201
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McClung JA. End-of-life care in the treatment of heart failure in the elderly. Heart Fail Clin 2007; 3:539-47. [PMID: 17905388 DOI: 10.1016/j.hfc.2007.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Much of the literature dedicated to the topic of medical care of dying patients has revolved around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.
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Affiliation(s)
- John Arthur McClung
- Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
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202
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Abstract
Optimum heart failure medication and an increasing array of interventions have had an enormous effect on morbidity and mortality over the past 10 years. However, patients with end stage disease can still be highly symptomatic. Moreover, such patients are disadvantaged compared with patients with malignant disease. They are less likely to have an understanding of their illness or have access to supportive care. They are also less likely to have the opportunity to plan for care with regard to death and dying. There is increasing demand that the multi-professional clinical team gain good communication and supportive care skills, and that appropriate access to specialist palliative care services is available.
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203
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Rainone F, Blank A, Selwyn PA. The early identification of palliative care patients: preliminary processes and estimates from urban, family medicine practices. Am J Hosp Palliat Care 2007; 24:137-40. [PMID: 17502439 DOI: 10.1177/1049909106296973] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Primary care providers are positioned to identify patients, well in advance of their deaths, who could benefit from palliative care services, but little is known about how to correctly identify these upstream palliative care patients. This article reports on efforts to devise a methodology for identifying such patients and to offer preliminary estimates of their prevalence in urban, primary care practices. The data presented here suggest 2 conclusions: (1) that electronic databases may be used to create a preliminary screen to assist clinicians in the early identification of patients in need of palliative care, and (2) that 1% to 3% of patients in primary care practices may benefit from palliative care services. Currently, there are no standards regarding the role of primary care providers in end-of-life care and it is hoped that this article will contribute to developing such standards.
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Affiliation(s)
- Francine Rainone
- Palliative Care, Abington Memorial Hospital, Abington, Pennsylvania 19001, USA.
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204
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Metra M, Ponikowski P, Dickstein K, McMurray JJ, Gavazzi A, Bergh CH, Fraser AG, Jaarsma T, Pitsis A, Mohacsi P, Böhm M, Anker S, Dargie H, Brutsaert D, Komajda M. Advanced chronic heart failure: A position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2007; 9:684-94. [DOI: 10.1016/j.ejheart.2007.04.003] [Citation(s) in RCA: 222] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 03/05/2007] [Accepted: 04/18/2007] [Indexed: 10/23/2022] Open
Affiliation(s)
- Marco Metra
- Section of Cardiovascular Diseases, Department of Experimental and Applied Medicine; University of Brescia; Italy
| | | | - Kenneth Dickstein
- Cardiology Division, University of Bergen; Stavanger University Hospital; Stavanger Norway
| | | | - Antonello Gavazzi
- Department of Cardiology; Ospedali Riuniti di Bergamo; Bergamo Italy
| | - Claes-Hakan Bergh
- Department of Cardiology; Sahlgrenska University Hospital/Sahlgrenska; Göteborg Sweden
| | - Alan G. Fraser
- Department of Cardiology, Wales Heart Research Institute; University of Wales College of Medicine; Cardiff UK
| | - Tiny Jaarsma
- Department of Cardiology, Programme Coördinator COACH; University Hospital Groningen; Groningen The Netherlands
| | - Antonis Pitsis
- Department of Cardiac Surgery; St. Luke's Hospital; Panorama Thessaloniki Greece
| | - Paul Mohacsi
- Swiss Cardiovascular Center Bern Head Heart Failure & Cardiac Transplant.; University Hospital (Inselspital); Bern Switzerland
| | - Michael Böhm
- Innere Medizin III, Universitätskliniken des Saarlandes; Homburg/Saar Germany
| | - Stefan Anker
- Applied Cachexia Research, Department of Cardiology; Charité Campus Virchow-Klinikum; Berlin Germany
- Clinical Cardiology; NHLI, Imperial College; London UK
| | - Henry Dargie
- Cardiac Department; Western Infirmary; Glasgow Scotland UK
| | - Dirk Brutsaert
- Department of Cardiology, A.Z. Middellheim Hospital; Univ. of Antwerp; Antwerp Belgium
| | - Michel Komajda
- Département de Cardiologie; Pitié Salpêtrière Hospital; Paris Cedex 13 France
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205
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206
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Abstract
Heart failure (HF) is a cardiovascular disease with a permanent increase in prevalence, incidence and mortality. Current optimal therapies for HF are effective only for slowing, but not stopping, its progression. HF-related mortality is high, even at the time of the disease onset. Approximately 40% of HF-attributable deaths will be related to disease progression - however, its course is difficult to predict and therefore identifying patients experiencing the terminal stage of the disease is not correctly done. Most patients and their relatives do not identify HF as a progressive, terminal disease, and this perception also stands among health professionals - in consequence, end-stage HF patients often undergo active treatment procedures, event near the occurrence of death, although its implementation will be occasionally futile. Efforts should be undertaken by all health professionals to improve the identification and management of HF patients in the terminal stage of their disease.
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Affiliation(s)
- Francesc Formiga
- UFISS Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
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207
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Abstract
This paper provides an evidence-based review of the principles underlying palliative care for heart failure (HF), including its pathogenesis, staging, assessment, prognosis, and treatment. Approaches to advanced care planning, symptom management, hospice eligibility, home inotropic infusions, device management and improving the continuum of care in HF are discussed. The reader will be able to recognize advanced HF, use important elements of physical assessment, utilize Web-based prognostic and risk-stratification models, facilitate advance care planning, ensure optimal treatment, manage common symptoms and comorbid conditions, determine hospice eligibility, and consider issues related to withholding or withdrawal of inotropic infusions and devices used in HF refractory to standard treatment. The ultimate goal of palliative care for heart failure is to integrate knowledge of treatment advances and comfort measures and to provide them concurrently in a seamless continuum to patients with late-stage disease.
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Affiliation(s)
- Brad Stuart
- Sutter VNA and Hospice, 1900 Powell Street, Emeryville, CA 94608, USA.
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208
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Zambroski CH. Managing beyond an uncertain illness trajectory: palliative care in advanced heart failure. Int J Palliat Nurs 2007; 12:566-73. [PMID: 17353842 DOI: 10.12968/ijpn.2006.12.12.22543] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A lack of comprehensive and effective palliative care is clearly evident in a number of studies describing the end of life for patients with advanced heart failure. These patients have been portrayed as experiencing a wide array of poorly managed symptoms. The primary rationale for the lack of care has been the uncertain illness trajectory that characterizes living with advanced heart failure. Nurses must manage care beyond the illness trajectory from an emphasis of palliative care as each of these patients may face significant illness burden and even sudden death. The purpose of this paper is to: discuss the current status of palliative care for patients with advanced heart failure; explain the basic pathophysiology and resulting signs and symptoms of advanced heart failure; describe pharmacological and non-pharmacological symptom management strategies for patients with advanced heart failure.
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209
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Bernabéu-Wittel M, García-Morillo S, González-Becerra C, Ollero-Baturone M, Fernández A, Cuello-Contreras J. Réplica. Rev Clin Esp 2007. [DOI: 10.1016/s0014-2565(07)73340-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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210
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Abstract
Much of the literature dedicated to the topic of medical care of dying patients has revolves around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.
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Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
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211
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Affiliation(s)
- Gary M Reisfield
- Community Health and Family Medicine, University of Florida College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA.
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212
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Carter CL, Zapka JG, O'Neill S, DesHarnais S, Hennessy W, Kurent J, Carter R. Physician perspectives on end-of-life care: factors of race, specialty, and geography. Palliat Support Care 2007; 4:257-71. [PMID: 17066967 DOI: 10.1017/s1478951506060330] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care. DESIGN AND METHODS Twenty-four African-American and 16 Caucasian physicians (N=40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties. RESULTS Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication. SIGNIFICANCE OF RESULTS Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.
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Affiliation(s)
- Cindy L Carter
- Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas Street, Charleston, SC 29425, USA.
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213
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Hauser JM, Bonow RO. Heart Failure. Palliat Care 2007. [DOI: 10.1016/b978-141602597-9.10023-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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214
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Nordgren L, Asp M, Fagerberg I. Living with moderate-severe chronic heart failure as a middle-aged person. QUALITATIVE HEALTH RESEARCH 2007; 17:4-13. [PMID: 17170239 DOI: 10.1177/1049732306296387] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
In this article the authors describe a study focusing on middle-aged persons living with chronic heart failure (CHF), a group with which few studies have been conducted. They used the lifeworld perspective to focus on persons' lived experiences of the phenomenon, that is, living with moderate-severe CHF as a middle-aged person. They interviewed 7 middle-aged persons (4 men, 3 women; aged 38 to 65 years) and analyzed the data obtained using a phenomenological approach. The phenomenon's essence is described as a life situation characterized by a failing body, a life constantly under threat, a rapidly changing health condition, and an altered self-image, which implies that the persons live in a changed life situation. The essence was further illuminated by three meaning constituents: an ambiguity of the body, losing track of life, and balancing life. Knowledge from this study will help caregivers understand and support patients with this debilitating condition.
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Affiliation(s)
- Lena Nordgren
- School of Health Sciences, Växjö University, Växjö, Sweden
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215
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Gérvasa J. [Strengthening primary care to improve the monitoring of heart failure in developed countries]. Aten Primaria 2006; 37:457-9. [PMID: 16756846 PMCID: PMC7679887 DOI: 10.1157/13088887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- J Gérvasa
- Medicina General, Fundación para la Formación de la Organización Médica Colegial, Equipo CESCA, Madrid, España.
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216
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Sullivan MD, O'Meara ES. Heart failure at the end of life: symptoms, function, and medical care in the Cardiovascular Health Study. ACTA ACUST UNITED AC 2006; 15:217-25. [PMID: 16849887 DOI: 10.1111/j.1076-7460.2006.05196.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Among Cardiovascular Health Study participants who died from coronary heart disease, the authors compared those with incident and definite congestive heart failure (CHF) (n=60; 15%) and those with prevalent or probable CHF (n=70; 17.5%) to those with no history of CHF (n=198; 50%) concerning health status at the end of life. Both CHF groups had worse health status before death than the group without CHF. Patients in the CHF groups were more likely to use benzodiazepines (20% and 19% vs. 6%; p=0.001) and to rate their health as fair or poor (68% and 63% vs. 41%; p<0.001). They were more likely to be hospitalized (33% and 28% vs. 11%; p<0.001), to have activity restrictions (79% and 62% vs. 38%; p<0.001), and to report a wide array of physical symptoms. These data suggest that patients who die from coronary heart disease in the presence of CHF have greater need for hospice or palliative care than those with no history of CHF.
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Affiliation(s)
- Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA.
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217
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Godfrey C, Harrison MB, Medves J, Tranmer JE. The symptom of pain with heart failure: a systematic review. J Card Fail 2006; 12:307-13. [PMID: 16679265 DOI: 10.1016/j.cardfail.2006.01.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Revised: 12/01/2005] [Accepted: 01/10/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pain is one of the most compelling reasons for seeking medical attention. Despite frequent hospitalizations and assessments, the symptom of pain is not often associated with heart failure (HF). The role of pain in exacerbations and hospitalization may be important. A systematic review to synthesize research related to reported pain in patients with HF was undertaken and factors considered to be related to the symptom of pain in this population were identified. METHODS AND RESULTS Relevant articles were identified using MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Included studies focused on patients with HF and reporting on pain. Nine descriptive studies were identified. Five studies focused specifically on patients with HF. The remaining studies examined a population of seriously ill patients including those with HF as an itemized subset. From 23% to 75% of patients with HF reported pain. Factors identified as related to pain include: anxiety, depression, quality of life rated as poor, dyspnea, and more dependencies in activities of daily living. CONCLUSION People with HF report having pain but as a complex health group, the symptom of pain is not well understood. Pain could be a contributing factor in the breakdown of self-management and the cycle of exacerbations and hospitalization.
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Affiliation(s)
- Christina Godfrey
- Queen's University, Faculty of Health Sciences, School of Nursing, Ontario, Canada
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218
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Abstract
Heart failure affects approximately 5 million Americans, half of whom are at least 75 years of age, and is the leading cause of hospital admission among older adults. Additionally, the prevalence of heart failure is increasing, largely owing to the aging of the population. Heart failure in older adults differs in many respects from heart failure that occurs during middle age, including an increased proportion of women, increasing prevalence of heart failure with preserved left ventricular systolic function, and a marked increase in the number of coexisting medical conditions. In light of these factors, this article reviews the epidemiology, pathophysiology, clinical features, and treatment of heart failure in older adults.
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Affiliation(s)
- Michael W Rich
- Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St. Louis, MO 63110, USA.
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219
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Abstract
AIMS To describe English specialist palliative care (SPC) services' provision for, and attitude to, heart failure patients, and to identify developments of particular interest or expertise in this area. METHOD Postal survey of all lead consultants of English SPC services, September 2004. RESULTS Of 397 services, 233 replied (response rate 59%); 222 (95%) thought SPC had a role in severe/end stage heart failure, while three (1%) did not. A total of 197 services (85%) accepted heart failure patients, 26 (11%) did not. The most common reasons for not accepting heart failure patients were lack of resources or beds, implications for staff training or an organizational decision. The mean number of heart failure patients currently under a service was 2.2, but 15 had more than five (maximum 53). Fifteen services (6%) had specific referral criteria for heart failure patients, including recurrent hospital admissions without symptomatic improvement, inappropriateness of further hospital admission and severity of heart failure. Twelve services (5%) had or were developing treatment guidelines for heart failure: five were end of life pathways, three covered breathlessness management and three were symptom control guidelines. Some 137 services (59%) described local collaborative initiatives between SPC, heart failure services and primary care, such as mutual education, joint working and working groups. A number of models of joint working practices were described in detail. Twenty-seven (12%) knew of national initiatives. CONCLUSIONS The current situation of SPC services in England for patients with heart failure varies widely. One in 10 SPC services in this audit did not accept heart failure patients. Few have developed services of significant size. Local collaborative initiatives are common. Specific referral criteria and symptom control guidelines have been developed. Their role in promoting good palliative care in patients with heart failure remains unclear. Better dissemination of practical knowledge gained by these initiatives could significantly improve the provision of SPC services to heart failure patients.
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220
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Abstract
Palliative care aims to improve quality of life and relieve suffering for patients with advanced illness and those close to them by specifically addressing communication, symptom management, coordination of care, psychosocial and spiritual realms, grief and bereavement support, and legal and ethical concerns. It has an interdisciplinary focus and may co-exist with curative and life-prolonging treatment. Palliative care is a key component of appropriate, routine medical care, especially for clinicians caring for older adults. In revisiting Mrs. B, the many needs of a typical elderly patient are apparent, as are the gaps in the current level of care. A discussion of prognosis and goals of care is a potential starting point. This includes obtaining input from an oncologist with regard to treatment options for Mrs. B's metastatic breast cancer and her pathologic hip fracture. Soliciting her treatment goals in the context of her chronic obstructive pulmonary disease and significant recent decline is the next challenge. Pain, dyspnea, constipation, anorexia, and anxiety could then be addressed with pointed assessment and symptom-specific management. Code status discussion, communication with her support network, and care coordination for her increased care needs would follow. Hospice should be introduced as a potential option. Advance care planning might also be initiated. Psychological and spiritual support needs could also be explored in time. Clearly, there is much to be done for Mrs. B and her loved ones in clarifying and coordinating whatever path comes to be. Older patients and their families face prolonged courses of chronic disease and gradual decline. Physicians caring for these patients need to be expert in the domains of palliative care so these patients and their families can receive the best quality of care while they are still living full lives and later as they approach the end of life.
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Affiliation(s)
- Laura J Morrison
- Department of Medicine, Section of Geriatrics, Baylor College of Medicine, 1709 Dryden, Suite 850, Houston, TX 77030, USA.
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221
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Riegel B, Moser DK, Powell M, Rector TS, Havranek EP. Nonpharmacologic care by heart failure experts. J Card Fail 2006; 12:149-153. [PMID: 16520265 DOI: 10.1016/j.cardfail.2005.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Revised: 10/04/2005] [Accepted: 10/20/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nonpharmacologic clinical management practices have not been studied widely in heart failure (HF). The purpose of this survey was to describe the practices of self-identified experts in HF to identify: topics with uniformity of practice (> or =75% agreement) and topics with variability in practice (no uniformity and 2 or more choices endorsed by >/=10% of respondents). METHODS AND RESULTS An online survey of members of the Heart Failure Society of America (HFSA) actively engaged in clinical practice was conducted in Fall 2004. A total of 347 of the 1420 HFSA members in clinical practice (24.4%) responded to the survey. Of these, 321 completed the survey and 290 (90.3%) identified themselves as experts in HF. Areas in which there appears to be variability in practice include advising patients about: (1) sodium-restricted diet; (2) alcohol; (3) sexual activity; (4) increased swelling or weight gain, including use of a flexible diuretic regimen; and (5) palliative care. Providers vary in their treatment of risk factors and comorbid illnesses, the attention given to subtle losses of weight over time, beliefs about treatment adherence and ways to improve it, and opinions about the most important areas for patient education, and beliefs about health literacy. CONCLUSION Research on which to base advice for HF patients is greatly needed.
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Affiliation(s)
- Barbara Riegel
- School of Nursing, Leonard Davis Institute, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104, USA
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222
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Carter MW, Datti B, Winters JM. ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions. Am J Emerg Med 2006; 24:428-34. [PMID: 16787800 DOI: 10.1016/j.ajem.2005.12.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 12/15/2005] [Accepted: 12/17/2005] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine the effect of advanced age on ED outcomes, including hospitalization for any reason, ambulatory care-sensitive hospitalizations (ACSHs), and supply-sensitive hospitalizations. METHODS A secondary data analysis of the National Hospital Ambulatory Care Survey was conducted. National estimates of patient visits were obtained using available sampling weights from National Hospital Ambulatory Care Survey, and population estimates were calculated using estimates published by the US Census Bureau. RESULTS Older adults made 48 million patient visits to ED between 2000 and 2002. Overall, 20.3% was for an ambulatory care-sensitive condition, yielding 5 million ACSH, whereas 62% was for a supply-sensitive condition, yielding 9.5 million supply-sensitive hospitalizations. Residents from nursing homes and patients aged 85 years or older were more likely to be hospitalized for any reason, for ACSH, and for supply-sensitive conditions. CONCLUSIONS Further research is needed to understand how comorbidity contributes to increasing ED and hospital use among older adults.
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Affiliation(s)
- Mary W Carter
- Center on Aging, West Virginia University School of Medicine, Morgantown, WV 26506-9127, USA.
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223
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Affiliation(s)
- Karl A Lorenz
- Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA.
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224
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Agård A, Hermerén G, Herlitz J. When is a patient with heart failure adequately informed? A study of patients' knowledge of and attitudes toward medical information. Heart Lung 2006; 33:219-26. [PMID: 15252411 DOI: 10.1016/j.hrtlng.2004.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The primary aim was to explore patients' knowledge of heart failure and their attitudes toward medical information (prognostic information in particular) and to assess different patient-related factors that might hamper the improvement of patients' knowledge. Moreover, taking the data obtained into account, we analyzed ethical aspects of information disclosure to patients with heart failure. SETTING The study was performed at Sahlgren's University Hospital in Gothenburg, Sweden. DESIGN The study was a qualitative analysis of semistructured interviews. PATIENTS The sample included 40 patients with various stages of chronic heart failure. RESULTS Many patients had only a limited understanding of their disease, but they still claimed that they were satisfied with the information they received. Some of them seemed to accept, to be indifferent to, or to be unaware of their low level of knowledge. The majority did not request prognostic information. CONCLUSION We argue that patients with heart failure are adequately informed when they have reached the level of knowledge that enables them to be managed as effectively and securely as possible while being satisfied with the information provided. To give adequate information, health care providers should determine the patients' level of knowledge and explore why those patients who have a limited understanding do not assimilate or request information.
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Affiliation(s)
- Anders Agård
- Department of Medicine, Sahlgren's University Hospital, Gothenburg, Sweden
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225
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Knops KM, Srinivasan M, Meyers FJ. Patient desires: A model for assessment of patient preferences for care of severe or terminal illness. Palliat Support Care 2006; 3:289-99. [PMID: 17039984 DOI: 10.1017/s1478951505050455] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective:Patient-centered care is better achieved through a comprehensive understanding of patients' preferences for how they want to live their life and how they want to influence their own death. Though much has been written on identifying goals of care, it is often difficult for clinicians to articulate patient goals to guide care planning. We explored the literature on patient's preferences for their care in chronic or life-limiting illness to develop a model for assessment of patient perspectives. We then illustrated our model with composite patients from our clinics and we provide questions to guide patient discussion.Methods:We searched MEDLINE from 1986 to 2004 for primary research articles that relate primarily to a patient's preferences for his or her care. We reviewed over 3500 titles, abstracts, and research papers. Hundreds of articles described patients' quality of life, health status, or satisfaction. We excluded consensus guidelines, non-English papers, reviews, and articles focused on medical professional perspectives. Forty-eight studies focused primarily on patient preferences. Using an iterative process, we identified unique issues and broader themes in patients' desires for their care.Results:Studies focused on patients with cancer, those in hospice or those with terminal disease. Three domains emerged: patient feelings about disease, feelings about suffering, and feelings about the circumstances of death. Attention was given to the differences between patients in terms of the strength and persistence of feelings in each domain.Significance of results:Based on existing data, there are three fundamental domains of patient perspective that influence preferences for care. These domains can be assessed by the care team to guide the development of a plan of care and to identify areas of conflict. Our review identifies gaps in the end-of-life literature and areas for future work in patient preferences.
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Affiliation(s)
- Karen M Knops
- Department of Medicine, University of California, Davis Medical Center, Sacramento, California, USA.
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226
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Hooley PJD, Butler G, Howlett JG. The relationship of quality of life, depression, and caregiver burden in outpatients with congestive heart failure. ACTA ACUST UNITED AC 2006; 11:303-10. [PMID: 16330905 DOI: 10.1111/j.1527-5299.2005.03620.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Primary caregivers of patients with congestive heart failure withstand enormous burden, often sacrificing their own quality of life. The relationship between caregiver burden and depression and patient quality of life and depression in this setting is unknown. Fifty outpatients were prospectively administered the Minnesota Living with Heart Failure Questionnaire and Beck Depression Inventory II (BDI-II). Caregivers were administered the Zarit Caregiver Burden Interview and BDI-II. The mean quality of life score was 35, and 26% had a BDI-II score >10. The mean Zarit Caregiver Burden Interview score was 16. Minnesota Living with Heart Failure Questionnaire, BDI-II, and Zarit Caregiver Burden Interview scores were all associated with lower ejection fraction, need for hospitalization, increased number of medications, and comorbidities. Patient Minnesota Living with Heart Failure Questionnaire score correlated with patient BDI-II, caregiver BDI-II, and Zarit Caregiver Burden Interview scores. Caregiver burden score correlated with both caregiver BDI-II and patient BDI-II. Death or hospitalization at 6 months was associated with caregiver burden and depressive symptoms and with patient quality of life and depressive symptoms. Caregivers of patients with congestive heart failure experience high caregiver burden and prevalence of depressive symptoms, which are related to the patient disease burden.
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Affiliation(s)
- Peter J D Hooley
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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227
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Gérvas J. Sustitución de la primaria por la especializada. Algunas cuestiones en torno al seguimiento de los pacientes con insuficiencia cardíaca. Semergen 2006. [DOI: 10.1016/s1138-3593(06)73236-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Willems DL, Hak A, Visser FC, Cornel J, van der Wal G. Patient work in end-stage heart failure: a prospective longitudinal multiple case study. Palliat Med 2006; 20:25-33. [PMID: 16482755 DOI: 10.1191/0269216306pm1095oa] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The most recent WHO definition of palliative care regards living as actively as possible as an important aim. We explored, over a 1-year period, the work this involves for patients with end-stage heart failure. DESIGN Prospective longitudinal multiple case study using qualitative interview techniques. PARTICIPANTS Thirty-one respondents from two hospitals who fulfilled one or more of the following criteria: NYHA III or IV, ejection fraction <25%, at least one hospitalization for heart failure. MAIN OUTCOMES Types and content of patient work involved in living with end-stage heart failure. RESULTS For patients with advanced heart failure, work consisted mainly of four types of tasks, as identified by Glaser and Strauss: 'managing illness', 'everyday work to keep life going', 'biographical work' and 'arrangement work'. CONCLUSIONS Systematic attention to patient work, for example using these four categories, could improve the quality of care from the patient's perspective.
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Affiliation(s)
- D L Willems
- Department of General Practice, Academic Medical Centre/University of Amsterdam, The Netherlands.
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230
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Charette SL. The Next Step: Palliative Care for Advanced Heart Failure. J Am Med Dir Assoc 2006; 7:63-4. [PMID: 16413438 DOI: 10.1016/j.jamda.2005.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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231
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Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006; 31:58-69. [PMID: 16442483 DOI: 10.1016/j.jpainsymman.2005.06.007] [Citation(s) in RCA: 735] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2005] [Indexed: 11/27/2022]
Abstract
Little attention has been paid to the symptom management needs of patients with life-threatening diseases other than cancer. In this study, we aimed to determine to what extent patients with progressive chronic diseases have similar symptom profiles. A systematic search of medical databases (MEDLINE, EMBASE, and PsycINFO) and textbooks identified 64 original studies reporting the prevalence of 11 common symptoms among end-stage patients with cancer, acquired immunodeficiency syndrome (AIDS), heart disease, chronic obstructive pulmonary disease, or renal disease. Analyzing the data in a comparative table (a grid), we found that the prevalence of the 11 symptoms was often widely but homogeneously spread across the five diseases. Three symptoms-pain, breathlessness, and fatigue-were found among more than 50% of patients, for all five diseases. There appears to be a common pathway toward death for malignant and nonmalignant diseases. The designs of symptom prevalence studies need to be improved because of methodological disparities in symptom assessment and designs.
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Affiliation(s)
- Joao Paulo Solano
- Division of Internal Medicine, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
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232
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Brush S, Zambroski CH, Rasmusson K. Palliative care for the patient with end-stage heart failure. PROGRESS IN CARDIOVASCULAR NURSING 2006; 21:166-70. [PMID: 16957466 DOI: 10.1111/j.0889-7204.2006.05320.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Sally Brush
- Heart Failure Prevention and Treatment Program, LDS Hospital, Salt Lake City, UT 84103, USA.
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233
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Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005; 46:e1-82. [PMID: 16168273 DOI: 10.1016/j.jacc.2005.08.022] [Citation(s) in RCA: 1123] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs 2005; 4:198-206. [PMID: 15916924 DOI: 10.1016/j.ejcnurse.2005.03.010] [Citation(s) in RCA: 296] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Accepted: 03/31/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Heart failure is an escalating health problem around the world. Despite significant scientific advances, heart failure patients experience multiple physical and psychological symptoms that can impact the quality of life. AIMS To determine the (1) symptom prevalence, severity, distress and symptom burden in patients with heart failure; (2) impact of age and gender on symptom prevalence, severity, distress and symptom burden; and (3) impact of symptom prevalence and symptom burden on health-related quality of life (HRQOL) in patients with heart failure. METHODS A convenience sample of 53 heart failure patients participated in this descriptive, cross-sectional design. Symptoms and HRQOL were measured using the Memorial Symptom Assessment Scale-Heart Failure and the Minnesota Living with Heart Failure Questionnaire. RESULTS Patients experienced a mean of 15.1+/-8.0 symptoms. Shortness of breath and lack of energy were the most prevalent. Difficulty sleeping was the most burdensome symptom. Lower age, worse functional status, total symptom prevalence and total symptom burden predicted 67% of the variance in HRQOL. CONCLUSION Patients with heart failure experience a high level of symptoms and symptom burden. Nurses should target interventions to decrease frequency, severity, distress and overall symptom burden and improve HRQOL.
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235
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Rabow MW, Dibble SL. Ethnic differences in pain among outpatients with terminal and end-stage chronic illness. PAIN MEDICINE 2005; 6:235-41. [PMID: 15972087 DOI: 10.1111/j.1526-4637.2005.05037.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore ethnic and country of origin differences in pain among outpatients with terminal and end-stage chronic illness. DESIGN Cohort study within a year-long trial of a palliative care consultation. SETTING Outpatient general medicine practice in an academic medical center. PATIENTS Ninety patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer, and with a prognosis between 1 and 5 years. OUTCOME MEASURES Patients' report of pain using the Brief Pain Inventory and analgesic medications prescribed by primary care physicians. Differences in pain report and treatment were assessed at study entry, at 6 and 12 months. RESULTS The overall burden of pain was high. Patients of color reported more pain than white patients, including measures of least pain (P = 0.02), average pain (P = 0.05), and current pain (P = 0.03). No significant ethnic group differences in pain were found comparing Asian, black, and Latino patients. Although nearly all patients who were offered opioid analgesics reported using them, opioids were rarely prescribed to any patient. There were no differences in pain between patients born in the U.S. and immigrants. CONCLUSIONS Pain is common among outpatients with both terminal and end-stage chronic illness. There do not appear to be any differences in pain with regard to country of origin, but patients of color report more pain than white patients. Patients of all ethnicities are inadequately treated for their pain, and further study is warranted to explore the relative patient and physician contributions to the finding of unequal symptom burden and inadequate treatment effort.
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Affiliation(s)
- Michael W Rabow
- Department of Medicine, The University of California, San Francisco, California 94115, USA.
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236
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005; 112:e154-235. [PMID: 16160202 DOI: 10.1161/circulationaha.105.167586] [Citation(s) in RCA: 1524] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Heart failure is growing in prevalence. Despite an array of treatments targeting a complicated pathophysiology, heart failure ultimately leads to death, and thus there is a clear need to provide palliative care to persons with end-stage heart failure. Palliative care, or education and support of the patient and family and management of distressing symptoms, should be provided throughout the course of the illness. Clinicians need additional information about how to palliate symptoms in advanced heart failure. This article summarizes recent reports about prognostication and identification of patients who are likely to die soon, and the management of fatigue, dyspnea, pain, and depression in heart failure. Palliative care or supportive care of the patient and family should be incorporated into comprehensive care throughout the course of heart failure. Data about hospice care for persons with heart failure are summarized.
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Affiliation(s)
- Sarah J Goodlin
- Institute for Health Care Delivery Research, Intermountain Health Care and Patient-centered Education and Research, 681 East 17th Avenue, Salt Lake City, UT 84103, USA.
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238
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Goldstein NE, Morrison RS. The Intersection Between Geriatrics and Palliative Care: A Call for a New Research Agenda. J Am Geriatr Soc 2005; 53:1593-8. [PMID: 16137293 DOI: 10.1111/j.1532-5415.2005.53454.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Palliative care is interdisciplinary treatment focused on the relief of suffering and achieving the best possible quality of life for patients and their caregivers. It differs for geriatric patients from what is usually appropriate in a younger population because of the nature and duration of chronic illness during old age. In spite of the fact that death occurs far more commonly in older people than in any age group, the evidence base for palliative care in older adults is sparse. Over the coming years, the research foci in the field of geriatrics and palliative care that must be addressed include establishing the prevalence of symptoms in patients with chronic disease; evaluating the association between treatment of symptoms and outcomes; increasing the evidence base for treatment of symptoms; understanding psychological well-being, spiritual well-being, and quality of life of patients and elucidating and alleviating sources of caregiver burden; reevaluating service delivery; adapting research methodologies specifically for geriatric palliative care; and increasing the number of geriatricians trained as investigators in palliative care research. This article discusses specific methods to improve the current situation within each of these seven areas.
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Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Adult Development, The Mount Sinai Medical Center, New York, New York 10029, USA
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239
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Borbasi S, Wotton K, Redden M, Champan Y. Letting go: a qualitative study of acute care and community nurses' perceptions of a ‘good’ versus a ‘bad’ death. Aust Crit Care 2005. [DOI: 10.1016/s1036-7314(05)80011-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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240
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241
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Mast KR, Salama M, Silverman GK, Arnold RM. End-of-life content in treatment guidelines for life-limiting diseases. J Palliat Med 2005; 7:754-73. [PMID: 15684843 DOI: 10.1089/jpm.2004.7.754] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical guidelines are systematically developed statements that influence medical practice, education, and funding. Guidelines represent the consensus of leaders, often based on systematic reviews of the literature, regarding the "state of the art." OBJECTIVE To assess the degree to which end-of-life care is integrated into nationally developed guidelines for chronic, noncurable, life-limiting diseases. DESIGN Four compendia were reviewed: The Healthcare Standards Directory ECRI, 2001; the Clinical Practice Guidelines Directory, 2000 edition; the National Guidelines Clearinghouse, (guideline.gov); and the National Library of Medicine's MEDLINE database on the OVID platform for guidelines on nine chronic diseases (chronic obstructive pulmonary disease, end-stage liver disease, amyotrophic lateral sclerosis, congestive heart failure, dementia, cerebrovascular accident, end-stage renal disease, cancer [breast, colon, prostate, lung], and human immunodeficiency virus). They were assessed by two reviewers for end-of-life content in 15 domains (e.g., epidemiology of death, symptom management, spiritual, family roles, and settings of care), the presence of eight specific terms dealing with palliative care, integration of palliative care information into the guideline, and descriptive variables. SETTING/SUBJECTS Not available. MEASUREMENTS Each guideline was examined and rated on a 0-2 scale (0, absent content; 1, minimal content; 2, helpful content) using 15 end-of-life content domains. Scores from domains were summed and classified into 3 categories: 4 or less, minimal; 5-12, moderate; and more than 12, significant content. RESULTS Ten percent of guidelines had significant palliative care content, 64% had minimal content, and 26% had moderate content. The least addressed domains dealt with spirituality, ethics, advocacy and family roles. When guidelines that dealt solely with prevention, acute exacerbations or complications of an illness, or specific treatment modalities were excluded 28% and 16% of these general guidelines (n = 58) had moderate and significant palliative care content, respectively, compared to 24% and 0% of all nongeneral guidelines. Similar results were found when analyzing the data by disease course or treatment focus. Only 14% of guidelines advised physicians to consider palliative care at a specific point in the disease course. Ninety-one percent of the guidelines mentioned death, dying, end of life, mortality, or terminal illness but only 36% mentioned palliation or hospice. CONCLUSION Current national guidelines on nine chronic, life-limiting illnesses offer little guidance in end-of-life care issues despite a recent increase in attention to this aspect of medical care.
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Affiliation(s)
- Kimberly R Mast
- McAuley Medical Associates, Mercy Hospital, Pittsburgh, Pennsylvania, USA
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242
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Affiliation(s)
- Scott A Murray
- Division of Community Health Sciences, General Practice Section, University of Edinburgh, Edinburgh EH8 9DX.
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243
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Abstract
BACKGROUND Patients with end-stage heart failure experience disability, dyspnea, pain, and suffering at the end of life despite progress in treatment approaches. Little is known about the patients with heart failure in hospice and the impact of hospice care on health-related outcomes. METHODS AND RESULTS The purposes of this retrospective, descriptive chart review were to (1) describe the characteristics of patients who receive hospice care, (2) identify symptoms most commonly reported by patients with heart failure in hospice during the last 7 days of life, and (3) identify interventions used by hospice nurses to manage the symptoms. The majority of the patients were women, widowed, and white. Median length of stay was 10 days. Nearly 37% of the patients were admitted to hospice during the last week of life. Primary symptoms at admission for hospice care included dyspnea, confusion at least some of the time, and poor appetite. There was no statistically significant difference in symptoms between the day of admission for hospice care and the day of death. Symptom management strategies included oxygen, family reassurance or education, skin care, and patient education. Medications commonly used to relieve symptoms included antianxiety medications, morphine, and/or other narcotics. Although mainstay heart failure drugs had been prescribed for some patients, prescription rates were low and not in line with current guideline recommendations, nor were those medications recorded as being used for symptom management. CONCLUSION Further research including prospective study is needed to clearly articulate the impact of hospice care on patients and families affected by heart failure.
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Segal DI, O'Hanlon D, Rahman N, McCarthy DJ, Gibbs JSR. Incorporating palliative care into heart failure management: a new model of care. Int J Palliat Nurs 2005; 11:135-6. [PMID: 15966456 DOI: 10.12968/ijpn.2005.11.3.18033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Diane I Segal
- Cardiology Department, 5th Floor, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
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245
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Thompson DR, Roebuck A, Stewart S. Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure. Eur J Heart Fail 2005; 7:377-84. [PMID: 15718178 DOI: 10.1016/j.ejheart.2004.10.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Revised: 06/01/2004] [Accepted: 10/14/2004] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Few studies have examined the potential benefits of specialist nurse-led programs of care involving home and clinic-based follow-up to optimise the post-discharge management of chronic heart failure (CHF). OBJECTIVE To determine the effectiveness of a hybrid program of clinic plus home-based intervention (C+HBI) in reducing recurrent hospitalisation in CHF patients. METHODS CHF patients with evidence of left ventricular systolic dysfunction admitted to two hospitals in Northern England were assigned to a C+HBI lasting 6 months post-discharge (n=58) or to usual, post-discharge care (UC: n=48) via a cluster randomization protocol. The co-primary endpoints were death or unplanned readmission (event-free survival) and rate of recurrent, all-cause readmission within 6 months of hospital discharge. RESULTS During study follow-up, more UC patients had an unplanned readmission for any cause (44% vs. 22%: P=0.019, OR 1.95 95% CI 1.10-3.48) whilst 7 (15%) versus 5 (9%) UC and C+HBI patients, respectively, died (P=NS). Overall, 15 (26%) C+HBI versus 21 (44%) UC patients experienced a primary endpoint. C+HBI was associated with a non-significant, 45% reduction in the risk of death or readmission when adjusting for potential confounders (RR 0.55, 95% CI 0.28-1.08: P=0.08). Overall, C+HBI patients accumulated significantly fewer unplanned readmissions (15 vs. 45: P<0.01) and days of recurrent hospital stay (108 vs. 459 days: P<0.01). C+HBI was also associated with greater uptake of beta-blocker therapy (56% vs. 18%: P<0.001) and adherence to Na restrictions (P<0.05) during 6-month follow-up. CONCLUSION This is the first randomised study to specifically examine the impact of a hybrid, C+HBI program of care on hospital utilisation in patients with CHF. Its beneficial effects on recurrent readmission and event-free survival are consistent with those applying either a home or clinic-based approach.
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246
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Enguidanos SM, Cherin D, Brumley R. Home-based palliative care study: site of death, and costs of medical care for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2005; 1:37-56. [PMID: 17387068 DOI: 10.1300/j457v01n03_04] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
PURPOSE To examine differences in site of death and costs of services by primary diagnosis for patients receiving home-based palliative care as compared to usual care at the end of life. DESIGN AND METHODS A nonequivalent group design was employed with 298 terminally ill patients diagnosed with cancer, CHF, or COPD enrolled. The treatment group received an interdisciplinary home-based palliative care program and the comparison group received usual Kaiser Permanente services. Data collected included patient demographics, severity of illness, service use, and site of death. RESULTS Among all diseases, patients enrolled in palliative care were more likely to die at home. Enrollment in palliative care was significant associated with cost reductions for patients with cancer, COPD, and CHF. No significant difference was found between diagnostic groups in terms of magnitude of cost savings. IMPLICATIONS Provision of interdisciplinary home-based palliative care at end of life can effectively increase the likelihood of dying at home for patients with CHF, COPD, and cancer while realizing significant cost savings.
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247
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Stapleton RD, Nielsen EL, Engelberg RA, Patrick DL, Curtis JR. Association of Depression and Life-Sustaining Treatment Preferences in Patients With COPD. Chest 2005; 127:328-34. [PMID: 15654000 DOI: 10.1378/chest.127.1.328] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE Depressive symptoms and reduced health-related quality of life are common in patients with severe COPD. Therefore, understanding the association between preferences for life-sustaining treatment and depression or quality of life is important in providing care. No prior studies have examined the effects of depression and quality of life on treatment preferences in this population. DESIGN AND PATIENTS Cross-sectional study of 101 patients with oxygen-prescribed COPD. METHODS Patients completed the St. George's Respiratory Questionnaire, Center for Epidemiologic Studies-Depression survey, and questions regarding their preferences for mechanical ventilation and cardiopulmonary resuscitation if needed to sustain life. RESULTS Median age was 67.4 years, and median FEV1 was 26.3% predicted. Depression was significantly associated with preferences for resuscitation (50% of depressed patients and 23% of patients without depression refused resuscitation; p = 0.007), but was not associated with preferences for mechanical ventilation. Health-related quality of life was not associated with preferences for either resuscitation or mechanical ventilation. CONCLUSIONS Clinicians caring for patients with oxygen-prescribed COPD should understand that health-related quality of life does not predict treatment preferences and should not influence clinicians' views of patients' treatment preferences. However, depression does appear to influence patients' treatment decisions for cardiopulmonary resuscitation, and improvement in depressive symptoms should trigger a reassessment of these preferences.
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Affiliation(s)
- Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
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248
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Formiga F, Chivite D, Pujol R. Preferencias de reanimación cardiopulmonar en el paciente hospitalizado con insuficiencia cardíaca. Rev Esp Cardiol (Engl Ed) 2005. [DOI: 10.1157/13070517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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249
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Abstract
UNLABELLED There is a major deficiency in the end-of-life care offered to patients dying in the intensive care unit (ICU). HYPOTHESIS Hospitalized dying patients had informed discussions on end-of-life and palliative care options before admission to ICU. PATIENTS AND METHODS A descriptive non-interventional study was performed at a teaching hospital to examine if patients who died in hospital had informed discussions on end-of-life care before admission to ICU. The impact of these discussions on subsequent patient care: aggressive therapy in the ICU, the quality of palliation, use of hospice care services and utilization of hospital resources were examined. Data were collected from medical records for all hospital deaths over 24 months. RESULTS Of 252 hospital deaths, 196 (78%) were treated and subsequently 165 (65%) died in the ICU. Patients treated either in the ICU or general hospital wards had similar frequency of ultimately or rapidly fatal pre-existing disease (47% versus 62%, P: ns) and readmission to hospital within one year before death (43% versus 57%, P, ns). The median age (10-90% percentile) was slightly younger for the ICU than hospital wards patients: 73 (45-85) versus 76 (55-91) years, P < 0.01. Of the 156 patients who were transferred to ICU from hospital wards: 136 (87%) were managed by house staff on teaching services and 20 (13%) were managed by attending staff hospitalists, P < 0.01. None of those transferred to the ICU who subsequently died had discussion of palliation or end-of-life care as an alternative treatment. Of those who died who were treated on general wards, 14 (25%) patients had discussion of palliation as an alternative treatment option before death. Do-not-resuscitate decisions were made in 48% of cases two days before death. Patients who were treated in the ICU had more invasive tests performed on them and were less likely to have adequate pain control or referral to hospice care services than on a general ward. Median hospital charge was much higher for patients who received ICU versus general ward care (33,252 dollars versus 8549 dollars, P < 0.001). CONCLUSIONS Patients who died in the ICU did not have informed discussions of end-of-life or palliative care as an alternative treatment option before admission. The quality of end-of-life care was disrupted for patients with fatal pre-existing chronic disease who were admitted to the ICU before death. Lack of clinical experience, knowledge and competency with end-of-life care influenced admission of patients to ICU regardless of poor prognosis. Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources.
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Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Scottsdale, Phoenix, AZ 85054, USA
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Emanuel L, Alexander C, Arnold RM, Bernstein R, Dart R, Dellasantina C, Dykstra L, Tulsky J. Integrating Palliative Care into Disease Management Guidelines. J Palliat Med 2004; 7:774-83. [PMID: 15684844 DOI: 10.1089/jpm.2004.7.774] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Palliative care should not be reserved for those who are close to dying; as a comprehensive approach to minimizing illness-related suffering, it is appropriate for patients with significant illness from the time of diagnosis on. OBJECTIVE The American Hospice Foundation Guidelines Committee's initiative aims to provide a practical approach for guideline writers and others to integrate palliative care into disease management and care services whenever it is relevant. DESIGN A consensus approach was used to design recommendations for upgrading existing disease management and service guidelines to include palliative care. RESULTS A template is described for identifying stages in disease management guidelines when integration of palliative care is appropriate: (1) Introductory sections to disease management guidelines should include prognosis and other disease consequences; (2) Diagnostic sections should include recommendations for conducting a whole patient assessment; (3) Treatment sections should include discernment of patient goals for care, continuous goal reassessment, palliative care interventions to reduce suffering as needed, and treatment decisions should include discussion of the type of expected improvement. Service guidelines should note the role of interdisciplinary team care as well as palliative care consultative or care services; (4) Sections that conclude the care provided to incurable patients should not end without recommendations on grief and bereavement care, and care during the last hours of living. CONCLUSION The American Hospice Foundation Guidelines Committee recommends integration of relevant aspects of palliative care in introductory, diagnostic, treatment, and closing sections of management guidelines for all significant illnesses.
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Affiliation(s)
- Linda Emanuel
- Buehler Center on Aging, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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