, mixed death trajectory, and unexpected death trajectory. The sample includes informal family caregivers (n = 46) providing unpaid end-of-life care to others suffering varied conditions (e.g., cancer, organ failure, amyotrophic lateral sclerosis). The unifying theme of end-of-life caregiving is “seeking normal” as family caregivers worked toward achieving a steady state, or sense of normal during their caregiving experiences. Distinct variations in the caregiving experience correspond to the death trajectory. Understanding caregiving trajectories that are manifest in typical cases encountered in clinical practice will guide nurses to better support informal caregivers as they traverse complex trajectories of end-of-life care.
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Affiliation(s)
- Janice Penrod
- School of Nursing and College of Medicine, The Pennsylvania State University, East University Park, PA 16802, USA.
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Burkmar JA, Iyengar R. Utility of the APACHE IV, PPI, and combined APACHE IV with PPI for predicting overall and disease-specific ICU and ACU mortality. Am J Hosp Palliat Care 2011; 28:321-7. [PMID: 21242123 DOI: 10.1177/1049909110396504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The Acute Physiology and Chronic Health Evaluation (APACHE) IV and Palliative Performance Index (PPI) are scales commonly used to assess prognosis in intensive care units (ICUs) and acute care units (ACUs). OBJECTIVE To compare the utility of APACHE IV, PPI, and combined APACHE IV with PPI for predicting overall and disease-specific mortality. DESIGN This is a prospective cohort study using admission data during the first 24 hours. Chi-square contingency tables were used to analyze mortality data for each scale. SETTING This study was conducted at a community hospital. PATIENTS Participants were admitted between December 24, 2008 and April 2, 2010. RESULTS The APACHE IV, PPI, and APACHE IV plus PPI (n = 599) were significant for predicting overall mortality (P < .0001 each). The APACHE IV was also significant in predicting mortality in patients with congestive heart failure (CHF), pulmonary edema (PULEDEM), stroke (cerebrovascular accident [CVA]), terminal or metastatic cancer (CA), and dementia. The PPI was significant for predicting mortality in PULEDEM, CA, and dementia but not CVA or CHF, while the APACHE IV with PPI was significant for all diseases but CVA. The APACHE IV was the most robust in predicting ICU/ACU mortality. The combined APACHE IV and PPI improved the specificity of the PPI to predict mortality but caused a decline in sensitivity. LIMITATIONS Limitations are due to the subjective nature of the PPI and Glasgow Coma scale (GCS), differences in illness trajectories, and a lack of reliable follow-up of all participants. CONCLUSION The benefits of combining scales were best exemplified in participants with dementia. Inconsistencies in the predictive value of specific participant populations are likely due to difference in the illness trajectories of disease processes.
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Affiliation(s)
- Jennifer A Burkmar
- Jackson Park Hospital Department of Geriatrics, Wound Care, and Palliative Care, Chicago, IL, USA.
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Kaufman SR, Mueller PS, Ottenberg AL, Koenig BA. Ironic technology: Old age and the implantable cardioverter defibrillator in US health care. Soc Sci Med 2010; 72:6-14. [PMID: 21126815 DOI: 10.1016/j.socscimed.2010.09.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 09/23/2010] [Accepted: 09/28/2010] [Indexed: 11/30/2022]
Abstract
We take the example of cardiac devices, specifically the implantable cardioverter defibrillator, or ICD, to explore the complex cultural role of technology in medicine today. We focus on persons age 80 and above, for whom ICD use is growing in the U.S. We highlight an ironic feature of this device. While it postpones death and 'saves' life by thwarting a lethal heart rhythm, it also prolongs living in a state of dying from heart failure. In that regard the ICD is simultaneously a technology of life extension and dying. We explore that irony among the oldest age group -- those whose considerations of medical interventions are framed by changing societal assumptions of what constitutes premature death, the appropriate time for death and medicine's goals in an aging society. Background to the rapidly growing use of this device among the elderly is the 'technological imperative' in medicine, bolstered today by the value given to evidence-based studies. We show how evidence contributes to standards of care and to the expansion of Medicare reimbursement criteria. Together, those factors shape the ethical necessity of physicians offering and patients accepting the ICD in late life. Two ethnographic examples document the ways in which those factors are lived in treatment discussions and in expectations about death and longevity.
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Affiliation(s)
- Sharon R Kaufman
- University of California, Institute for Health and Aging, San Francisco, CA 94118, USA.
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Health span or life span: the role of patient-reported outcomes in informing health policy. Health Policy 2010; 100:96-104. [PMID: 20813420 DOI: 10.1016/j.healthpol.2010.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 06/21/2010] [Accepted: 07/03/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Population ageing and the increasing burden of chronic conditions challenge traditional metrics of assessing the efficacy of health care interventions and as a consequence policy and planning. Using chronic heart failure (CHF) as an exemplar this manuscript seeks to describe the importance of patient-reported outcomes to inform policy decisions. METHODS The method of an integrative review has been used to identify patient-reported outcomes (PROs) in assessing CHF outcomes. Using the Innovative Care for Chronic Conditions the case for developing a metric to incorporate PROs in policy planning, implementation and evaluation is made. RESULTS In spite of the increasing use of PROs in assessing CHF outcomes, their incorporation in the policy domain is limited. CONCLUSIONS Effective policy and planning is of health care services is dependent on the impact on the individual and their families. Epidemiological transitions and evolving treatment paradigms challenge traditional metrics of morbidity and mortality underscoring the importance of assessing PROs.
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Howlett J, Morin L, Fortin M, Heckman G, Strachan PH, Suskin N, Shamian J, Lewanczuk R, Aurthur HM. End-of-life planning in heart failure: it should be the end of the beginning. Can J Cardiol 2010; 26:135-41. [PMID: 20352133 DOI: 10.1016/s0828-282x(10)70351-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Cardiovascular disease (CVD) is a chronic, progressive, incurable condition characterized by periods of apparent stability interspersed with acute exacerbations. Despite many important advances in its treatment, approximately one-third of deaths in Canada each year result from CVD. While this might lead one to assume that a comprehensive medical approach exists to the management of this inevitable outcome, the reality is much different. The current Canadian medical model emphasizes the management of acute exacerbations of CVD during which end-of-life issues figure frequently and prominently, although in a setting that is inappropriate to address the comprehensive needs of patients and their families.As a result, end-of-life care was made a theme of the recently reported Canadian Heart Health Strategy and Action Plan (www.chhs-scsc.ca). From this, several recommendations are made, central to which is the need to reframe CVD as a condition ideally suited to a chronic disease management approach. In addition, replacement of the term 'palliative care' with the term 'end-of-life planning and care' is proposed to foster earlier and more integrated comprehensive care, which, it is proposed, denotes the provision of advanced care planning, palliative care, hospice care and advanced directives, with a focus on decision making and planning. Finally, end-of-life planning and care should be a routine part of assessment of any patient with CVD, should be reassessed whenever important clinical changes occur and should be provided in a manner consistent with relevant CVD practice guidelines. Specifically, a Canadian strategy to improve end-of-life planning and care should focus on the following: * Integrated end-of-life planning and care across the health care system; * Facilitated communication and seamless care provision across all providers involved in end-of-life planning and care; * Adequate resources in the community for end-of-life planning and care; * Specialized training in sensitive communication and supportive care as part of core training for all members of the interdisciplinary care team; * Measurement of key performance indicators for end-of-life planning and care; and * Research into effective end-of-life planning and care.Heart failure is an advanced form of CVD with very high morbidity, mortality and burden of care, making it an ideal condition for implementation and testing of interventions to improve end-of-life planning and care.
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Goebel JR, Doering LV, Shugarman LR, Asch SM, Sherbourne CD, Lanto AB, Evangelista LS, Nyamathi AM, Maliski SL, Lorenz KA. Heart failure: the hidden problem of pain. J Pain Symptom Manage 2009; 38:698-707. [PMID: 19733032 PMCID: PMC2908037 DOI: 10.1016/j.jpainsymman.2009.04.022] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 04/08/2009] [Accepted: 04/09/2009] [Indexed: 12/17/2022]
Abstract
Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain>or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P<0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P<0.001); interference with relations (P<0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF.
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Affiliation(s)
- Joy R Goebel
- School of Nursing, California State University, Long Beach, Long Beach, California 90840-1006, USA.
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Goebel JR, Doering LV, Lorenz KA, Maliski SL, Nyamathi AM, Evangelista LS. Caring for special populations: total pain theory in advanced heart failure: applications to research and practice. Nurs Forum 2009; 44:175-85. [PMID: 19691653 PMCID: PMC2905139 DOI: 10.1111/j.1744-6198.2009.00140.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TOPIC Total pain theory. PURPOSE Describe total pain theory and apply it to research and practice in advanced heart failure (HF). SOURCE OF INFORMATION Total pain theory provides a holistic perspective for improving care, especially at the end of life. In advanced HF, multiple domains of well-being known to influence pain perception are adversely affected by declining health and increasing frailty. A conceptual framework is suggested which addresses domains of well-being identified by total pain theory. CONCLUSION By applying total pain theory, providers may be more effective in mitigating the suffering of individuals with progressive, life-limiting diseases.
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Affiliation(s)
- Joy R Goebel
- Department of Nursing, California State University, Long Beach, CA, USA.
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The nature of heart failure as a challenge to the integration of palliative care services. Curr Opin Support Palliat Care 2008; 1:249-54. [PMID: 18685370 DOI: 10.1097/spc.0b013e3282f283b6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite its increasing prevalence and high mortality risk, heart failure is widely regarded as 'treatable'. Aggressive measures are employed even in its end stages. This review explores the clinical characteristics of heart failure, patterns of clinician response, and new data that may help to surmount current barriers to palliative approaches. RECENT FINDINGS The 'treatment imperative' that has helped to reduce overall cardiovascular mortality marginalizes palliative approaches in heart failure. The possibility of dying remains unacknowledged, and communication about palliative options tends not to occur. Both the apparently benign nature of heart failure and its inherent unpredictability discourage end-of-life considerations. Recent studies, however, provide evidence that these barriers may be surmountable, and also furnish tools to help with prognosis. A true heart failure continuum including palliative care would be desirable, although structural barriers exist. SUMMARY Therapeutic successes have encouraged clinicians to pursue heart failure treatment through the end stages of disease. These very successes, however, have made the course of advanced heart failure easier to predict. What is needed now is courage among clinicians to open early dialog about disease process, prognosis and palliative options with the growing number of patients with advanced disease.
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Russo MJ, Gelijns AC, Stevenson LW, Sampat B, Aaronson KD, Renlund DG, Ascheim DD, Hong KN, Oz MC, Moskowitz AJ, Rose EA, Miller LW. The cost of medical management in advanced heart failure during the final two years of life. J Card Fail 2008; 14:651-8. [PMID: 18926436 DOI: 10.1016/j.cardfail.2008.06.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 05/27/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To examine patterns of resource use and the cost of care for patients with advanced heart failure treated with medical management (MM) during the final 2 years of life. METHODS AND RESULTS The study population (n=47, mean age 70.4 years+/-7.06) included patients randomized to the MM arm of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial. Inpatient and outpatient use data were obtained from the clinical dataset and Centers for Medicare and Medicaid Services (beginning January 1, 1998). Cost and resource use were tracked from the date of death (t(d)) backward in 3-month intervals (eg, t(d-1), t(d-2)). In the primary analysis, costs were summed across intervals. The mean cost of MM in the final 2 years of life was $156,169, with 50.5% ($78,880.39) expended in the final 6 months. The mean quarterly cost increased (P < .01) 4.9-fold from t(d-8) ($8,816 +/- $14,270) to t(d-1) ($42,836 +/- $41,407). The number of inpatient days increased (P < .01) 6.6-fold from 3.8+/-4.7 days to 22.2+/-23.5 days during the same time intervals. CONCLUSION This current economic analysis extends on previous findings by demonstrating that medical therapy in advanced and end-stage heart failure is associated with significant costs and resource consumption; these costs and resource consumption increase significantly as death approaches.
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McClung JA. End-of-life care in the treatment of heart failure in the elderly. Heart Fail Clin 2007; 3:539-47. [PMID: 17905388 DOI: 10.1016/j.hfc.2007.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Much of the literature dedicated to the topic of medical care of dying patients has revolved around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.
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Affiliation(s)
- John Arthur McClung
- Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
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Abstract
Much of the literature dedicated to the topic of medical care of dying patients has revolves around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.
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Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
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Jakobsson E, Bergh I, Gaston-Johansson F, Stolt CM, Ohlén J. The Turning Point: Clinical Identification of Dying and Reorientation of Care. J Palliat Med 2006; 9:1348-58. [PMID: 17187543 DOI: 10.1089/jpm.2006.9.1348] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Palliative care is increasingly organized within the setting of formal health care systems but the demarcation has become unclear between, on the one hand, care directed at cure and rehabilitation and palliative care aimed at relief of suffering on the other. With the purpose to increase the understanding about the turning point reflecting identification of dying and reorientation of care, this study explores this phenomenon as determined from health care records of a representative sample (n = 229). A turning point was identified in 160 records. Presence of circulatory diseases, sporadic confinement to bed, and deterioration of condition had a significant impact upon the incidence of such turning point. The time interval between the turning point and actual death ranged between one and 210 days. Thirty percent of these turning points were documented within the last day of life, 33% during the last 2-7 days, 19.5% during the last 8-30 days, 13% during the last 31-90 days, and 4.5% during the last 91-210 days of life. The time interval between the turning point and actual death was significantly longer among individuals with neoplasm(s) and significantly shorter among individuals suffering from musculoskeletal diseases. Perhaps this reflects a discrepancy between the ideals of palliative care, and a misinterpretation of the meaning of palliative care in everyday clinical practice. The findings underscore that improvement in timing of clinical identification of dying and reorientation of care will likely favour a shift from life-extending care to palliative care.
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Affiliation(s)
- Eva Jakobsson
- Faculty of Health Caring Sciences, The Sahlgrenska Academy at Göteborg University, Institute of Nursing, Gothenburg, Sweden.
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