Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients

Application of Transformational Leadership Principles in the Development and Integration of Palliative Care Within an Advanced Heart Failure Program

Heart failure (HF) is a major health problem in United States, and it has reached epidemic proportions. Heart failure is associated with significant morbidity, mortality, and cost. Although the prognosis of HF is worse than many forms of cancer, many patients, families, and clinicians are unaware of the dire prognosis. As the disease progress to advanced HF, patients are faced with many challenges, such as poor quality of life due to worsening symptoms and frequent hospitalizations. Heart failure management adds significant financial burden to the health care system. Palliative care can be integrated into HF care to improve quality of life and symptom management and to address physical, spiritual, and psychosocial needs of patients and families. Palliative care can be used concurrently with or independent of curative or life-prolonging HF therapies. Transformational leadership principles were used to guide the development of a plan to enhance integration of palliative care within traditional advanced HF care.

Spirituality, Spiritual Well-Being, and Spiritual Coping in Advanced Heart Failure: Review of the Literature

Heart failure is a chronic and terminal disease that affects a significant portion of the U.S. population. It is marked by considerable suffering, for which palliative care has been recommended. Palliative care standards require the inclusion of spiritual care, but there is a paucity of literature supporting effective spiritual interventions for the heart failure population. A literature search resulted in 30 articles meeting the criteria for review of spirituality and spiritual coping in the heart failure population. Findings within this body of literature include descriptive evidence of the uniqueness of spirituality in this population, quantitative and qualitative approaches to inquiry, theoretical models of spiritual coping, and proposed interventions. The article concludes with implications for future research and practice.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

Patterns of Self-care in Adults With Heart Failure and Their Associations With Sociodemographic and Clinical Characteristics, Quality of Life, and Hospitalizations: A Cluster Analysis

BACKGROUND

Self-care is important in heart failure (HF) treatment, but patients may have difficulties and be inconsistent in its performance. Inconsistencies in self-care behaviors may mirror patterns of self-care in HF patients that are worth identifying to provide interventions tailored to patients.

OBJECTIVES

The aims of this study are to identify clusters of HF patients in relation to self-care behaviors and to examine and compare the profile of each HF patient cluster considering the patient's sociodemographics, clinical variables, quality of life, and hospitalizations.

METHODS

This was a secondary analysis of data from a cross-sectional study in which we enrolled 1192 HF patients across Italy. A cluster analysis was used to identify clusters of patients based on the European Heart Failure Self-care Behaviour Scale factor scores. Analysis of variance and χ test were used to examine the characteristics of each cluster.

RESULTS

Patients were 72.4 years old on average, and 58% were men. Four clusters of patients were identified: (1) high consistent adherence with high consulting behaviors, characterized by younger patients, with higher formal education and higher income, less clinically compromised, with the best physical and mental quality of life (QOL) and lowest hospitalization rates; (2) low consistent adherence with low consulting behaviors, characterized mainly by male patients, with lower formal education and lowest income, more clinically compromised, and worse mental QOL; (3) inconsistent adherence with low consulting behaviors, characterized by patients who were less likely to have a caregiver, with the longest illness duration, the highest number of prescribed medications, and the best mental QOL; (4) and inconsistent adherence with high consulting behaviors, characterized by patients who were mostly female, with lower formal education, worst cognitive impairment, worst physical and mental QOL, and higher hospitalization rates.

CONCLUSION

The 4 clusters identified in this study and their associated characteristics could be used to tailor interventions aimed at improving self-care behaviors in HF patients.

Symptom experience and symptom burden of patients following first-ever stroke within 1 year: a cross-sectional study

Symptoms that are multidimensional and concurrent should be assessed from different dimensions and managed together. Few studies have evaluated concurrent and multidimensional symptoms in patients with stroke. Most studies of stroke focused on dysfunctions and complications. We hypothesize that patients with stroke have a heavy symptom burden within 1 year. This study aimed to describe multidimensional and concurrent symptoms within 1 year after stroke. This study recruited 230 patients with stroke from the Rehabilitation Department of Xuhui District Center Hospital of Shanghai and the Shanghai Sunshine Rehabilitation Center in China from March to September 2017. The patients’ multidimensional symptom experience and symptom burden were analyzed using a self-made structured questionnaire and the influential factors for symptom burden were identified. The mean number of symptoms in patients with stroke was 11.7 ± 3.5. More than two thirds of the participants suffered from at least 10 co-occurring symptoms. Unilateral limb weakness had the highest prevalence and frequency. Participation restriction had the highest symptom dimensions of severity and distress. Lack of self-care ability (severity), memory deterioration (frequency), imbalance of body (distress), moodiness (distress), being unable to move limbs at will (distress), shoulder pain (distress), and slower response (frequency) were independent factors of the total symptom burden score. These findings can provide essential information for efficient symptom management of patients with stroke. This trial was registered with the ISRCTN registry (registration number: ISRCTN18421629).

A mixed methods analysis of quality of life among late-life patients diagnosed with chronic illnesses

BACKGROUND

Quality of life (QOL) is an important consideration for people living with advancing chronic conditions. Palliative care providers speak about how, despite physical decline in late life, many patients report growth and meaning in other domains. This mixed methods study uses QOL survey responses to explore domain trajectories and interview data to explore how patients with advancing chronic conditions experience distinct QOL domains.

METHODS

The study sample includes 156 now-deceased participants who completed the FACIT-Pal quarterly, and 40 (10 now-deceased) participants who discussed QOL in an interview. Mean subscale scores were plotted over participants' last 18 months to reveal QOL trajectories. Interview data were analyzed to reveal how participants' experience, actions and cognitive processes influenced QOL scores.

RESULTS

Physical and functional subscale ratings show gradual decline. Emotional QOL maintains with a small dip 2-3 months before death, and social QOL ratings improve in participants' final 3 months. Participants create and strengthen relationships that help them better manage health and receive instrumental and emotional support; seek activities in which they can find joy, meaning, and purpose; and support cognitions through which patients accept and communicate about illness, and emphasize positives.

CONCLUSION

QOL domains exist in different trajectories. Despite physical and functional decline, participant ratings of emotional QOL maintain and ratings of social QOL improve at end of life. Understanding the processes through which participants countered declining QOL may help providers identify how to best support and promote improved QOL for patients during their final months.

Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities

Patients with heart failure (HF) and their families experience stress and suffering from a variety of sources over the course of the HF experience. Palliative care is an interdisciplinary service and an overall approach to care that improves quality of life and alleviates suffering for those living with serious illness, regardless of prognosis. In this review, we synthesize the evidence from randomized clinical trials of palliative care interventions in HF. While the evidence base for palliative care in HF is promising, it is still in its infancy and requires additional high-quality, methodologically sound studies to clearly elucidate the role of palliative care for patients and families living with the burdens of HF. Yet, an increase in attention to primary palliative care (e.g., basic physical and emotional symptom management, advance care planning), provided by primary care and cardiology clinicians, may be a vehicle to address unmet palliative needs earlier and throughout the illness course.

Symptom Clusters and Quality of Life in Hospice Patients with Cancer

Background: Symptom control is an important part of palliative care and important to achieve optimal quality of life (QOL). Studies have shown that patients with advanced cancer suffer from diverse and often severe physical and psychological symptoms. The aim is to explore the influence of symptom clusters on QOL among patients with advanced cancer. Materials and Methods: 709 patients with advanced cancer were recruited to participate in a clinical trial focusing on symptom management and QOL. Patients were adults newly admitted to hospice home care in one of two hospices in southwest Florida, who could pass mental status screening. The instruments used for data collection were the Demographic Data Form, Memorial Symptom Assessment Scale (MSAS), and the Hospice Quality of Life Index-14. Results: Exploratory factor analysis and multiple regression were used to identify symptom clusters and their influence on QOL. The results revealed that the participants experienced multiple concurrent symptoms. There were four symptom clusters found among these cancer patients. Individual symptom distress scores that were the strongest predictors of QOL were: feeling pain; dry mouth; feeling drowsy; nausea; difficulty swallowing; worrying and feeling nervous. Conclusions: Patients with advanced cancer reported various concurrent symptoms, and these form symptom clusters of four main categories. The four symptoms clusters have a negative influence on patients’ QOL and required specific care from different members of the hospice healthcare team. The results of this study should be used to guide health care providers’ symptom management. Proper attention to symptom clusters should be the basis for accurate planning of effective interventions to manage the symptom clusters experienced by advanced cancer patients. The health care provider needs to plan ahead for these symptoms and manage any concurrent symptoms for successful promotion of their patient’s QOL.

Improving care for people with heart failure in Uganda: serial in-depth interviews with patients' and their health care professionals

BACKGROUND

The short prognosis of patients with advanced heart failure (HF) and the associated multidimensional distress as illustrated in literature from high income countries necessitates the integration of palliative care into the care of advanced HF patients to address these needs and improve their quality of life. These needs, which are subjective, have not been described from the patients' and health care professionals'(HPs) view point in the Ugandan setting, a low income country with a different socio-cultural context. This study aimed at bridging this gap in knowledge by eliciting patients' and HPs' views of HF patients' needs over the course of their illness to enable generalists, cardiologists and palliative care clinicians to develop guidelines to provide patient-centred realistic care in Uganda.

METHODS

Serial qualitative in-depth interviews were conducted with HF patients who were purposively sampled and recruited in Mulago National Referral Hospital (MNRH) until thematic saturation. In-depth interviews were conducted at three time points with intervals of 3 month between interviews over the course of their illness in the hospital and their home context. One-off interviews were conducted with HPs that manage HF in MNRH. We used a grounded theory approach in data analysis. The Uganda National Council of science and technology approved the research.

RESULTS

Forty-eight interviews were conducted with 21 patients and their carers and eight interviews with their HPs. Multidimensional needs including physical, psychological, social, spiritual and information needs were identified. These highlighted the underpinning need to have normal functioning, control, to cope and adapt to a changed life and to find meaning. Spiritual needs were less recognised by HPs than the other multidimensional needs. Information needs were commonly unmet. Patients and HPs suggested improvements in care that were congruent with the recommendations in chronic disease care and the six pillars of the WHO health systems strengthening approach.

CONCLUSION

Management of HF in Uganda requires an approach that targets multidimensional needs, embraces multidisciplinary care and strengthens health systems which are all important tenets of palliative care.

Palliative Care Training in Cardiology Fellowship: A National Survey of the Fellows

Objectives:

To address perspectives of cardiology fellows on the current state of palliative education and palliative and hospice resource utilization within their fellowship experiences.

Methods:

We conducted an online national survey of cardiology fellows during the 2015 to 2016 academic year. Survey questions aimed to assess perceived importance of palliative care education, level of palliative care education during fellowship, and the structure of palliative care support at respondent institutions. Responses were collected anonymously. A total of 519 programs, including subspecialty programs, were contacted.

Results:

We received 365 responses, a number that represents roughly 14% of all cardiology fellows nationwide during the 2015 to 2016 academic year. Fellows reported discordance in the quality of education between general cardiology and palliative care principles as it relates to care of the patient approaching the end of life. Fellows infrequently received explicit training nor were observed or mentored in delivering end-of-life discussions. Respondents reported an underutilization of palliative care and hospice resources during fellowship training and also a perception that attending faculty were not routinely addressing goals of care.

Conclusions:

Our survey results highlight a need for enhanced palliative care and end-of-life training experiences for cardiology fellows and also suggest underutilization of hospice and palliative care resources for patients with advanced cardiac diseases. These findings create a platform for future work that might: (1) confirm this training deficit, (2) lead to exploration of educational models that could reconcile this deficit, and (3) potentially help improve palliative care support for patients and families facing advanced heart disease.

Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

MOTIVATional intErviewing to improve self-care in Heart Failure patients (MOTIVATE-HF): Study protocol of a three-arm multicenter randomized controlled trial

AIMS

Heart Failure (HF) self-care improves patient outcomes but trials designed to improve HF self-care have shown inconsistent results. Interventions may be more effective in improving self-care if they mobilize support from providers, promote self-efficacy, increase understanding of HF, increase the family involvement, and are individualized. All of these elements are emphasized in motivational interviewing (MI); few trials have been conducted using MI in HF patients and rarely have caregivers been involved in MI interventions. The aim of this study will be to evaluate if MI improves self-care maintenance in HF patients, and to determine if MI improves the following secondary outcomes: a) in HF patients: self-care management, self-care confidence, symptom perception, quality of life, anxiety/depression, cognition, sleep quality, mutuality with caregiver, hospitalizations, use of emergency services, and mortality; b) in caregivers: caregiver contribution to self-care, quality of life, anxiety/depression, sleep, mutuality with patient, preparedness, and social support.

METHODS

A three-arm randomized controlled trial will be conducted in a sample of 240 HF patients and caregivers. Patients and caregivers will be randomized to the following arms: 1) MI intervention to patients only; 2) MI intervention to patients and caregivers; 3) standard of care to patients and caregivers. The primary outcome will be measured in patients 3months after enrollment. Primary and secondary outcomes also will be evaluated 6, 9 and 12months after enrollment.

CONCLUSION

This study will contribute to understand if MI provided to patients and caregivers can improve self-care. Because HF is rising in prevalence, findings can be useful to reduce the burden of the disease.

Health Status Trajectories Among Outpatients With Heart Failure

CONTEXT

Health status (i.e., symptoms, function, and quality of life) is an important palliative care outcome in patients with heart failure; however, patterns of health status over time (i.e., trajectories) are not well described.

OBJECTIVES

The objective of this study was to identify health status trajectories in outpatients with heart failure and assess whether depression, symptom burden, or sense of peace predict health status trajectory.

METHODS

This is an observational study utilizing data from the Patient-Centered Disease Management for Heart Failure trial. Participants completed Kansas City Cardiomyopathy Questionnaires at baseline, three, six, and 12 months. Latent class growth analysis identified health status trajectories; multinomial logistic regression models identified predictors of trajectory membership.

RESULTS

Patients (n = 384) were primarily men (97%) and older (mean age 67.6 ± 10.1). Three health status trajectories were identified. All three trajectories improved at three months; however, the marked improvement health status trajectory (n = 19) showed progressive improvement over one year, whereas the poor (n = 119) and moderate (n = 246) health status trajectories had little change after three months. In adjusted analyses, worse baseline depression (odds ratio 1.10; 95% confidence interval 1.01-1.20), symptom burden (1.45; 1.15-1.83), and sense of peace (0.41; 0.22-0.75) predicted membership in the poor vs. moderate health status trajectory.

CONCLUSION

We identified three one-year health status trajectories in patients with heart failure, with the two most common trajectories characterized by early improvement followed by limited change. Future research should assess these findings in nonveterans and women and explore whether treatment of depression, high symptom burden, and low sense of peace leads to improved long-term heart failure health status trajectory.

Comparing the symptom experience of cancer patients and non-cancer patients

PURPOSE

Symptom burden is an established concept in oncology encompassing the presence and severity of symptoms experienced by cancer patients. Few studies have examined differences in symptom burden between cancer patients and non-cancer patients. This study seeks to examine the differences in symptom burden between cancer patients (CP) and non-cancer patients (NCP) in order to better understand symptom burden in both populations.

METHODS

Two groups of patients completed the Memorial Symptom Assessment Scale: 301 patients from a general medical clinic and 558 cancer patients from a cancer tumor registry. Participants provided demographic information-age, race/ethnicity, and sex and completed the Memorial Symptom Assessment Scale. Medical comorbidity was also measured.

RESULTS

Most symptoms were more common in CP, except for pain, which was more prevalent in the NCP (45% of CP vs. 54% of NCP, p < .05). There was no difference in prevalence for the following symptoms: dry mouth, mouth sores, feeling nervous, worry, cough, and dizziness. The CP had greater mean MSAS Total scores (0.53 vs. 0.43, p < .01), number of symptoms (9.11 vs. 6.13, p < .01), and psychological subscale scores (0.77 vs. 0.64, p < .05). There was no difference by group in the physical nor the GDI subscale scores.

CONCLUSION

The results of this study support the perception that cancer patients have greater symptom burden. There were some unexpected results, particularly in terms of pain, which was more common in NCP and other symptoms that were experienced equally in both patient populations.

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.

Palliative care for patients with heart failure: facilitators and barriers - a cross sectional survey of German health care professionals

Background

Compared to patients with cancer, heart failure patients are seldom candidates for palliative care. Numerous studies have investigated reasons why heart failure patients do not receive palliative care; however, none of these studies have ever evaluated the situation in the German health care setting. This study aims to identify German healthcare providers’ (HCP) perception of barriers and facilitators to palliative care of patients with chronic heart failure.

Methods

We conducted an online-survey with 315 nurses and physicians of different medical disciplines.

Results

Even though heart failure patients’ need of palliative care and its advantages has been recognized, HCP see potential for development and improvement. A lack of knowledge about the content and measures of palliative care, poor communication and unclear responsibilities between medical disciplines, difficulties to determine the right time to initiate palliative care, and the feeling not to be prepared to discuss end-of-life issues with the patient has been identified as barriers. Further, HCP believe that patients and relatives do not possess adequate knowledge about the disease and its progression and are therefore unprepared in asking questions regarding palliative care. They rather tend to demand everything possible to be done in order prolong life, and are reluctant to accept that life is limited. Overall, HCP perceive that dying is a taboo subject within our society placing palliative care on the same level as assisted dying. In addition, results indicate that HCP have an inappropriate notion of ideal medicine fearing to lose patient and are worried about the appropriateness of PC remuneration.

Conclusions

In order to overcome the described barriers, HCP, patients, and relatives need to be educated in palliative care. Information and education encompassing the aim, content and measures of palliative care needs to be provided for all parties in order to optimize patient care, to foster communication between healthcare professionals, patients, and relatives, and to overcome perceived barriers.

Trial registration

DRKS00007119

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1609-x) contains supplementary material, which is available to authorized users.

Burdensome Physical and Depressive Symptoms Predict Heart Failure-Specific Health Status Over One Year

CONTEXT

Heart failure (HF)-specific health status (symptom burden, functional status, and health-related quality of life) is an important patient-reported outcome that is associated with palliative care needs, hospitalizations, and death.

OBJECTIVES

To identify potentially modifiable patient-reported factors that predict HF-specific health status over one year.

METHODS

This was a prospective cohort study using data from the Patient-Centered Disease Management trial. Participants were identified using population-based sampling of all patients with an HF diagnosis at four VA Medical Centers. Patients were enrolled with reduced HF-specific health status (i.e., significant HF symptoms, limited functional status, and poor quality of life, defined by a Kansas City Cardiomyopathy Questionnaire [KCCQ] score <60). Patient-reported factors at baseline were chest pain, other noncardiac pain, dry mouth, numbness/tingling, constipation, nausea, cough, dizziness, depressive symptoms (Patient Health Questionnaire-9), and spiritual well-being (validated, single-item measure). Patients reported HF-specific health status (KCCQ) at 3, 6, and 12 months.

RESULTS

Of 384 U.S. veterans, 42% screened positive for depression and 76% described burdensome physical symptoms at baseline. In bivariate analyses, all patient-reported factors were correlated with KCCQ score over one year. Multivariable mixed-effect modeling showed that baseline chest pain, numbness/tingling, depressive symptoms, and higher comorbidity count predicted HF-specific health status over the following year.

CONCLUSION

Burdensome physical and depressive symptoms independently predicted subsequent HF-specific health status in patients with symptomatic HF. Whether addressing these aspects of the patient experience can improve health status and well-being in symptomatic HF should be studied further.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

The Cardio-oncology Program: A Multidisciplinary Approach to the Care of Cancer Patients With Cardiovascular Disease

Improved cancer survivorship has resulted in a growing number of Canadians affected by cancer and cardiovascular disease. As a consequence, cardio-oncology programs are rapidly emerging to treat cancer patients with de novo and preexisting cardiovascular disease. The primary goal of a cardio-oncology program is to preserve cardiovascular health to allow the timely delivery of cancer therapy and achieve disease-free remission. Multidisciplinary programs in oncology and cardiology have been associated with enhanced patient well-being and improved clinical outcomes. Because of the complex needs of these multisystem patients, a similar model of care is gaining acceptance. The optimal composition of the cardio-oncology team will typically involve support from cardiology, oncology, and nursing. Depending on the clinical scenario, additional consultation from dietetics, pharmacy, and social services might be required. Timely access to consultation and testing is another prerequisite for cardio-oncology programs because delays in treating cardiac complications and nonadherence to prescribed cancer therapy are each associated with poor outcomes. Recommended reasons for referral to cardio-oncology programs include primary prevention for those at high risk for cardiotoxicity and the secondary treatment of new or worsening cardiovascular disease in cancer patients and survivors. Management is multifaceted and can involve lifestyle education, pharmacotherapy, enhanced cardiovascular surveillance, and support services, such as exercise training. The lack of evidence to guide clinical decisions and recommendations in cardio-oncology is a major challenge and opportunity for health care professionals. Large multicentre prospective registries are needed to adequately power risk model calculations and generate hypotheses for novel interventions.

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.

Parkinson disease patients' perspectives on palliative care needs: What are they telling us?

BACKGROUND

A growing body of literature suggests that patients with Parkinson disease (PD) have many unmet needs under current models of care that may be addressed through palliative care approaches. A first step in improving care for patients with PD through palliative care principles is to better understand patient perspectives on their perceived needs and care preferences.

METHODS

A total of 30 in-depth individual interviews and 4 focus groups were held to elicit the perspectives of patients with PD on unmet palliative care needs and preferences for addressing these needs. We used ATLAS.ti and inductive qualitative data analysis techniques to interpret responses.

RESULTS

Patients articulated major challenges in living with a diverse and complex set of motor and nonmotor symptoms; feelings of loss; changes in roles, relationships, and concept of self; and expressed concerns about the future. Participants discussed gaps in their care, including support at the time of diagnosis, education about the disease, and advance care planning. There was an expressed interest in and openness of participants to interdisciplinary approaches for addressing these needs.

CONCLUSIONS

PD has a profound effect on multiple domains of a person's life starting at diagnosis. Patients desired individualized care and identified several areas where care from their primary neurologist could be improved. Patients were receptive to outpatient team-based palliative care services to address psychosocial issues, adjustment to illness (particularly at diagnosis and with progression), nonmotor symptom control, and advance care planning as an adjunct to usual care. Future research is needed to develop and test the effectiveness of palliative approaches to improve the care of patients with PD.

Intensive care at the end of life in patients dying due to non-cancer chronic diseases versus cancer: a nationwide study in Denmark

Introduction

It is unknown to what extent use of palliative care and focus on proactive planning of end-of-life (EOL) care among cancer patients is also reflected by less use of intensive care. We aimed to examine the use of intensive care in the EOL in patients dying as a result of non-cancer diseases compared with patients dying due to cancer.

Methods

We conducted a nationwide follow-up study among 240,757 adults dying as a result of either non-cancer chronic disease or cancer in Denmark between 2005 and 2011. Using the Danish Intensive Care Database, we identified all admissions and treatments in intensive care units (ICU) during the patients’ last 6 months before death. We used prevalence ratios (aPRs) adjusted for age, sex, comorbidity, marital status and residential region to compare the 6-month prevalence of ICU admissions as well as treatment with invasive mechanical ventilation (MV), non-invasive ventilation (NIV), renal replacement therapy (RRT) and inotropes and/or vasopressors. In addition, length of ICU stay and death during ICU admission were compared among non-cancer and cancer patients dying between 2009 and 2011.

Results

Overall 12.3 % of non-cancer patients were admitted to an ICU within their last 6 months of life, compared with 8.7 % of cancer patients. The overall aPR for ICU admission was 2.11 [95 % confidence interval (CI) 1.98–2.24] for non-cancer patients compared with cancer patients and varied widely within the non-cancer patients (patients with dementia, aPR 0.19, 95 % CI 0.17–0.21; patients with chronic obstructive lung disease, aPR 3.19, 95 % CI 2.97–3.41). The overall aPRs for treatment among non-cancer patients compared with cancer patients were 1.40 (95 % CI 1.35–1.46) for MV, 1.62 (95 % CI 1.50–1.76) for NIV, 1.19 (95 % CI 1.07–1.31) for RRT and 1.05 (95 % CI 0.87–1.28) for inotropes and/or vasopressors. No difference in admission length was observed. Non-cancer patients had an increased risk of dying in an ICU (aPR 1.23, 95 % CI 0.99–1.54) compared with cancer patients.

Conclusions

Overall, patients dying as a result of non-cancer diseases were twice as likely to be admitted to ICUs at the EOL as patients dying due to cancer. Further studies are warranted to explore whether this difference in use of intensive care reflects an unmet need of palliative care, poor communication about the EOL or lack of prognostic tools for terminally ill non-cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1124-1) contains supplementary material, which is available to authorized users.

Improving Spiritual Well-Being in Patients with Lung Cancers

Patients with lung cancer report more disease burden and lower spiritual well-being (SWB) compared with other cancer patients. Understanding variables that lessen disease burden and improve SWB is essential. The aim of this study was to explore the relationship between motivational level for physical activity and SWB in patients with lung cancer. Linear regression showed increased SWB as stage of change for physical activity increased (p < 0.0001), even after adjusting for multiple demographic variables.

Using a supportive care framework to understand and improve palliative care among cancer patients in Africa

OBJECTIVE

Cancer incidence and mortality are increasing in Africa, which is leading to greater demands for palliative care. There has been little progress in terms of research, pain management, and policies related to palliative care. Palliative care in Africa is scarce and scattered, with most African nations lacking the basic services. To address these needs, a guiding framework that identifies care needs and directs palliative care services could be utilized. Therefore, using the supportive care framework developed by Fitch (Fitch, 2009), we here review the literature on palliative care for patients diagnosed with cancer in Africa and make recommendations for improvement.

METHOD

The PubMed, Scopus, CINAHL, Web of Science, Embase, PsycINFO, Social Sciences Citation Index, and Medline databases were searched. Some 25 English articles on research from African countries published between 2004 and 2014 were selected and reviewed. The reviewed literature was analyzed and presented using the domains of the supportive care framework.

RESULTS

Palliative care patients with cancer in Africa, their families, and caregivers experience increasing psychological, physical, social, spiritual, emotional, informational, and practical needs. Care needs are often inadequately addressed because of a lack of awareness as well as deficient and scattered palliative care services and resources. In addition, there is sparse research, education, and policies that address the dire situation in palliative care.

SIGNIFICANCE OF RESULTS

Our review findings add to the existing body of knowledge demonstrating that palliative care patients with cancer in Africa experience disturbing care needs in all domains of the supportive care framework. To better assess and address these needs, holistic palliative care that is multidomain and multi-professional could be utilized. This approach needs to be individualized and to offer better access to services and information. In addition, research, education, and policies around palliative care for cancer patients in Africa could be more comprehensive if they were based on the domains of the supportive care framework.

A health education booklet and telephone follow-ups can improve medication adherence, health-related quality of life, and psychological status of patients with heart failure

BACKGROUND

Heart failure is an increasing public health problem globally. Interventions are imperative in managing the disease.

OBJECTIVE

To examine the effectiveness of a health education booklet and telephone follow-ups on patients' medication adherence, health-related quality of life, and psychological status.

METHODS

One hundred and sixty heart failure patients were assigned to either the experimental group (health education booklet and telephone follow-ups) or the control group (usual care). An independent t-test and the generalized estimating equation (GEE) model were used to compare the differences in the study outcomes. The statistical tests were two-sided and a p value below 0.05 was considered statistically significant.

RESULTS

The patients in the experimental group showed greater improvement throughout the study period compared with those in the control group regarding all the study outcomes.

CONCLUSIONS

The study provided clues for healthcare professionals to develop interventions while undertaking clinical work with limited resources in China.

Is There a Need for Early Palliative Care in Patients With Life-Limiting Illnesses? Interview Study With Patients About Experienced Care Needs From Diagnosis Onward

The early integration of specialist palliative care has been shown to benefit the quality of life of patients with advanced cancer. In order to explore whether other seriously ill people and people at even earlier phases would also benefit from early palliative care, we conducted 18 qualitative interviews with people having cancer, chronic obstructive lung disease, heart failure, or dementia at different phases of the illness trajectory about how they experienced care needs related to their disease from diagnosis onward. Respondents experienced needs within the different domains of palliative care at different stages of the illness and different illness types or duration of the illness. This study contributes to the understanding of primary care needs of patients for whom palliative care (not necessarily specialized palliative care) could be beneficial.

Symptom frequency, severity, and quality of life among persons with three disease trajectories: cancer, ALS, and CHF

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.

The Role of Gratitude in Spiritual Well-being in Asymptomatic Heart Failure Patients

Spirituality and gratitude are associated with wellbeing. Few if any studies have examined the role of gratitude in heart failure (HF) patients or whether it is a mechanism through which spirituality may exert its beneficial effects on physical and mental health in this clinical population. This study examined associations bet ween gratitude, spiritual wellbeing, sleep, mood, fatigue, cardiac-specific self-efficacy, and inflammation in 186 men and women with Stage B asymptomatic HF (age 66.5 years ±10). In correlational analysis, gratitude was associated with better sleep (r=-.25, p<0.01), less depressed mood (r=-.41, p<0.01), less fatigue (r=-.46, p<0.01), and better self-efficacy to maintain cardiac function (r=.42, p<0.01). Patients expressing more gratitude also had lower levels of inflammatory biomarkers (r=-.17, p<0.05). We further explored relationships among these variables by examining a putative pathway to determine whether spirituality exerts its beneficial effects through gratitude. We found that gratitude fully mediated the relationship between spiritual wellbeing and sleep quality (z=-2.35, SE=.03, p=.02) and also the relationship between spiritual wellbeing and depressed mood (z=-4.00, SE=.075, p<.001). Gratitude also partially mediated the relationships between spiritual wellbeing and fatigue (z=-3.85, SE=.18, p<.001), and between spiritual wellbeing and self-efficacy (z=2.91, SE=.04, p=.003). In sum, we report that gratitude and spiritual wellbeing are related to better mood and sleep, less fatigue, and more self-efficacy, and that gratitude fully or partially mediates the beneficial effects of spiritual wellbeing on these endpoints. Efforts to increase gratitude may be a treatment for improving wellbeing in HF patients' lives and be of potential clinical value.

Assessing patient preferences in heart failure using conjoint methodology

AIM

The course of heart failure (HF) is characterized by frequent hospitalizations, a high mortality rate, as well as a severely impaired health-related quality of life (HRQoL). To optimize disease management, understanding of patient preferences is crucial. We aimed to assess patient preferences using conjoint methodology and HRQoL in patients with HF.

METHODS

Two modules were applied: an initial qualitative module, consisting of in-depth interviews with 12 HF patients, and the main quantitative module in 300 HF patients from across Germany. Patients were stratified according to the time of their last HF hospitalization. Each patient was presented with ten different scenarios during the conjoint exercise. Additionally, patients completed the generic HRQoL instrument, EuroQol health questionnaire (EQ-5D™).

RESULTS

The attribute with the highest relative importance was dyspnea (44%), followed by physical capacity (18%). Of similar importance were exhaustion during mental activities (13%), fear due to HF (13%), and autonomy (12%). The most affected HRQoL dimensions according to the EQ-5D questionnaire were anxiety/depression (23% with severe problems), pain/discomfort (19%), and usual activities (15%). Overall average EQ-5D score was 0.39 with stable, chronic patients (never hospitalized) having a significantly better health state vs the rest of the cohort.

CONCLUSION

This paper analyzed patient preference in HF using a conjoint methodology. The preference weights resulting from the conjoint analysis could be used in future to design HRQoL questionnaires which could better assess patient preferences in HF care.

Depressive symptoms and spiritual wellbeing in asymptomatic heart failure patients

Depression adversely predicts prognosis in individuals with symptomatic heart failure. In some clinical populations, spiritual wellness is considered to be a protective factor against depressive symptoms. This study examined associations among depressive symptoms, spiritual wellbeing, sleep, fatigue, functional capacity, and inflammatory biomarkers in 132 men and women with asymptomatic stage B heart failure (age 66.5 years ± 10.5). Approximately 32 % of the patients scored ≥10 on the Beck Depression Inventory, indicating potentially clinically relevant depressive symptoms. Multiple regression analysis predicting fewer depressive symptoms included the following significant variables: a lower inflammatory score comprised of disease-relevant biomarkers (p < 0.02), less fatigue (p < 0.001), better sleep (p < 0.04), and more spiritual wellbeing (p < 0.01) (overall model F = 26.6, p < 0.001, adjusted R square = 0.629). Further analyses indicated that the meaning (p < 0.01) and peace (p < 0.01) subscales, but not the faith (p = 0.332) subscale, of spiritual wellbeing were independently associated with fewer depressive symptoms. Interventions aimed at increasing spiritual wellbeing in patients lives, and specifically meaning and peace, may be a potential treatment target for depressive symptoms asymptomatic heart failure.

Understanding the epidemic of heart failure: past, present, and future

Heart failure (HF) is a major public health problem affecting more than five million Americans and more than 23 million patients worldwide. The epidemiology of HF is evolving. Data suggests that the incidence of HF peaked in the mid-1990s and has since declined. Survival after HF diagnosis has improved, leading to an increase in prevalence. The case mix is also changing, as a rising proportion of patients with HF have preserved ejection fraction and multimorbidity is increasingly common. After diagnosis, HF can have a profound associated morbidity. Hospitalizations in HF remain both frequent and costly, though they may be declining as a result of preventive efforts. The need for skilled nursing facility care in HF has risen. The role of palliative medicine in the care of patients with advanced HF is evolving as we learn how to best care for this population with a large symptom burden.

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.

The beneficial role of spiritual counseling in heart failure patients

To ascertain the beneficial role of spiritual counseling in patients with chronic heart failure. This is a pilot study evaluating the effects of adjunct spiritual counseling on quality of life (QoL) outcomes in patients with heart failure. Patients were assigned to "religious" or "non-religious" counseling services based strictly on their personal preferences and subsequently administered standardized QoL questionnaires. A member of the chaplaincy or in-house volunteer organization visited the patient either daily or once every 2 days throughout the duration of their hospitalization. All patients completed questionnaires at baseline, at 2 weeks, and at 3 months. Each of the questionnaires was totaled, with higher scores representing positive response, except for one survey measure where lower scores represent improvement (QIDS-SR16). Twenty-three patients (n = 23, age 57 ± 11, 11 (48 %) male, 12 (52 %) female, mean duration of hospital stay 20 ± 15 days) completed the study. Total mean scores were assessed on admission, at 2 weeks and at 3 months. For all patients in the study, the mean QIDS-SR16 scores were 8.5 (n = 23, SD = 3.3) versus 6.3 (n = 18, SD = 3.5) versus 7.3 (n = 7, SD = 2.6). Mean FACIT-Sp-Ex (version 4) scores were 71.1 (n = 23, SD = 15.1) versus 74.7 (n = 18, SD = 20.9) versus 81.4 (n = 7, SD = 8.8). The mean MSAS scores were 2.0 (n = 21, SD = 0.6) versus 1.8 (n = 15, SD = 0.7) versus 2.5 (n = 4, SD = 0.7). Mean QoL Enjoyment and Satisfaction scores were 47.2 % (n = 23, SD = 15.0 %) versus 53.6 % (n = 18, SD = 16.4 %) versus 72.42 % (n = 7, SD = 22 %). The addition of spiritual counseling to standard medical management for patients with chronic heart failure patients appears to have a positive impact on QoL.

Spiritual wellbeing of Iranian patients with acute coronary syndromes: a cross-sectional descriptive study

Spiritual wellbeing harmonises several dimensions of human life and is essential for coping with diseases. Acute coronary syndromes (ACS) cause crisis in physical, psychological aspects and spiritual dimensions of patients’ lives. The purpose of this study was to determine the level of spiritual wellbeing and its dimensions in patients with ACS. For this, a cross-sectional descriptive study was conducted. For data collection, Paloutzian and Ellison’s Spiritual Wellbeing Self-report Questionnaire was filled in by 364 patients with ACS. Patients referred to the cardiac wards of five teaching hospitals in Tehran between August 2011 and April 2012 were recruited using the convenience sampling method. The data were analysed using descriptive and inferential statistics. The findings revealed that the majority of patients (97.9%) benefited from moderate spiritual wellbeing, although religious wellbeing was higher than existential wellbeing in the patients. It is concluded that nurses are required to improve their cultural and contextual knowledge of patients’ spiritual wellbeing to meet patients’ needs in nursing care. Spiritual beliefs can influence coping with diseases, help patients to find meaning and purpose in life to deal with problems resulting from physical and mental illnesses. These findings can be used to suggest the incorporation of religious aspects of spirituality into care programmes designed to improve the quality of life of patients with ACS.

[Palliative care for patients with heart failure]

PURPOSE

Heart failure is a common disease and its progression to end-stage heart failure is responsible of high mortality. The aim of this retrospective study was to assess the access to integrated palliative care to the usual management, 6 months prior to their death, and especially during the last hospitalization.

PATIENTS AND METHODS

A retrospective study was performed in patients who died of heart failure in 2009 in two hospitals. The analysis was performed on 20 cases of each institution. The records of consecutive patients were included in an anti-chronological order from 31st December 2009.

RESULTS

For their last hospitalization, 37 patients (93%) were hospitalized in emergency. Within 3 days prior to death, the most frequent symptoms were dyspnea (n=33, 82%), and pain (n=30, 75%). Therapeutic most frequently used were oxygen (n=31, 77%) and analgesics (n=30, 75%). No patient was seen by a psychologist. The decision to limit treatment for comfort care was reported for 24 patients (60%) and the median of the average time between the decision and death was 2 days (Q1-Q3, 1-5 days).

CONCLUSION

Patients with terminal heart failure have many symptoms often requiring multidisciplinary care. This type of study relating practices shows that there is still a lot to do to integrate palliative care in the usual management of patients with heart failure.