Consensus statement: Palliative and supportive care in advanced heart failure

Changing our Approach to Stage D Heart Failure

Despite the tremendous progress made in the management of heart failure (HF), many patients reach advanced stages. This paper aims to present a practical approach to the stage D HF patient who is no longer responding to optimal medical therapy. We discuss all available therapies for this patient population. We also offer some important caveats with regard to identification, risk stratification, evaluation and treatment including early patient referral to a center with an advanced HF program. Given the changing landscape of heart transplantation and an impending change in the allocation system, we also intend to engage a discussion on the need for a paradigm shift towards left ventricular assist device therapy in this population.

Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial

BACKGROUND

Advanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life.

OBJECTIVES

The authors investigated whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes.

METHODS

The authors randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC) (n = 75) or UC plus a palliative care intervention (UC + PAL) (n = 75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale [HADS]), spiritual well-being (measured via the FACIT-Spiritual Well-Being scale [FACIT-Sp]), hospitalizations, and mortality.

RESULTS

Patients randomized to UC + PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT-Pal scores from randomization to 6 months (KCCQ difference = 9.49 points, 95% confidence interval [CI]: 0.94 to 18.05, p = 0.030; FACIT-Pal difference = 11.77 points, 95% CI: 0.84 to 22.71, p = 0.035). Depression improved in UC + PAL patients (HADS-depression difference = -1.94 points; p = 0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference = -1.83 points; p = 0.048). Spiritual well-being was improved in UC + PAL versus UC-alone patients (FACIT-Sp difference = 3.98 points; p = 0.027). Randomization to UC + PAL did not affect rehospitalization or mortality.

CONCLUSIONS

An interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. (Palliative Care in Heart Failure [PAL-HF]; NCT01589601).

New role of ventricular assist devices as bridge to transplantation: European perspective

PURPOSE OF REVIEW

Progress of ventricular assist devices (VAD) technology led to improved survival and apparently low morbidity. However, from the European perspective, updated analysis of EUROMACS reveals a somewhat less impressive picture with respect to mortality and morbidity.

RECENT FINDINGS

We describe the great demand of cardiac allografts versus the lack of donors, which is larger in Europe than in the United States. Technical progress of VADs made it possible to work out a modern algorithm of bridge-to-transplant, which is tailored to the need of the particular patient. We analyze the burden of patients undergoing bridge-to-transplant therapy. They are condemned to an intermediate step, coupled with additional major surgery and potential adverse events during heart transplantation.

SUMMARY

Based on current registry data, we do have to question the increasingly popular opinion, that the concept of heart transplantation is futureless, which seems to be for someone who treats and compares both patients (VAD and heart transplantation) in daily practice, questionable. Up to now, left ventricular assist device therapy remains a bridge to a better future, which means a bridge to technical innovations or to overcome the dramatic lack of donors in Europe.

The State of the Science on Integrating Palliative Care in Heart Failure

BACKGROUND

Heart failure (HF) is a chronic progressive illness associated with physical and psychological burdens, high morbidity, mortality, and healthcare utilization. Palliative care is interdisciplinary care that aims to relieve suffering and improve quality of life for persons with serious illness and their families. It is offered simultaneously with disease-oriented care, unlike hospice or end-of-life care. Despite the demonstrated benefits of palliative care in other populations, evidence for palliative care in the HF population is limited.

OBJECTIVE

The objective of this article is to describe the current evidence and the gaps in the evidence that will need to be improved to demonstrate the benefits of integrating palliative care into the care of patients with advanced HF and their family caregivers.

METHODS

We reviewed the literature to examine the state of the science and to identify gaps in palliative care integration for persons with HF and their families. We then convened an interdisciplinary working group at an NIH/NPCRC sponsored workshop to review the evidence base and develop a research agenda to address these gaps.

RESULTS

We identified four key research priorities to improve palliative care for patients with HF and their families: (1) to better understand patients' uncontrolled symptoms, (2) to better characterize and address the needs of the caregivers of advanced HF patients, (3) to improve patient and family understanding of HF disease trajectory and the importance of advance care planning, and (4) to determine the best models of palliative care, including models for those who want to continue life-prolonging therapies.

CONCLUSIONS

The goal of this research agenda is to motivate patient, provider, policy, and payor stakeholders, including funders, to identify the key research topics that have the potential to improve the quality of care for patients with HF and their families.

End-of-Life Care in the Treatment of Heart Failure in Older Adults

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.

Risk Stratification Model for 30-Day Heart Failure Readmission in a Multiethnic South East Asian Community

There are limited accurate 30-day heart failure (HF) readmission risk scores using readily available clinical patient information on a well-defined HF cohort. We analyzed 1,475 admissions discharged from our hospital with a primary diagnosis of HF between 2010 and 2012. HF diagnostic criteria included satisfying clinical Framingham criteria, elevated serum N-terminal pro-natriuretic peptide, and evidence of cardiac dysfunction on transthoracic echocardiography. The patients were randomly divided into 2 groups; 60% were used as the derivation cohort and 40% as the validation cohort. Bivariate analysis and logistic regression were used to develop the model. Weighted risk scores were derived from the odds ratio of the logistic regression model. Total risk scores were computed by simple summation for each patient. The 7 significant independent predictors of 30-day HF readmission used to derive the risk scoring tool were the number of previous HF-related admission in the preceding 1 year, index admission length of stay, serum creatinine level, electrocardiograph QRS duration, serum N-terminal pro-natriuretic peptide level, number of Medical Social Service needs, and β blocker prescription on discharge. The area under the curve was 0.76. Sensitivity and specificity were 78.3% and 60.7%, respectively. The positive predictive value and negative predictive value were 18.9% and 96%, respectively. The actual observed and predicted 30-day heart failure readmission rates matched. In conclusion, we have developed the first 30-day HF readmission risk score, with good discriminatory ability, for an urban multiethnic Asian heart failure cohort with stringent diagnostic criteria. It consists of 7 easily obtained variables.

Goals of care: a concept clarification

AIM

To report an analysis and clarification of the concept of goals of care.

BACKGROUND

Goals of care have been used by healthcare providers since 1978, but no operationalized, consensual definition exists.

DESIGN

Norris's method of concept clarification was used to create an operational definition, conceptual model and testable hypotheses of goals of care from the healthcare provider's perspective.

DATA SOURCES

Data came from current research reports, interviews with experts and web sites of professional organizations. Research reports were published between 2003-2013.

METHODS

Antecedents, definitions and consequences were systematized and organized into coherent and more abstract groups to define goals of care. A conceptual model and testable hypotheses were created from this process.

RESULTS

Goals of care are desired health expectations that are formulated through the thoughtful interaction between a human being seeking medical care and the healthcare team in the healthcare system and are appropriate, agreed on, documented and communicated.

CONCLUSIONS

Development of clear goals of care can increase patient satisfaction and quality of care while decreasing costs, hospital length of stay and hospital readmission. Goals of care are dynamic and should be reassessed regularly. How and when goals of care transition from implicit to explicit should be explored further, and what prompts this transition. Nurses, physicians and healthcare providers need education on how to best fill their roles in the development of goals of care.

Palliative Care Interventions for Patients with Heart Failure: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically characterize interventions and effectiveness of palliative care for advanced heart failure (HF) patients.

BACKGROUND

Patients with advanced heart failure experience a high burden of distressing symptoms and diminished quality of life. Palliative care expertise with symptom management and healthcare decision-making benefits HF patients.

METHODS

A systematic PubMed search was conducted from inception to June 2016 for studies of palliative care interventions for HF patients. Studies of humans with a HF diagnosis who underwent a palliative care intervention were included. Data were extracted on study design, participant characteristics, intervention components, and in three groups of outcomes: patient-centered outcomes, quality-of-death outcomes, and resource utilization. Study characteristics were examined to determine if meta-analysis was possible.

RESULTS

The fifteen identified studies varied in design (prospective, n = 10; retrospective, n = 5). Studies enrolled older patients, but greater variability was found for race, sex, and marital status. A majority of studies measuring patient-centered outcomes demonstrated improvements including quality of life and satisfaction. Quality-of-death outcomes were mixed with a majority of studies reporting clarification of care preferences, but less improvement in death at home and hospice enrollment. A meta-analysis in three studies found that home-based palliative care consults in HF patients lower the risk of rehospitalization by 42% (RR = 0.58; 95% Confidence Interval 0.44, 0.77).

DISCUSSION

Available evidence suggests that home and team-based palliative interventions for HF patients improve patient-centered outcomes, documentation of preferences, and utilization. Increased high quality studies will aid the determination of the most effective palliative care approaches for the HF population.

Supportive care for older people with frailty in hospital: An integrative review

BACKGROUND

Growing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care.

AIM

To identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation.

DESIGN

An integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term 'supportive care'. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken.

DATA SOURCES

Literature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n=52) were integrated using synthesis of themes.

RESULTS

Relevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings.

CONCLUSION

The findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.

30-Day Readmission Rates in Patients Admitted for Heart Failure Exacerbation with and without Palliative Care Consultation: A Retrospective Cohort Study

BACKGROUND

Palliative care consultation improves quality of care through symptom management, communication, care coordination, and earlier hospice referral, and it may decrease burdensome hospital readmissions at the end of life.

OBJECTIVES

To compare 30-day readmission rates for patients admitted with exacerbation of congestive heart failure (CHF) receiving palliative care consultation services compared with controls.

DESIGN

Retrospective cohort study using propensity score matching. A secondary, subgroup analysis compared patients with palliative care consults and patients with an incomplete consult order. Settings/Subjects: Single-center study in an academic acute inpatient setting. Of a pool of 8215 admissions from January 1, 2011 to April 6, 2014, 356 included a palliative care consultation, and 356 matched controls were found.

RESULTS

The 30-day readmission rate was 50.8% for admissions including a palliative care consult and 36.0% for controls (OR 1.8, 95% CI 1.4-2.5). Those with a completed consult had fewer readmissions compared with those with an incomplete order, but this difference was not statistically significant (43% vs. 53%, χ² = 1.9, p = 0.171).

CONCLUSION

No reduction in the risk of 30-day readmission was observed in the palliative care group, suggesting that palliative care services may not have the same effect on readmission rates in CHF patients compared with others. The subgroup analysis suggests that the difference between palliative care and control groups may reflect residual confounding, possibly due to critical social variables that are not captured in the electronic medical record, highlighting the difficulty in studying this population.

The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program

Although patients within a transplant program are awaiting or have received disease modifying or curative treatment, they are also facing advanced illness and the possibility of death. The involvement of specialized palliative care services for these patients may improve symptom management and facilitate advance care planning. However, patients in organ transplantation programs have difficulty accessing palliative care resources and often do so only sporadically in the inpatient setting. Currently, there is little access to ambulatory palliative care for these patients and there have been no descriptions of programs delivering such care in the medical literature. We outline the development and structure of a Transplant Palliative Care Clinic within the University Health Network's Multi-Organ Transplant Program, in Toronto, Canada. This information may be helpful for others aiming to provide early, integrated palliative care to patients awaiting and receiving organ transplantation.

Advancing palliative and end-of-life science in cardiorespiratory populations: The contributions of nursing science

Nursing science has a critical role to inform practice, promote health, and improve the lives of individuals across the lifespan who face the challenges of advanced cardiorespiratory disease. Since 1997, the National Institute of Nursing Research (NINR) has focused attention on the importance of palliative and end-of-life care for advanced heart failure and advanced pulmonary disease through the publication of multiple funding opportunity announcements and by supporting a cadre of nurse scientists that will continue to address new priorities and future directions for advancing palliative and end-of-life science in cardiorespiratory populations.

Health care professionals' attitudes regarding palliative care for patients with chronic heart failure: an interview study

Background

Even though struggling with similar symptom burden, patients with chronic heart failure (CHF) receive less palliative care than patients suffering from malignant diseases. Researchers have found that this might be related to lack of knowledge about palliative care, insufficient interprofessional communication as well as the cyclic course of disease which makes accurate prognosis difficult. However, research findings have shown that patients with CHF benefit from palliative care. As there are no studies for the German health care system this study aimed to assess health care professionals’ attitudes regarding palliative care of CHF patients in order to identify barriers and facilitators for this patient group and hence to develop recommendations for improvement of CHF patients’ access to palliative care in Germany.

Method

Problem-centered interviews with 23 health care professionals involved in care of CHF patients (nurses: hospital, outpatient, heart failure, PC; physicians: hospital and resident cardiologists, general practitioners) were conducted and analysed according to Mayring’s qualitative content analysis.

Results

Most interviewees perceived a need for palliative care for CHF patients. Regarding barriers patients’, public’s, and professionals’ lack of knowledge of palliative care and CHF; shortcomings in communication and cooperation of different professional groups; inability of cardiology to accept medical limits; difficult prognosis of course of disease; and patients’ concerns regarding palliative care were described. Different attitudes regarding appropriate time of initiation of palliative care for CHF patients (late vs. early) were found. Furthermore, better communication and closer cooperation between different professional groups and medical disciplines as well as better education about palliative care and CHF for professionals, patients, and public were cited.

Conclusions

Palliative care for CHF patients is a neglected topic in both practice and research and should receive more attention. Barriers to palliative care for CHF patients might be overcome by: better education for the public, patients, and professionals, closer cooperation between the different professional groups involved as well as development of a joint agreement regarding the appropriate time to administer palliative care to CHF patients.

Trial registration

DRKS00007119.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0149-9) contains supplementary material, which is available to authorized users.

Systematic Review of Health-Related Quality of Life in Patients with Pulmonary Arterial Hypertension

BACKGROUND

The increasing survival of patients with pulmonary arterial hypertension (PAH) has shifted attention towards the disease burden that PAH imposes on patients and healthcare systems. Most studies emphasize epidemiology and medications, while large observational studies reporting on the health-related quality of life (HRQOL) of patients with PAH are lacking.

OBJECTIVE

Our objective was to study the HRQOL of patients with PAH and to summarize the factors that influence it.

METHODS

We conducted systematic literature searches in English (PubMed, Web of Knowledge, ScienceDirect and OVID) and Chinese (China National Knowledge Infrastructure, Wanfang Data, Chongqing VIP and SinoMed) databases to identify studies published from 2000 to 2015 assessing the HRQOL of patients with PAH. Search results were independently reviewed and extracted by two reviewers.

RESULTS

Of 3392 records identified in the initial search, 20 eligible papers (19 English, 1 Chinese) were finally included. Studies used a range of instruments; the generic 36-item Short Form Survey (SF-36) was the most widely used, and the disease-specific Cambridge Pulmonary Hypertension Outcome Survey (CAMPHOR) was the second mostly widely used. Mean HRQOL scores assessed via the SF-36 (physical component summary [PCS] 25.4-80.1; mental component summary [MCS] 33.2-76.0) and CAMPHOR (symptom scores 3.1-17; total HRQOL 2.8-12.6; activity scores 3.8-18.1) varied across studies, reporting decreased HRQOL in patients. Mental health (depression, anxiety, stress), physical health (exercise capacity, symptoms) and medical therapies were reported to affect HRQOL.

CONCLUSION

We found that PAH places a substantial burden on patients, particularly in terms of HRQOL; however, the paucity of large observational studies in this area requires the attention of researchers, especially in China.

Unravelling the Tensions Between Chronic Disease Management and End-of-Life Planning

An increasing appreciation for the burden that chronic conditions represent for people and for societies has triggered an evolving body of popular and professional conceptualizations of the nature of the chronic disease challenge. In this discussion article, we trace the trajectory of thinking about chronic illness care, surfacing underlying assumptions and drivers that have shaped current dominant models of service delivery. We note significant gaps in these conceptualizations, especially with respect to the reality that many chronic conditions are life limiting. Contrasting chronic disease theorizing with the conversations that have arisen around end-of-life care for other kinds of health conditions, we argue for a shift in our thinking to accommodate the implications of life limitation in our service delivery planning. We see significant leadership potential in optimizing the role nurses can play across the chronic disease trajectory by integrating the healthy optimism of self-care management with the profound compassion of a person-centered palliative approach.

Personalized support for chronic conditions. A novel approach for enhancing self-management and improving lifestyle

OBJECTIVE

Solutions for improving management of chronic conditions are under the attention of healthcare systems, due to the increasing prevalence caused by demographic change and better survival, and the relevant impact on healthcare expenditures. The objective of this study was to propose a comprehensive architecture of a mHealth system aimed at boosting the active and informed participation of patients in their care process, while at the same time overcoming the current technical and psychological/clinical issues highlighted by the existing literature.

METHODS

After having studied the current challenges outlined in the literature, both in terms of technological and human requirements, we focused our attention on some specific psychological aspects with a view to providing patients with a comprehensive and personalized solution. Our approach has been reinforced through the results of a preliminary assessment we conducted on 22 patients with chronic conditions. The main goal of such an assessment was to provide a preliminary understanding of their needs in a real context, both in terms of self-awareness and of their predisposition toward the use of IT solutions.

RESULTS

According to the specific needs and features, such as mindfulness and gamification, which were identified through the literature and the preliminary assessment, we designed a comprehensive open architecture able to provide a tailor-made solution linked to specific individuals' needs.

CONCLUSION

The present study represents the preliminary step towards the development of a solution aimed at enhancing patients' actual perception and encouraging self-management and self-awareness for a better lifestyle. Future work regards further identification of pathology-related needs and requirements through focus groups including all stakeholders in order to describe the architecture and functionality in greater detail.

Care at the End of Life

Objective: To profile communication and recommendations reported by adults with terminal illness and explore differences by patient and physician characteristics.

Method: This pilot was a cross-sectional study sample of 90 patients (39 Caucasian, 51 African American) with advanced heart failure or cancer. Participants completed an in-person, race-matched interview.

Results: Participation was high (94%). Discussion about end-of-life topics was low. For example, only 30% reported discussion of advance directives, and 22% reported their physician inquired about spiritual support. Participants with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. African American participants who were under the care of African American physicians were less likely to report pain and/or symptom management than other racial matches.

Discussion: Although additional research on factors related to communication is important, initiation of patient-centered counseling by all physicians with seriously ill patients is essential.

Prediction of critical illness in elderly outpatients using elder risk assessment: a population-based study

Rationale

Identifying patients at high risk of critical illness is necessary for the development and testing of strategies to prevent critical illness. The aim of this study was to determine the relationship between high elder risk assessment (ERA) score and critical illness requiring intensive care and to see if the ERA can be used as a prediction tool to identify elderly patients at the primary care visit who are at high risk of critical illness.

Methods

A population-based historical cohort study was conducted in elderly patients (age >65 years) identified at the time of primary care visit in Rochester, MN, USA. Predictors including age, previous hospital days, and comorbid health conditions were identified from routine administrative data available in the electronic medical record. The main outcome was critical illness, defined as sepsis, need for mechanical ventilation, or death within 2 years of initial visit. Patients with an ERA score of 16 were considered to be at high risk. The discrimination of the ERA score was assessed using area under the receiver operating characteristic curve.

Results

Of the 13,457 eligible patients, 9,872 gave consent for medical record review and had full information on intensive care unit utilization. The mean age was 75.8 years (standard deviation ±7.6 years), and 58% were female, 94% were Caucasian, 62% were married, and 13% were living in nursing homes. In the overall group, 417 patients (4.2%) suffered from critical illness. In the 1,134 patients with ERA >16, 154 (14%) suffered from critical illness. An ERA score ≥16 predicted critical illness (odds ratio 6.35; 95% confidence interval 3.51–11.48). The area under the receiver operating characteristic curve was 0.75, which indicated good discrimination.

Conclusion

A simple model based on easily obtainable administrative data predicted critical illness in the next 2 years in elderly outpatients with up to 14% of the highest risk population suffering from critical illness. This model can facilitate efficient enrollment of patients into clinical programs such as care transition programs and studies aimed at the prevention of critical illness. It also can serve as a reminder to initiate advance care planning for high-risk elderly patients. External validation of this tool in different populations may enhance its generalizability.

Acceptability and Reliability of a Novel Palliative Care Screening Tool Among Emergency Department Providers

BACKGROUND

The Palliative Care and Rapid Emergency Screening (P-CaRES) Project is an initiative intended to improve access to palliative care (PC) among emergency department (ED) patients with life-limiting illness by facilitating early referral for inpatient PC consultations. In the previous two phases of this project, we derived and validated a novel PC screening tool. This paper reports on the third and final preimplementation phase.

OBJECTIVES

Examine the acceptability of the P-CaRES tool among PC and ED providers as well as test its reliability on case vignettes. Compare variations in reliability and acceptability of the tool based on ED providers' roles (attendings, residents, and nurses) and lengths of experience.

METHODS

A two-part electronic survey was distributed to ED providers at multiple sites across the United States. We tested the reliability of the tool in the first part of the survey, through a series of case vignettes. A criterion standard of correct responses was first defined by consensus input from expert PC physicians' interpretations of the vignettes. The experts' input was validated using the Gwet's AC1 coefficient for inter-rater reliability. ED providers were then presented with the case vignettes and asked to use the P-CaRES tool to correctly identify which patients had unmet PC needs. ED provider responses were compared both against the criterion standard and against different subsets of respondents (divided both by role and by level of experience). The second part of the survey assessed acceptability of the P-CaRES tool among ED providers using responses to questions from a modified Ottawa Acceptability of Decision Rules Instrument, based on a 1-5 Likert rating scale. Descriptive statistics were used to report all outcomes.

RESULTS

In total, 213 ED providers employed in three different regions across the country responded to the survey (39.4%) and 185 (86.9%) of those completed it. The majority of providers felt that the tool would be useful in their practice (80.5%), agreed that the tool was clear and unambiguous (87.1%), thought that use of the tool would likely benefit patients (87.5%), and thought that it would result in improved use of resources to help severely ill patients (83.6%). Over three-quarters of ED providers (78.5%) also self-reported that they refer patients with unmet PC needs less than 10% of the time, and only 10.8% of respondents believed that they are already utilizing an effective strategy to screen or refer patients to PC. Applying our P-CaRES tool to case vignettes, ED providers generated PC referrals in concordance with PC experts over 88.7% of the time (95% confidence interval = 86.4% to 90.6%), with an overall sensitivity of more than 90%. These results varied minimally regardless of the respondent's role in the ED or their level of experience.

CONCLUSION

Screening by emergency medicine providers for unmet PC needs using a brief, novel, content-validated screening tool is acceptable and is also reliable when applied to case vignettes-regardless of provider role or experience. Clinical trial and further study are warranted and are currently under way.

Systematic Review of the Economic Burden of Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH), as a life-threatening disease with no efficient cure, may impose a tremendous economic burden on patients and healthcare systems. However, most existing studies have mainly emphasised epidemiology and medications, while large observational studies reporting on the economic burden are currently lacking.

OBJECTIVES

To review and evaluate evidence on the costs of PAH and the cost effectiveness of PAH treatments, and to summarise the corresponding cost drivers.

METHODS

Systematic literature searches were conducted in English-language databases (PubMed, Web of Science, ScienceDirect) and Chinese-language databases (China National Knowledge Infrastructure, Wanfang Data, Chongqing VIP) to identify studies (published from 2000 to 2014) assessing the costs of PAH or the cost effectiveness of PAH treatments. The search results were independently reviewed and extracted by two reviewers. Costs were converted into 2014 US dollars.

RESULTS

Of 1959 citations identified in the initial search, 19 papers were finally included in this analysis: eight on the economic burden of PAH and 11 on economic evaluation of PAH treatments. The economic burden on patients with PAH was rather large, with direct healthcare costs per patient per month varying from $2476 to $11,875, but none of the studies reported indirect costs. Sildenafil was universally reported to be a cost-effective treatment, with lower costs and better efficacy than other medications. Medical costs were reported to be the key cost drivers.

CONCLUSION

The economic burden of patients with PAH is substantial, while the paucity of comprehensive country-specific evidence in this area and the lack of reports on indirect costs of PAH warrant researchers' concern, especially in China.

Team-based Palliative and End-of-life Care for Heart Failure

Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.

Training general practitioners contributes to the identification of palliative patients and to multidimensional care provision: secondary outcomes of an RCT

Introduction

To support general practitioners (GPs) in providing early palliative care to patients with cancer, chronic obstructive pulmonary disease or heart failure, the RADboud university medical centre indicators for PAlliative Care needs tool (RADPAC) and a training programme were developed to identify such patients and to facilitate anticipatory palliative care planning. We studied whether GPs, after 1 year of training, identified more palliative patients, and provided multidimensional and multidisciplinary care more often than untrained GPs.

Methods

We performed a survey 1 year after GPs in the intervention group of an RCT were trained. With the help of a questionnaire, all 134 GPs were asked how many palliative patients they had identified, and whether anticipatory care was provided. We studied number of identified palliative patients, expected lifetime, contact frequency, whether multidimensional care was provided and which other disciplines were involved.

Results

Trained GPs identified more palliative patients than did untrained GPs (median 3 vs 2; p 0.046) and more often provided multidimensional palliative care (p 0.024). In both groups, most identified patients had cancer.

Conclusions

RADPAC sensitises GPs in the identification of palliative patients. Trained GPs more often provided multidimensional palliative care. Further adaptation and evaluation of the tools and training are necessary to improve early palliative care for patients with organ failure.

Trial registration number

NTR2815; post results.

Effects of a transitional palliative care model on patients with end-stage heart failure: study protocol for a randomized controlled trial

Background

Heart failure (HF) is characterized by high rates of readmission after hospitalization, and readmission is a major contributor to healthcare costs. The transitional care model has proven efficacy in reducing the readmission rate and economic outcomes, and increasing satisfaction with care. However, the effectiveness of the transitional care model has not been evaluated in patients with end-stage HF. This study was designed to compare the customary hospital-based care and a comprehensive transitional care model, namely the Home-based Palliative HF Program (HPHP), in terms of readmission rate, quality of life, and satisfaction with care among end-stage HF patients under palliative care.

Methods/design

This is a randomized controlled trial taking place in hospitals in Hong Kong. We have been recruiting patients with end-stage HF who are identified as appropriate for palliative care during hospitalization, on referral by their physicians. A set of questionnaires is collected from each participant upon discharge. Participants are randomized to receive usual care (customary hospital-based care) or the intervention (HPHP). The HPHP will be implemented for up to 12 months. Outcome measures will be performed at 1, 3, 6, and 12 months post-discharge. The primary outcome of this study is quality of life measured by the Chronic Heart Failure Questionnaire - Chinese version; secondary outcomes include readmission rate, symptom intensity, functional status, and satisfaction with care.

Discussion

This study is original and will provide important information for service development in the area of palliative care. The introduction of palliative care to end-stage organ failure patients is new and has received increasing attention worldwide in the last decade. This study adopts the randomized controlled trial, a vigorous research design, to establish scientific evidence in exploring the best model for end-stage HF patients receiving palliative care.

Trial registration

This trial was registered as NCT02086305 on 7 March 2014 in the United States Clinical Trials Registration, and in the Clinical Trials Registry, Hong Kong University with the trial number UW12202.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1303-7) contains supplementary material, which is available to authorized users.

Background and design of the profiling biobehavioral responses to mechanical support in advanced heart failure study

BACKGROUND

Unexplained heterogeneity in response to ventricular assist device (VAD) implantation for the management of advanced heart failure impedes our ability to predict favorable outcomes, provide adequate patient and family education, and personalize monitoring and symptom management strategies. The purpose of this article was to describe the background and the design of a study entitled "Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure" (PREMISE).

STUDY DESIGN AND METHODS

PREMISE is a prospective cohort study designed to (1) identify common and distinct trajectories of change in physical and psychological symptom burden; (2) characterize common trajectories of change in serum biomarkers of myocardial stress, systemic inflammation, and endothelial dysfunction; and (3) quantify associations between symptoms and biomarkers of pathogenesis in adults undergoing VAD implantation. Latent growth mixture modeling, including parallel process and cross-classification modeling, will be used to address the study aims and will entail identifying trajectories, quantifying associations between trajectories and both clinical and quality-of-life outcomes, and identifying predictors of favorable symptom and biomarker responses to VAD implantation.

CONCLUSIONS

Research findings from the PREMISE study will be used to enhance shared patient and provider decision making and to shape a much-needed new breed of interventions and clinical management strategies that are tailored to differential symptom and pathogenic responses to VAD implantation.

Rawlsian Justice and Palliative Care

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.

Training general practitioners in early identification and anticipatory palliative care planning: a randomized controlled trial

BACKGROUND

Most patients with advanced cancer, debilitating COPD or chronic heart failure (CHF) live at home. General practitioners (GPs) asked for guidance in how to recognize patients in need of palliative care in a timely way and to structure anticipatory care. For that reason, we developed a training for GPs in identifying patients in need of palliative care and in structuring anticipatory palliative care planning and studied its effect on out-of-hours contacts, contacts with their own GP, hospitalizations and place of death.

METHODS

We performed a cluster randomised controlled trial. GPs in the intervention group were trained in identifying patients in need of palliative care and anticipatory care planning. Next, for each identified patient, they were offered a coaching session with a specialist in palliative care to fine-tune a structured care plan. The GPs in the control group did not receive training or coaching, and were asked to provide care as usual. After one year, characteristics of patients deceased of cancer, COPD or CHF in both study groups were compared with mixed effects models for out-of-hours contacts (primary outcome), contacts with their own GP, place of death and hospitalizations in the last months of their life (secondary outcomes). As a post-hoc analysis, of identified patients (of the intervention GPs) these figures were compared to all other deceased patients, who had not been identified as in need of palliative care.

RESULTS

We did not find any differences between the intervention and control group. Yet, only half of the trained GPs (28) identified patients (52), which was only 24% of the deceased patients. Those identified patients had significantly more contacts with their own GP (B 4.5218; p <0.0006), were less often hospitalized (OR 0.485; p 0.0437) more often died at home (OR 2.126; p 0.0572) and less often died in the hospital (OR 0.380; p 0.0449).

CONCLUSIONS

Although we did not find differences between the intervention and control group, we found in a post-hoc analysis that those patients that had been identified as in need of palliative care had more contacts with their GP, less hospitalizations, and more often died at home. We recommend future controlled studies that try to further increase identification of patients eligible for anticipatory palliative care. The Netherlands National Trial Register: NTR2815 date 07-04-2010.

Unique challenges of hospice for patients with heart failure: A qualitative study of hospice clinicians

BACKGROUND

Patients with heart failure have end-of-life care needs that may benefit from hospice care. The goal of this descriptive study was to understand hospice clinicians' perspectives on the unique aspects of caring for patients with heart failure to inform approaches to improving end-of-life care.

METHODS

This qualitative study explored experiences, observations, and perspectives of hospice clinicians regarding hospice care for patients with heart failure. Thirteen hospice clinicians from a variety of professional disciplines and clinical roles, diverse geographic regions, and varying lengths of time working in hospice participated in semistructured interviews. Through team-based, iterative qualitative analysis, we identified 3 major themes.

RESULTS

Hospice clinicians identified 3 themes regarding care for patients with heart failure. First, care for patients with heart failure involves clinical complexity and a tailored approach to cardiac medications and advanced cardiac technologies. Second, hospice clinicians describe the difficulty patients with heart failure have in trusting hospice care due to patient optimism, prognostic uncertainty, and reliance on prehospice health care providers. Third, hospice clinicians described opportunities to improve heart failure-specific hospice care, highlighting the desire for collaboration with referring cardiologists.

CONCLUSIONS

From a hospice clinician perspective, caring for patients with heart failure is unique compared with other hospice populations. This study suggests potential opportunities for hospice clinicians and referring providers who seek to collaborate to improve care for patients with heart failure during the transition to hospice care.

Availability of Heart Failure Medications in Hospice Care

BACKGROUND

Availability of cardiac medications in hospice for acute symptom management of heart failure is unknown. This study explored hospice approaches to cardiac medications for patients with heart failure.

METHODS

Descriptive study using a quantitative survey of 46 US hospice agencies and clinician interviews.

RESULTS

Of 31 hospices that provided standard home medication kits for acute symptom management, only 1 provided medication with cardiac indications (oral furosemide). Only 22% of the hospice agencies had a specific cardiac medication kit. Just over half (57%) of the agencies could provide intravenous inotropic therapy, often in multiple hospice settings. Clinicians described an individualized approach to cardiac medications for patients with heart failure.

CONCLUSION

This study highlights opportunities for practice guidelines that inform medical therapy for hospice patients with heart failure.

End-of-life Heart Failure Care in the United States

Heart failure (HF) is increasingly common in the United States and is associated with a high degree of morbidity and mortality. As patients approach the end of life there is a significant increase in health care resource use. Patients with end-stage HF have a unique set of needs at the end of life, including symptoms such as dyspnea, uremia, and depression, as well as potentially deactivating implantable defibrillators and mechanical circulatory support devices. Improved palliative care services for patients with HF may improve quality of life and decrease health care resource use near the end of life.

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

BACKGROUND

The emergency department (ED) is increasingly used by patients with life-limiting illness. These patients are frequently admitted to the hospital, where they suffer from poorly controlled symptoms and are often subjected to marginally effective therapies. Palliative care (PC) has emerged as the specialty that cares for patients with advanced illness. PC has been shown to reduce symptoms, improve quality of life, and decrease resource utilization. Unfortunately, most patients who could benefit from PC are never identified. At present, there exists no validated screening tool to identify significant unmet PC needs among ED patients with life-limiting illness.

OBJECTIVES

The objective was to develop a simple, content-valid screening tool for use by ED providers to identify ED patients with significant PC needs. A positive screen would result in an inpatient PC consultation.

METHODS

An initial screening tool was developed based on a critical review of the literature. Content validity was determined by a two-round modified Delphi technique using a panel of PC experts. The expert panel reviewed the items of the tool for accuracy and necessity using a Likert scale and provided narrative feedback. Expert's responses were aggregated and analyzed to revise the tool until consensus was achieved. Greater than 80% agreement, as well as meeting Lawshe's critical values, was required to achieve consensus.

RESULTS

Fifteen experts completed two rounds of surveys to reach consensus on the content validity of the tool. Three screening items were accepted with minimal revisions. The remaining items were revised, condensed, or eliminated. The final tool contains 13 items divided into three steps: 1) presence of a life-limiting illness, 2) unmet PC needs, and 3) hospital admission. The majority of panelists (86%) endorsed adoption of the final screening tool.

CONCLUSIONS

Use of a modified Delphi technique resulted in the creation of a content-validated screening tool for identification of ED patients with significant unmet PC needs. Further validation testing of the instrument is warranted.

Palliative care needs in patients hospitalized with heart failure (PCHF) study: rationale and design

Aims

The primary aim of this study is to provide data to inform the design of a randomized controlled clinical trial (RCT) of a palliative care (PC) intervention in heart failure (HF). We will identify an appropriate study population with a high prevalence of PC needs defined using quantifiable measures. We will also identify which components a specific and targeted PC intervention in HF should include and attempt to define the most relevant trial outcomes.

Methods

An unselected, prospective, near‐consecutive, cohort of patients admitted to hospital with acute decompensated HF will be enrolled over a 2‐year period. All potential participants will be screened using B‐type natriuretic peptide and echocardiography, and all those enrolled will be extensively characterized in terms of their HF status, comorbidity, and PC needs. Quantitative assessment of PC needs will include evaluation of general and disease‐specific quality of life, mood, symptom burden, caregiver burden, and end of life care. Inpatient assessments will be performed and after discharge outpatient assessments will be carried out every 4 months for up to 2.5 years. Participants will be followed up for a minimum of 1 year for hospital admissions, and place and cause of death. Methods for identifying patients with HF with PC needs will be evaluated, and estimates of healthcare utilisation performed.

Conclusion

By assessing the prevalence of these needs, describing how these needs change over time, and evaluating how best PC needs can be identified, we will provide the foundation for designing an RCT of a PC intervention in HF.

The palliative care in heart failure trial: rationale and design

BACKGROUND

The progressive nature of heart failure (HF) coupled with high mortality and poor quality of life mandates greater attention to palliative care as a routine component of advanced HF management. Limited evidence exists from randomized, controlled trials supporting the use of interdisciplinary palliative care in HF.

METHODS

PAL-HF is a prospective, controlled, unblinded, single-center study of an interdisciplinary palliative care intervention in 200 patients with advanced HF estimated to have a high likelihood of mortality or rehospitalization in the ensuing 6 months. The 6-month PAL-HF intervention focuses on physical and psychosocial symptom relief, attention to spiritual concerns, and advanced care planning. The primary end point is health-related quality of life measured by the Kansas City Cardiomyopathy Questionnaire and the Functional Assessment of Chronic Illness Therapy with Palliative Care Subscale score at 6 months. Secondary end points include changes in anxiety/depression, spiritual well-being, caregiver satisfaction, cost and resource utilization, and a composite of death, HF hospitalization, and quality of life.

CONCLUSIONS

PAL-HF is a randomized, controlled clinical trial that will help evaluate the efficacy and cost effectiveness of palliative care in advanced HF using a patient-centered outcome as well as clinical and economic end points.

Advance directives among hospitalized patients with heart failure

OBJECTIVES

The purpose of this study was to assess the frequency and correlates of documented advance directives (ADs) among patients hospitalized for heart failure (HF).

BACKGROUND

Discussing ADs with patients with HF is critical for identifying treatment goals consistent with patients' values and preferences and for facilitating health care team communication.

METHODS

We retrospectively identified electronic medical records of adult patients admitted to 2 large tertiary care hospitals with either the primary or secondary discharge diagnosis of HF from September 2008 to August 2013 to assess the presence of ADs in electronic medical records. We performed analyses including HF as either the primary or secondary admission diagnosis and HF as the primary admission diagnosis only. Multivariable models were constructed to investigate independent predictors of documented ADs.

RESULTS

Data included 44,768 admissions from 24,291 individual patients over 5 years. Mean age of patients at admission was 64.8 ± 15.9 years; 47.9% of these patients were female, 51.8% were black. The median length of stay for all admissions was 5 (3 to 10) days; 12.7% of patients had documented ADs. Older age, female sex, white race, higher socioeconomic status, higher risk for adverse in-hospital outcomes, length of stay ≥5 days, hospice discharge, palliative care consultation, and a do-not-resuscitate order were all associated with a significantly higher chance of having documented ADs. A significant increase in ADs over time was noted, but more than 80% of patients did not have ADs in medical records at the end of the study period.

CONCLUSIONS

In a diverse population of hospitalized patients with HF, most did not have a documented AD in the medical records. Although several factors were associated with a higher probability, major opportunities exist for all subgroups of patients with HF to improve documentation of ADs.

End-of-life care in patients with heart failure

Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.

The provision of home-based palliative care for those with advanced heart failure

PURPOSE OF REVIEW

Although widely recognized as best practice for advanced heart failure patients, palliative care is underused by this population. The purpose of this brief review is to highlight recent findings related to home-based palliative care among patients with advanced heart failure.

RECENT FINDINGS

This review considers new models of home-based palliative care and reports recent evidence on the effectiveness, and burden of these models for patients with advanced heart failure and their caregivers. New models currently under investigation and gaps in current research are presented.

SUMMARY

New models integrating home-based palliative care and standard heart failure care have shown to be effective in reducing both physical and psychological symptoms in patients. Recent evidence suggests that home-based palliative care reduces hospitalizations and decrease the probability of 30-day re-admissions in patients with advanced heart failure; thus, potentially reducing costs of care and increasing likelihood of dying at home. However, caregiver burden for families of those with heart failure remains an issue. Research that addresses caregiver burden and the challenges of providing palliative care to patients with the uncertain disease trajectory seen in advanced heart failure require further research.

Struggling with issues about cardiopulmonary resuscitation (CPR) for end-stage heart failure patients

BACKGROUND

Integrating heart failure and palliative care teams combines unique expertise from both cardiology and palliative care. However, professionals from the two arenas of life-saving cardiology and palliative care may well have different experiences with and approaches to patient care. Little is known how to optimally discuss cardiopulmonary resuscitation with patients and their relatives and what challenges are for healthcare providers.

OBJECTIVE

The aim of this study was to describe the experiences and thoughts of members of an integrated heart failure and palliative care team concerning talking about CPR with end-stage heart failure patients.

METHOD

We used a descriptive qualitative design, conducting group interviews during 2011 with professionals from different disciplines working with heart failure patients over a 1-year period. A qualitative content analysis was performed to examine the interview data.

RESULTS

Professional caregivers in integrated heart failure and palliative homecare are struggling with the issue of CPR of end-stage heart failure patients. They wrestle with the question of whether CPR should be performed at all in these terminally ill patients. They also feel challenged by the actual conversation about CPR with the patients and their relatives. Despite talking them about CPR with patients and relatives is difficult, the study participants described that doing so is important, as it could be the start of a broader end-of-life conversation.

CONCLUSION

Talking with patient and relatives about CPR in end-stage heart failure, as suggested in the current heart failure guidelines, is a challenge in daily clinical practice. It is important to discuss the difficulties within the team and to decide whether, whom, how and when to talk about CPR with individual patients and their relatives.

Machines versus medication for biventricular heart failure: focus on the total artificial heart

ABSTRACT 

The medical/surgical management of advanced heart failure has evolved rapidly over the last few decades. With better understanding of heart failure pathophysiology, new pharmacological agents have been introduced that have resulted in improvements in survival. For those patients that fail to improve, mechanical circulatory support with left ventricular assist devices and total artificial hearts (TAHs) have served as a beneficial bridge to transplantation. The TAH has continued to play a significant role as a bridge to transplantation in patients with biventricular failure and more selected indications that could not be completely helped with left ventricular assist devices. Improved survival with the TAH has resulted in more patients benefiting from this technology. Improvements will eventually lead to a totally implantable device that will permanently replace the failing human heart.

Engaging heart failure clinicians to increase palliative care referrals: overcoming barriers, improving techniques

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.

Risk factors for potentially avoidable readmissions due to end-of-life care issues

BACKGROUND

Repeated hospitalizations are frequent toward the end of life, where each admission should be an opportunity to initiate advance-care planning to high-risk patients.

OBJECTIVE

To identify the risk factors for having a 30-day potentially avoidable readmission due to end-of-life care issues among all medical patients.

DESIGN

Nested case-control study.

SETTING/PATIENTS

All 10,275 consecutive discharges from any medical service of an academic tertiary medical center in Boston, Massachusetts between July 1, 2009 and June 30, 2010.

MEASUREMENTS

A random sample of all the potentially avoidable 30-day readmissions was independently reviewed by 9 trained physicians to identify the ones due to end-of-life issues.

RESULTS

Among 534, 30-day potentially avoidable readmission cases reviewed, 80 (15%) were due to an end-of-life care issue. In multivariable analysis, the following risk factors were significantly associated with a 30-day potentially avoidable readmission due to end-of-life care issues: number of admissions in the previous 12 months (odds ratio [OR]: 1.10 per admission, 95% confidence interval [CI]: 1.02-1.20), neoplasm (OR: 5.60, 95% CI: 2.85-10.98), opiate medications at discharge (OR: 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index (OR: 1.16 per 5-point increase, 95% CI: 1.10-1.22). The discrimination of the model (C statistic) was 0.85.

CONCLUSIONS

In a medical population, we identified 4 main risk factors that were significantly associated with 30-day potentially avoidable readmission due to end-of-life care issues, producing a model with very good to excellent discrimination. Patients with these risk factors might benefit from palliative care consultation prior to discharge in order to improve end-of-life care and possibly reduce unnecessary rehospitalizations.

On-going palliative care enhances perceived control and patient activation and reduces symptom distress in patients with symptomatic heart failure: a pilot study

INTRODUCTION

There is a paucity of research about the impact of palliative care (PC) on perceived control (i.e. one's perceived influence over outcomes or events in the environment) and activation (i.e. ability to self-manage) in patients with symptomatic heart failure (HF). Likewise, little is known about the association between perceived control, activation, and symptom distress in this patient population. We hypothesized that patients with advanced HF who received ongoing PC services (i.e. ≥2 PC consultations) vs no access or a single PC consultation would have greater improvements in perceived control and activation and greater reductions in symptom distress three months post-discharge for HF exacerbation.

METHODS

Forty-two patients (average age 53.9±8.0 years; predominantly male (72%), White (61%) and married (69%)) participated in the study. However, only 36 (85.7%) patients completed an outpatient PC consultation of which 29 (69%) patients returned for additional follow-up visits with the PC team. Data on perceived control, activation, and symptom distress were collected at baseline and three months. Parametric statistical models were applied to draw conclusions.

RESULTS

Findings showed that the patients who received ≥2 PC consultations had greater improvements in perceived control and activation than their counterparts; these increases were associated with greater reductions in symptom distress.

CONCLUSION

Our findings suggest that on-going PC interventions enhance perceived control and activation in patients with advanced HF and open up the possibility of planning larger studies to assess the effect of PC on these variables as possible mediators to improvements in self-management and clinical outcomes.

Comparing unmet needs between community-based palliative care patients with heart failure and patients with cancer

BACKGROUND

As the role of palliative care (PC) has yet to be clearly defined in patients with heart failure (HF), such patients may face barriers regarding PC referral. In order to maximally meet the needs of HF patients, it is necessary to understand how they compare to the classic PC population: patients with cancer.

OBJECTIVE

To characterize the unresolved symptom and treatment needs with which patients with HF and those with cancer present to PC.

METHODS

We used data from the Palliative Care Research Registry (PCRR), a repository of quality improvement data from three community-based PC organizations. We abstracted first PC visit data from the PCRR for patients with primary diagnoses of HF or cancer seen between 2008 and 2012. We assessed the association of primary diagnosis (i.e., HF or cancer) on three outcomes: unresolved symptoms, treatment gaps, and a composite indicator of symptom control and quality of life. Analyses included descriptive statistics and multivariate Poisson regression.

RESULTS

Our analytic sample comprised 334 patients with HF and 697 patients with cancer, the majority of whom were white and male. Compared to patients with cancer, patients with HF presented with fewer unresolved symptoms, both overall and at moderate/severe distress levels. Patients with HF more commonly reported moderately/severely distressful dyspnea (25% versus 18%, p=0.02), and more commonly experienced dyspnea-related treatment gaps (17% versus 8%, p<0.001).

CONCLUSIONS

Patients with HF possess care needs that are squarely within the purview of PC. Future work is needed to delineate how PC referral policies should be refined to optimize PC access for patients with HF.