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Huitema AA, Harkness K, Malik S, Suskin N, McKelvie RS. Therapies for Advanced Heart Failure Patients Ineligible for Heart Transplantation: Beyond Pharmacotherapy. Can J Cardiol 2020; 36:234-243. [DOI: 10.1016/j.cjca.2019.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 12/25/2022] Open
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Backman WD, Levine SA, Wenger NK, Harold JG. Shared decision-making for older adults with cardiovascular disease. Clin Cardiol 2020; 43:196-204. [PMID: 31580493 PMCID: PMC7021653 DOI: 10.1002/clc.23267] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022] Open
Abstract
Shared decision-making is appropriate for clinical decisions involving multiple reasonable options, which occur frequently in the cardiovascular care of older adults. The process includes the communication of relevant factual information between the patient and the clinician, elicitation of patient preferences, and a mutual agreement on the best course of action to meet the patient's personal goals. For older adults, there are common challenges and considerations with regard to shared decision-making, some of which (eg, cognitive impairment) may be biologically linked to cardiovascular disease. There are tools designed to facilitate the shared decision-making process, known as decision aids, which are broadly effective although have shortcomings when applied to older adults. Novel approaches in clinical research and health systems changes will go some way toward improving shared decision-making for older adults, but the greatest scope for improvement may be within the grass roots areas of communication skills, interdisciplinary teamwork, and simply asking our patients what matters most.
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Affiliation(s)
- Warren D. Backman
- Veterans Affairs New England Geriatric Research Education and Clinical CenterBostonMassachusetts
- Section of GeriatricsBoston University and Boston Medical CenterBostonMassachusetts
| | - Sharon A. Levine
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusetts
| | - Nanette K. Wenger
- Division of CardiologyEmory University School of MedicineAtlantaGeorgia
- Emory Heart and Vascular CenterAtlantaGeorgia
- Emory Women's Heart CenterAtlantaGeorgia
| | - John Gordon Harold
- Cedars‐Sinai Smidt Heart Institute and UCLA David Geffen School of MedicineLos AngelesCalifornia
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203
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Short-term mortality in end-stage heart failure patients. Aten Primaria 2020; 52:477-487. [PMID: 31932015 PMCID: PMC7393541 DOI: 10.1016/j.aprim.2019.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/08/2019] [Accepted: 07/22/2019] [Indexed: 12/21/2022] Open
Abstract
Objectives This study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF). Setting Patients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain). Participants Patients with Advanced HF. Design Multicenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV. Main measurements The primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months. Results Mean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months. The most important risk factor over the whole period was presenting a body mass index lower than 20 kg/m2 (three months OR 3.06, 95% CI: 1.58–5.92; six months OR 4.42, 95% CI: 2.08–9.38; and 12 months OR 3.68, 95% CI: 1.76–7.69). Conclusions We may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease.
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204
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Kim J, An M, Heo S, Shin MS. Attitudes toward advance directives and prognosis in patients with heart failure: a pilot study. Korean J Intern Med 2020; 35:109-118. [PMID: 30759965 PMCID: PMC6960039 DOI: 10.3904/kjim.2018.158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Advance directives (ADs) in Korean patients with heart failure (HF) and the associations of attitude towards ADs and HF prognosis with ADs were initially assessed using the model of the Korean-Advance Directive (K-AD). METHODS Twenty-four patients with HF (age, 67.1 years; men, 58.3%; ejection fraction, 35.9%) participated. A pilot test to evaluate the feasibility of ADs and the possible associations of attitudes towards ADs and prognosis with end-of-life treatment preferences among patients with HF was conducted. RESULTS Fifteen patients (62.5%) completed the K-ADs. The major reason for incomplete K-AD was knowledge deficit. Patients valued "comfortable death" the most (45.4%), followed by "giving no burden to the family" (13.6%). Among treatment preferences, hospice care was preferred by the majority (66.7%), while cardiopulmonary resuscitation (CPR) was preferred by the minority (31.8%). Children (50.0%) were mostly appointed as a proxy, followed by the spouse (33.3%). More patients with moderately positive attitudes completed the K-ADs than their counterparts (70.0% vs. 57.1%). The 5-year survival rate was 69.2%; the patients who preferred CPR had a higher survival rate (70.6% vs. 68.5%) whereas those who preferred hospice care had a lower survival rate than their counterparts (70.7% vs. 75.2%). CONCLUSION The findings support the feasibility of the K-AD model, with a high acceptance rate in two-thirds of the sample. Further studies are warranted to investigate whether treatment preferences are associated with attitude towards ADs and/or HF prognosis using larger sample size.
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Affiliation(s)
- JinShil Kim
- Gachon University College of Nursing, Incheon, Korea
| | - Minjeong An
- Chonnam National University College of Nursing, Gwangju, Korea
| | - Seongkum Heo
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mi-Seung Shin
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Correspondence to Mi-Seung Shin, M.D. Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82-32-460-3663 Fax: +82-32-469-1906 E-mail:
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"Whatever happens, happens" challenges of end-of-life communication from the perspective of older adults and family caregivers: a Qualitative study. BMC Palliat Care 2019; 18:113. [PMID: 31830967 PMCID: PMC6909516 DOI: 10.1186/s12904-019-0493-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/21/2019] [Indexed: 11/25/2022] Open
Abstract
Background Effective communication is integral to the delivery of goal-concordant care for older adults and their family caregivers, and yet, it is uncommon in people with serious illness. This study explores the challenges of integrating end-of-life communication into heart failure management from the perspectives of older adults and family caregivers. Methods In a qualitative study of older adults with heart failure and their family caregivers, fourteen semi-structured interviews were conducted with 19 participants in Ontario, Canada. The interviews were transcribed verbatim and thematic analysis was applied to analyze the data. Results Four themes were identified in the context of participants’ understanding of illness: 1) trivializing illness-related challenges, 2) positivity in late life, 3) discomfort in having end-of-life conversations, and 4) reluctant to engage despite need. These challenges often intertwine with one another. Most participants had not engaged in end-of-life discussions with their clinicians or family members. Conclusion The findings provide insights that can inform approaches to integrate end-of-life communication for older adults with serious illness and caregivers. The identified challenges highlight a need for end-of-life communication to occur earlier in illness to be able to support individuals throughout the period of decline. In addition, end-of-life communication should be introduced iteratively for those who may not be ready to engage. Alternative approaches to communication are needed to elicit the challenges that patients and caregivers experience throughout the progression of illness to improve care for people nearing the end of life.
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Xanthopoulos A, Butler J, Parissis J, Polyzogopoulou E, Skoularigis J, Triposkiadis F. Acutely decompensated versus acute heart failure: two different entities. Heart Fail Rev 2019; 25:907-916. [PMID: 31802377 DOI: 10.1007/s10741-019-09894-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) has been classified in chronic HF (CHF) and acute HF (AHF). The latter has been subdivided in acutely decompensated chronic HF (ADCHF) defined as the deterioration of preexisting CHF and de novo AHF defined as the rapid development of new symptoms and signs of HF that requires urgent medical attention. However, ADCHF and de novo AHF have fundamental pathophysiological differences. Most importantly, the typical illness trajectory of HF, which is similar to that of other chronic organ diseases including lung, renal, and liver failure, features a gradual decline, with acute episodes usually related to disease evolution followed by partial recovery. Thus, ADCHF should be considered part of the natural history of CHF and renamed CHF exacerbation (CHFE) in accordance with the appropriate terminology used in chronic obstructive pulmonary disease. AHF, in turn, should include only acute de novo HF. The clinical implications of this paradigm shift will be in CHFE the change in focus from in-hospital to optimal ambulatory CHF management aiming at primary and secondary CHFE prevention, while in AHF, the institution of measures for in-hospital limitation of cardiac injury and prevention or retardation of symptomatic CHF development.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John Parissis
- Heart Failure Unit, Second Cardiology Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eftihia Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Skoularigis
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece
| | - Filippos Triposkiadis
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece.
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Tchoukina I, Shah KB, Thibodeau JT, Estep JD, Lala A, Lanfear DE, Gilotra NA, Pamboukian SV, Horstmanshof DA, Mcnamara DM, Haas DC, Jorde UP, Mclean RC, Cascino TM, Khalatbari S, Richards B, Yosef M, Spino C, Baldwin JT, Mann DL, Aaronson KD, Stewart GC. Impact of Socioeconomic Factors on Patient Desire for Early LVAD Therapy Prior to Inotrope Dependence. J Card Fail 2019; 26:316-323. [PMID: 31809791 DOI: 10.1016/j.cardfail.2019.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/11/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Worsening heart failure (HF) and health-related quality of life (HRQOL) have been shown to impact the decision to proceed with left ventricular assist device (LVAD) implantation, but little is known about how socioeconomic factors influence expressed patient preference for LVAD. METHODS AND RESULTS Ambulatory patients with advanced systolic HF (n=353) reviewed written information about LVAD therapy and completed a brief survey to indicate whether they would want an LVAD to treat their current level of HF. Ordinal logistic regression analyses identified clinical and demographic predictors of LVAD preference. Higher New York Heart Association (NYHA) class, worse HRQOL measured by Kansas City Cardiomyopathy Questionnaire, lower education level, and lower income were significant univariable predictors of patients wanting an LVAD. In the multivariable model, higher NYHA class (OR [odds ratio]: 1.43, CI [confidence interval]: 1.08-1.90, P = .013) and lower income level (OR: 2.10, CI: 1.18 - 3.76, P = .012 for <$40,000 vs >$80,000) remained significantly associated with wanting an LVAD. CONCLUSION Among ambulatory patients with advanced systolic HF, treatment preference for LVAD was influenced by level of income independent of HF severity. Understanding the impact of socioeconomic factors on willingness to consider LVAD therapy may help tailor counseling towards individual needs.
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Affiliation(s)
| | - Keyur B Shah
- Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Anuradha Lala
- Mount Sinai Icahn School of Medicine, New York, New York
| | | | - Nisha A Gilotra
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Chuzi S, Pak ES, Desai AS, Schaefer KG, Warraich HJ. Role of Palliative Care in the Outpatient Management of the Chronic Heart Failure Patient. Curr Heart Fail Rep 2019; 16:220-228. [DOI: 10.1007/s11897-019-00440-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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209
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A Feature-Driven Decision Support System for Heart Failure Prediction Based on χ 2 Statistical Model and Gaussian Naive Bayes. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:6314328. [PMID: 31885684 PMCID: PMC6925936 DOI: 10.1155/2019/6314328] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 08/05/2019] [Indexed: 11/17/2022]
Abstract
Heart failure (HF) is considered a deadliest disease worldwide. Therefore, different intelligent medical decision support systems have been widely proposed for detection of HF in literature. However, low rate of accuracies achieved on the HF data is a major problem in these decision support systems. To improve the prediction accuracy, we have developed a feature-driven decision support system consisting of two main stages. In the first stage, χ2 statistical model is used to rank the commonly used 13 HF features. Based on the χ2 test score, an optimal subset of features is searched using forward best-first search strategy. In the second stage, Gaussian Naive Bayes (GNB) classifier is used as a predictive model. The performance of the newly proposed method (χ2-GNB) is evaluated by using an online heart disease database of 297 subjects. Experimental results show that our proposed method could achieve a prediction accuracy of 93.33%. The developed method (i.e., χ2-GNB) improves the HF prediction performance of GNB model by 3.33%. Moreover, the newly proposed method also shows better performance than the available methods in literature that achieved accuracies in the range of 57.85–92.22%.
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210
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Cardiac Biomarkers in Advanced Heart Failure: How Can They Impact Our Pre-transplant or Pre-LVAD Decision-making. Curr Heart Fail Rep 2019; 16:274-284. [PMID: 31741231 DOI: 10.1007/s11897-019-00447-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Decision-making in advanced heart failure (HF) is a complex process that involves careful consideration of competing tradeoffs of risks and benefits in regard to heart transplantation (HT) or left ventricular assist device (LVAD) placement. The purpose of this review is to discuss how biomarkers may affect decision-making for HT or LVAD implantation. RECENT FINDINGS N-Terminal probrain natriuretic peptide, soluble suppression of tumorigenicity-2, galectin-3, copeptin, and troponin T levels are associated with HF survival and can help identify the appropriate timing for advanced HF therapies. Patients at risk of right ventricular failure after LVAD implantation can be identified with preimplant biomarkers of extracellular matrix turnover, neurohormonal activation, and inflammation. There is limited data on the adoption of biomarker measurement for decision-making in the allocation of advanced HF therapies. Nonetheless, biomarkers can improve risk stratification and prognostication thereby optimizing patient selection for HT and LVAD implantation.
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211
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Patient and Professional Factors That Impact the Perceived Likelihood and Confidence of Healthcare Professionals to Discuss Implantable Cardioverter Defibrillator Deactivation in Advanced Heart Failure: Results From an International Factorial Survey. J Cardiovasc Nurs 2019; 33:527-535. [PMID: 29727378 PMCID: PMC6200367 DOI: 10.1097/jcn.0000000000000500] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental digital content is available in the text. Background: Rate of implantable cardioverter defibrillator (ICD) implantations is increasing in patients with advanced heart failure. Despite clear guideline recommendations, discussions addressing deactivation occur infrequently. Aim: The aim of this article is to explore patient and professional factors that impact perceived likelihood and confidence of healthcare professionals to discuss ICD deactivation. Methods and Results: Between 2015 and 2016, an international sample of 262 healthcare professionals (65% nursing, 24% medical) completed an online factorial survey, encompassing a demographic questionnaire and clinical vignettes. Each vignette had 9 randomly manipulated and embedded patient-related factors, considered as independent variables, providing 1572 unique vignettes for analysis. These factors were determined through synthesis of a systematic literature review, a retrospective case note review, and a qualitative exploratory study. Results showed that most healthcare professionals agreed that deactivation discussions should be initiated by a cardiologist (95%, n = 255) or a specialist nurse (81%, n = 215). In terms of experience, 84% of cardiologists (n = 53) but only 30% of nurses (n = 50) had previously been involved in a deactivation decision. Healthcare professionals valued patient involvement in deactivation decisions; however, only 50% (n = 130) actively involved family members. Five of 9 clinical factors were associated with an increased likelihood to discuss deactivation including advanced age, severe heart failure, presence of malignancy, receipt of multiple ICD shocks, and more than 3 hospital admissions during the previous year. Furthermore, nationality and discipline significantly influenced likelihood and confidence in decision making. Conclusions: Guidelines recommend that healthcare professionals discuss ICD deactivation; however, practice is suboptimal with multifactorial factors impacting on decision making. The role and responsibility of nurses in discussing deactivation require clarity and improvement.
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212
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A Context-oriented Communication Algorithm for Advance Care Planning: A Model to Assist Palliative Care in Heart Failure. J Cardiovasc Nurs 2019; 33:446-452. [PMID: 28248746 DOI: 10.1097/jcn.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Access to consultation or referral for decisions about advance care planning (ACP) is limited, particularly for nonmalignant models pertinent to palliative care in heart failure (HF). OBJECTIVES The aim of this study was to solicit professional opinions about the feasibility of using an exemplary context-oriented communication algorithm for ACP discussions. METHODS Using a panel of expert physicians and nurses in cardiovascular care, a 3-round Delphi study was conducted to evaluate the proposed model. RESULTS A consensus was determined based on a content validity ratio (CVR) of 0.318 or greater, a critical value for selection of an item scored as important (≥4 on a 5-point Likert scale). A total of 50, 44, and 38 experts in Korea completed each round, respectively. Item evaluation did not differ across rounds (Friedman χ > P = .05), except for timing of the ACP discussion. A lack of consensus was observed on the issue of after HF diagnosis for right timing of the ACP discussion across rounds (CVRs from -0.80 to -0.83); consensus was reached on the expectation of a terminal state (CVRs from 0.60 to 0.78). Content validity ratios were moderately high for Korean advance directive, ranging from 0.59 to 0.91. Experts also reached consensus about each of 5 steps of a communication model-patients' determination of decisional capacity (CVR, 0.72-1.0), awareness (CVR, 0.95-1.0), willingness for advance care planning (CVR, 0.76-0.84), family dynamics (CVR, 0.92-1.0) and patient readiness for advance care planning (CVR, 0.76-0.95). CONCLUSIONS A context-oriented communication model could be used to facilitate the decision-making process for palliative care and continuity of care in HF.
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213
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Tunuguntla H, Conway J, Villa C, Rapoport A, Jeewa A. Destination-Therapy Ventricular Assist Device in Children: "The Future Is Now". Can J Cardiol 2019; 36:216-222. [PMID: 31924452 DOI: 10.1016/j.cjca.2019.10.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 01/16/2023] Open
Abstract
Durable ventricular assist devices (VADs) have significantly improved survival to transplantation among children with advanced stages of heart failure. The fundamental goals of VAD therapy include decreasing mortality, minimizing adverse events, and improving quality of life. As the pediatric VAD experience has evolved with reduced device related complications and improved survival, VAD therapy is being considered not only as a bridge to transplantation (BTT) but also as a bridge to decision (BTD) and as destination therapy (DT). Data regarding pediatric DT VAD are limited to anecdotal or case reports of children being supported for long periods with VADs and by default being classified as DT VAD. This article reviews current trends in the use of DT VAD and adverse events in children vs adults on VAD, and provides a framework for patient selection with the use of a multidisciplinary approach including palliative care. The general approach to determining DT VAD candidacy should include: 1) a reasonable success that the patient will survive the peri- and postoperative state; and 2) a high likelihood that the patient will be able to be discharged out of hospital and have adequate caregiver support. Patients with muscular dystrophy and failing Fontan physiology are examples of pediatric populations for whom DT VAD may be considered and which require unique considerations.
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Affiliation(s)
- Hari Tunuguntla
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Conway
- Department of Paediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Chet Villa
- Pediatric Cardiology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Adam Rapoport
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aamir Jeewa
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
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Severino P, Mather PJ, Pucci M, D'Amato A, Mariani MV, Infusino F, Birtolo LI, Maestrini V, Mancone M, Fedele F. Advanced Heart Failure and End-Stage Heart Failure: Does a Difference Exist. Diagnostics (Basel) 2019; 9:diagnostics9040170. [PMID: 31683887 PMCID: PMC6963179 DOI: 10.3390/diagnostics9040170] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/16/2022] Open
Abstract
Advanced heart failure (AdHF) represents a challenging aspect of heart failure patients. Because of worsening clinical symptoms, high rates of re-hospitalization and mortality, AdHF represents an unstable condition where standard treatments are inadequate and additional interventions must be applied. A heart transplant is considered the optimal therapy for AdHF, but the great problem linked to the scarcity of organs and long waiting lists have led to the use of mechanical circulatory support with ventricular-assist device (VAD) as a destination therapy. VAD placement improves the prognosis, functional status, and quality of life of AdHF patients, with high rates of survival at 1 year, similar to transplant. However, the key element is to select the right patient at the right moment. The complete assessment must include a careful clinical evaluation, but also take into account psychosocial factors that are of crucial importance in the out-of-hospital management. It is important to distinguish between AdHF and end-stage HF, for which advanced therapy interventions would be unreasonable due to severe and irreversible organ damage and, instead, palliative care should be preferred to improve quality of life and relief of suffering. The correct selection of patients represents a great issue to solve, both ethically and economically.
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Affiliation(s)
- Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Paul J Mather
- Department of Medicine, Division of Cardiology University of Pennsylvania, Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Mariateresa Pucci
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Andrea D'Amato
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Fabio Infusino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Lucia Ilaria Birtolo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Viviana Maestrini
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Massimo Mancone
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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Goldstein NE, Mather H, McKendrick K, Gelfman LP, Hutchinson MD, Lampert R, Lipman HI, Matlock DD, Strand JJ, Swetz KM, Kalman J, Kutner JS, Pinney S, Morrison RS. Improving Communication in Heart Failure Patient Care. J Am Coll Cardiol 2019; 74:1682-1692. [PMID: 31558252 PMCID: PMC7000126 DOI: 10.1016/j.jacc.2019.07.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. OBJECTIVES The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. METHODS In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. RESULTS A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. SECONDARY OUTCOMES Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. CONCLUSIONS The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).
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Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, Arizona
| | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, New Jersey; Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Jacob J Strand
- Division of General Internal Medicine, Department of Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, Alabama
| | - Jill Kalman
- Lenox Hill Hospital, Northwell Health, New York, New York
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sean Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
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216
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Training, Triggers, and a Team for the Right Discussions. J Am Coll Cardiol 2019; 74:1693-1696. [DOI: 10.1016/j.jacc.2019.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 11/21/2022]
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217
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O'Donnell AE, Schaefer KG, Stevenson LW, DeVoe K, Walsh K, Mehra MR, Desai AS. Social Worker-Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial. JAMA Cardiol 2019; 3:516-519. [PMID: 29641819 DOI: 10.1001/jamacardio.2018.0589] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Palliative care considerations are typically introduced late in the disease trajectory of patients with advanced heart failure (HF), and access to specialty-level palliative care may be limited. Objective To determine if early initiation of goals of care conversations by a palliative care-trained social worker would improve prognostic understanding, elicit advanced care preferences, and influence care plans for high-risk patients discharged after HF hospitalization. Design, Setting, and Participants This prospective, randomized clinical trial of a social worker-led palliative care intervention vs usual care analyzed patients recently hospitalized for management of acute HF who had risk factors for poor prognosis. Analyses were conducted by intention to treat. Interventions Key components of the social worker-led intervention included a structured evaluation of prognostic understanding, end-of-life preferences, symptom burden, and quality of life with routine review by a palliative care physician; communication of this information to treating clinicians; and longitudinal follow-up in the ambulatory setting. Main Outcomes and Measures Percentage of patients with physician-level documentation of advanced care preferences and the degree of alignment between patient and cardiologist expectations of prognosis at 6 months. Results The study population (N = 50) had a mean (SD) age of 72 (11) years and had a mean (SD) left ventricular ejection fraction of 0.33 (13). Of 50 patients, 41 (82%) had been hospitalized more than once for HF management within 12 months of enrollment. At enrollment, treating physicians anticipated death within a year for 32 patients (64%), but 42 patients (84%) predicted their life expectancy to be longer than 5 years. At 6 months, more patients in the intervention group than in the control group had physician-level documentation of advanced care preferences in the electronic health record (17 [65%] vs 8 [33%]; χ2 = 5.1; P = .02). Surviving patients allocated to intervention were also more likely to revise their baseline prognostic assessment in a direction consistent with the physician's assessment (15 [94%] vs 4 [26%]; χ2 = 14.7; P < .001). Among the 31 survivors at 6 months, there was no measured difference between groups in depression, anxiety, or quality-of-life scores. Conclusions and Relevance Patients at high risk for mortality from HF frequently overestimate their life expectancy. Without an adverse impact on quality of life, prognostic understanding and patient-physician communication regarding goals of care may be enhanced by a focused, social worker-led palliative care intervention that begins in the hospital and continues in the outpatient setting. Trial Registration clinicaltrials.gov Identifier: NCT02805712.
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Affiliation(s)
| | - Kristen G Schaefer
- Palliative Medicine Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lynne W Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristen DeVoe
- Department of Social Work, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kayley Walsh
- Department of Social Work, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mandeep R Mehra
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
PURPOSE OF REVIEW Advanced heart failure in children is characterized by dynamic clinical trajectories, uncertainty of prognosis, and intermittent need for difficult decision-making, often related to novel therapeutic interventions with uncertain impact on quality of life. This review will examine the current role of palliative care to support this unique population. RECENT FINDINGS Pediatric heart failure patients commonly die in ICUs with high burden of invasive therapies together with end of life care needs. In addition, several studies advocate for integration of palliative care early in disease trajectory, not only focused on end of life care. Many advocate for the core tenets of palliative care (symptom management, communication of prognosis, and advanced care planning) to be provided by the primary cardiology team, with consultation by pediatric palliative care specialists. There is also a consensus that palliative care training should be incorporated into pediatric advanced heart disease training programs. SUMMARY Palliative care is an important component of pediatric heart failure care. Research and quality improvement efforts are needed to determine the most effective palliative care interventions for children with advanced heart disease. Provision of palliative care is an essential component of training for pediatric heart failure and transplant specialists.
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219
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Im J, Mak S, Upshur R, Steinberg L, Kuluski K. 'The Future is Probably Now': Understanding of illness, uncertainty and end-of-life discussions in older adults with heart failure and family caregivers. Health Expect 2019; 22:1331-1340. [PMID: 31560824 PMCID: PMC6882266 DOI: 10.1111/hex.12980] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/15/2019] [Accepted: 09/10/2019] [Indexed: 01/01/2023] Open
Abstract
Background Earlier end‐of‐life communication is critical for people with heart failure given the uncertainty and high‐risk of mortality in illness. Despite this, end‐of‐life communication is uncommon in heart failure. Left unaddressed, lack of end‐of‐life discussions can lead to discordant care at the end of life. Objective This study explores patients' and caregivers’ understanding of illness, experiences of uncertainty, and perceptions of end‐of‐life discussions in advanced illness. Design Interpretive descriptive qualitative study of older adults with heart failure and family caregivers. Fourteen semi‐structured interviews were conducted with 19 participants in Ontario, Canada. Interviews were transcribed verbatim and content analysis was used to analyse the data. Main results Understanding of illness was shaped by participants’ illness‐related experiences (e.g. symptoms, hospitalizations and self‐care routines) and the ability to adapt to challenges of illness. Participants were knowledgeable of heart failure management, and yet, were limited in their understanding of the consequences of illness. Participants adapted to the challenges of illness which appeared to influence their perception of overall health. Uncertainty reflected participants’ inability to connect manifestations of heart failure as part of the progression of illness towards the end of life. Most participants had not engaged in prior end‐of‐life discussions. Conclusion Detailed knowledge of heart failure management does not necessarily translate to an understanding of the consequences of illness. The ability to adapt to illness‐related challenges may delay older adults and family caregivers from engaging in end‐of‐life discussions. Future research is needed to examine the impact of addressing the consequences of illness in facilitating earlier end‐of‐life communication.
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Affiliation(s)
- Jennifer Im
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Susanna Mak
- Division of Cardiology, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Ross Upshur
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leah Steinberg
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Kerry Kuluski
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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220
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Tsutsui H, Isobe M, Ito H, Ito H, Okumura K, Ono M, Kitakaze M, Kinugawa K, Kihara Y, Goto Y, Komuro I, Saiki Y, Saito Y, Sakata Y, Sato N, Sawa Y, Shiose A, Shimizu W, Shimokawa H, Seino Y, Node K, Higo T, Hirayama A, Makaya M, Masuyama T, Murohara T, Momomura SI, Yano M, Yamazaki K, Yamamoto K, Yoshikawa T, Yoshimura M, Akiyama M, Anzai T, Ishihara S, Inomata T, Imamura T, Iwasaki YK, Ohtani T, Onishi K, Kasai T, Kato M, Kawai M, Kinugasa Y, Kinugawa S, Kuratani T, Kobayashi S, Sakata Y, Tanaka A, Toda K, Noda T, Nochioka K, Hatano M, Hidaka T, Fujino T, Makita S, Yamaguchi O, Ikeda U, Kimura T, Kohsaka S, Kosuge M, Yamagishi M, Yamashina A. JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure - Digest Version. Circ J 2019; 83:2084-2184. [PMID: 31511439 DOI: 10.1253/circj.cj-19-0342] [Citation(s) in RCA: 409] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Affiliation(s)
- Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | | | - Hiroshi Ito
- Department of Cardiovascular and Respiratory Medicine, Akita University Graduate School of Medicine
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Division of Biophysiological Sciences, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center
| | | | - Yasuki Kihara
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Atsushi Hirayama
- The Division of Cardiology, Department of Medicine, Nihon University Graduate School of Medicine
| | | | - Tohru Masuyama
- Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Masafumi Yano
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Kenji Yamazaki
- Department of Cardiology Surgery, Tokyo Women's Medical University
| | - Kazuhiro Yamamoto
- Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University
| | | | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Shiro Ishihara
- Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | | | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Takatoshi Kasai
- Cardiovascular Respiratory Sleep Medicine, Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Mahoto Kato
- Department of Cardiovascular Medicine, Nihon University Graduate School of Medicine
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | | | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Shigeki Kobayashi
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | | | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Kyushu University Graduate School of Medical Sciences
| | - Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center
| | - Osamu Yamaguchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Masakazu Yamagishi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Akira Yamashina
- Medical Education Promotion Center, Tokyo Medical University
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221
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Stoevelaar R, Brinkman-Stoppelenburg A, van Driel AG, van Bruchem-Visser RL, Theuns DA, Bhagwandien RE, Van der Heide A, Rietjens JA. Implantable cardioverter defibrillator deactivation and advance care planning: a focus group study. Heart 2019; 106:190-195. [PMID: 31537636 PMCID: PMC6993024 DOI: 10.1136/heartjnl-2019-315721] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Implantable cardioverter defibrillators can treat life-threatening arrhythmias, but may negatively influence the last phase of life if not deactivated. Advance care planning conversations can prepare patients for future decision-making about implantable cardioverter defibrillator deactivation. This study aimed at gaining insight in the experiences of patients with advance care planning conversations about implantable cardioverter defibrillator deactivation. Methods In this qualitative study, we held five focus groups with 41 patients in total. Focus groups were audio-recorded and transcribed. Transcripts were analysed thematically, using the constant comparative method, whereby themes emerging from the data are compared with previously emerged themes. Results Most patients could imagine deciding to have their implantable cardioverter defibrillator deactivated, for instance because the benefits of an active device no longer outweigh the harm of unwanted shocks, when having another life-limiting illness, or when relatives would think this would be in their best interest. Some patients expressed a need for advance care planning conversations with a healthcare professional about deactivation, but few had had these. Others did not, saying they solely focused on living. Some patients were hesitant to record their preferences about deactivation in advance care directives, because they were unsure whether their current preferences would reflect future preferences. Conclusions Although patients expressed a need for more information, advance care planning conversations about implantable cardioverter defibrillator deactivation seemed to be uncommon. Deactivation should be more frequently addressed by healthcare professionals, tailored to the disease stage of the patient and readiness to discuss this topic.
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Affiliation(s)
- Rik Stoevelaar
- Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Anne Geert van Driel
- Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands.,Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
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222
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Jones NR, Roalfe AK, Adoki I, Hobbs FDR, Taylor CJ. Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis. Eur J Heart Fail 2019; 21:1306-1325. [PMID: 31523902 PMCID: PMC6919428 DOI: 10.1002/ejhf.1594] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 12/25/2022] Open
Abstract
Aim To provide reliable survival estimates for people with chronic heart failure and explain variation in survival by key factors including age at diagnosis, left ventricular ejection fraction, decade of diagnosis, and study setting. Methods and results We searched in relevant databases from inception to August 2018 for non‐interventional studies reporting survival rates for patients with chronic or stable heart failure in any ambulatory setting. Across the 60 included studies, there was survival data for 1.5 million people with heart failure. In our random effects meta‐analyses the pooled survival rates at 1 month, 1, 2, 5 and 10 years were 95.7% (95% confidence interval 94.3–96.9), 86.5% (85.4–87.6), 72.6% (67.0–76.6), 56.7% (54.0–59.4) and 34.9% (24.0–46.8), respectively. The 5‐year survival rates improved between 1970–1979 and 2000–2009 across healthcare settings, from 29.1% (25.5–32.7) to 59.7% (54.7–64.6). Increasing age at diagnosis was significantly associated with a reduced survival time. Mortality was lowest in studies conducted in secondary care, where there were higher reported prescribing rates of key heart failure medications. There was significant heterogeneity among the included studies in terms of heart failure diagnostic criteria, participant co‐morbidities, and treatment rates. Conclusion These results can inform health policy and individual patient advanced care planning. Mortality associated with chronic heart failure remains high despite steady improvements in survival. There remains significant scope to improve prognosis through greater implementation of evidence‐based treatments. Further research exploring the barriers and facilitators to treatment is recommended.
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Affiliation(s)
- Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrea K Roalfe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ibiye Adoki
- Foundation Training Programme, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare J Taylor
- Foundation Training Programme, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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223
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Hollenberg SM, Warner Stevenson L, Ahmad T, Amin VJ, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Peterson PN, Reed BN, Roy CL, Storrow AB. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2019; 74:1966-2011. [PMID: 31526538 DOI: 10.1016/j.jacc.2019.08.001] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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224
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Abshire M, Bidwell JT, Page G, Budhathoki C, Davidson PM, Russell SD, Han HR, Desai S, Himmelfarb CD. Physiological and Psychological Stress in Patients Living With a Left Ventricular Assist Device. ASAIO J 2019; 64:e172-e180. [PMID: 30199387 PMCID: PMC6218313 DOI: 10.1097/mat.0000000000000847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Patients with a left ventricular assist device (LVAD) commonly experience psychological distress post-implantation, but physiological stress and differences by implant strategy remain unstudied. This study describes indicators of physiological (salivary cortisol, C-reactive protein, sleep quality) and psychological (perceived stress, depression, and fatigue) stress by implant strategy and examines relationships between stress and outcomes (quality of life [QOL] and functional status). Prospective, cross-sectional data were collected from patients ≥3 months post-LVAD implantation (n = 44), and descriptive statistics and logistic regression were used. The study sample was average age 57.7 ± 13 years, mostly male (73%), married (70.5%), and racially diverse. Median LVAD support was 18.2 months. Most had normal cortisol awakening response and fair sleep quality, with moderate psychological stress. There were no differences in stress by implant strategy. Normal cortisol awakening response was correlated with low depressive symptoms. Sleep quality and psychological stress were associated with QOL, whereas cortisol and C-reactive protein levels were associated with functional status. This is the first report of salivary biomarkers and stress in LVAD outpatients. Future research should examine physiological and psychological stress and consider potential clinical implications for stress measurement for tailored approaches to stress management in this population.
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Affiliation(s)
- Martha Abshire
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Julie T. Bidwell
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA, USA
| | - Gayle Page
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | | | | | - Hae-Ra Han
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Cheryl Dennison Himmelfarb
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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225
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Goyal P. Do We Need Shared Decision Making When Prescribing Guideline-Directed Medical Therapy? J Card Fail 2019; 25:701-702. [DOI: 10.1016/j.cardfail.2019.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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226
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Stahl EP, Dickert NW, Cole RT, Laskar SR, Morris AA, Smith AL, Vega JD, Gupta D. Decisional regret in left ventricular assist device patient-caregiver dyads. Heart Lung 2019; 48:400-404. [DOI: 10.1016/j.hrtlng.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 01/11/2023]
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227
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Sobanski PZ, Alt-Epping B, Currow DC, Goodlin SJ, Grodzicki T, Hogg K, Janssen DJA, Johnson MJ, Krajnik M, Leget C, Martínez-Sellés M, Moroni M, Mueller PS, Ryder M, Simon ST, Stowe E, Larkin PJ. Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement. Cardiovasc Res 2019; 116:12-27. [DOI: 10.1093/cvr/cvz200] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 04/19/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Abstract
Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Waldeggstrasse 10, 6430 Schwyz, Switzerland
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Medical Center Göttingen Georg August University, Robertkochstrasse 40, 37075 Göttingen, Germany
| | - David C Currow
- University of Technology Sydney, Broadway, Ultimo, Sydney, 2007 New South Wales, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Sydney, New South Wales, Australia
| | - Sarah J Goodlin
- Department of Medicine-Geriatrics, Portland Veterans Affairs Medical Center and Patient-cantered Education and Research, 3710 SW US Veterans Rd, Portland, 97239 OR, USA
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, 31-531 Kraków, Śniadeckich 10, Poland
| | | | - Daisy J A Janssen
- Department of Research and Education, CIRO, Hornerheide 1, 6085 NM Horn, The Netherlands
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Allam Medical Building University of Hull, Cottingham Road, Hull, HU6 7RX, UK
| | - Małgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Carlo Leget
- University of Humanistic Studies, Chair Care Ethics, Kromme Nieuwegracht 29, Utrecht, The Netherlands
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Matteo Moroni
- S.S.D. Cure Palliative, sede di Ravenna, AUSL Romagna, Via De Gasperi 8, 48121 Ravenna, Italy
| | - Paul S Mueller
- Mayo Clinic Health System, Mayo Clinic Collage of Medicine and Science, 700 West Avennue South, La Crosse, 54601 Wisconsin, USA
| | - Mary Ryder
- School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland St. Vincent’s University Hospital Dublin,Belfield, Dublin 4, Ireland
| | - Steffen T Simon
- Department of Palliative Medicine, Medical Faculty of the Universityof Cologne, Köln, Germany
- Centre for Integrated Oncology Cologne/Bonn (CIO), Medical Faculty ofthe University of Cologne, Kerpener Strasse 62, 50924 Köln, Germany
| | | | - Philip J Larkin
- Service des soins palliatifs Lausanne University Hospital, CHUV, Centre hospitalier univeritaire vaudois, Lausanne Switzerland
- Institut universitaire de formation et de recherche en soins – IUFRS, Faculté de viologie et de medicine – FBM, Lausanne, Switzerland
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Lohmueller LC, Naik A, Breitfeller L, McIlvennan CK, Kanwar M, Murali S, Rosé C, Antaki JF. Factors Affecting Health Care Engagement of Patients With End-Stage Heart Failure: An Exploratory Survey Study. MDM Policy Pract 2019; 4:2381468319865515. [PMID: 31453361 PMCID: PMC6699010 DOI: 10.1177/2381468319865515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background. The decision to receive a permanent left ventricular assist device (LVAD) to treat end-stage heart failure (HF) involves understanding and weighing the risks and benefits of a highly invasive treatment. The goal of this study was to characterize end-stage HF patients across parameters that may affect their decision making and to inform the development of an LVAD decision support tool. Methods. A survey of 35 end-stage HF patients at an LVAD implant hospital was performed to characterize their information-seeking habits, interaction with physicians, technology use, numeracy, and concerns about their health. Survey responses were analyzed using descriptive statistics, grounded theory method, and Bayesian network learning. Results. Most patients indicated an interest in using some type of decision support tool (roadmap of health progression: 46%, n = 16; personal prognosis: 51%, n = 18; short videos of patients telling stories of their experiences with an LVAD: 57%, n = 20). Information patients desired in a hypothetical decision support tool fell into the following topics: prognoses for health outcomes, technical information seeking, expressing emotions, and treatment decisions. Desire for understanding their condition was closely related to whether they had difficult interpreting their electronic medical record in the past. Conclusions. Most patients reported interest in engaging in their health care decision making and seeing their prognosis and electronic health record information. Patients who were less interested in their own treatment decisions were characterized by having less success understanding their health information. Design of a decision support tool for potential LVAD patients should consider a spectrum of health literacy and include information beyond the technical specifications of LVAD support.
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Affiliation(s)
- Lisa Carey Lohmueller
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aakanksha Naik
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Luke Breitfeller
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Srinivas Murali
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Carolyn Rosé
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - James F Antaki
- Biomedical Engineering, Cornell University, Ithaca, New York
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Kittleson MM, Shah P, Lala A, McLean RC, Pamboukian S, Horstmanshof DA, Thibodeau J, Shah K, Teuteberg J, Gilotra NA, Taddei-Peters WC, Cascino TM, Richards B, Khalatbari S, Jeffries N, Stevenson LW, Mann D, Aaronson KD, Stewart GC. INTERMACS profiles and outcomes of ambulatory advanced heart failure patients: A report from the REVIVAL Registry. J Heart Lung Transplant 2019; 39:16-26. [PMID: 31522912 DOI: 10.1016/j.healun.2019.08.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/17/2019] [Accepted: 08/20/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Ambulatory patients with advanced heart failure (HF) are often considered for advanced therapies, including durable mechanical circulatory support (MCS). The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles are a commonly used descriptor of disease severity in patients receiving MCS devices, but their role in defining the prognosis of ambulatory patients is less well established, especially for Profiles 6 and 7. METHODS Registry Evaluation of Vital Information on Ventricular Assist Devices in Ambulatory Life is a prospective observational study of 400 outpatients from 21 MCS and cardiac transplant centers. Eligible patients had New York Heart Association Class II to IV symptoms despite optimal medical and electrical therapies with a recent HF hospitalization, heart transplant listing, or evidence of high neurohormonal activation. RESULTS The cohort included 33 INTERMACS Profile 4 (8%), 83 Profile 5 (21%), 155 Profile 6 (39%), and 129 Profile 7 (32%). Across INTERMACS profiles, there were no differences in age, gender, ejection fraction, blood pressure, or use of guideline-directed medical therapy. A lower INTERMACS profile was associated with more hospitalizations, greater frailty, and more impaired functional capacity and quality of life. The composite end point of death, durable MCS, or urgent transplant at 12 months occurred in 39%, 27%, 24%, and 14% subjects with INTERMACS Profiles 4, 5, 6, and 7, respectively (p = 0.004). CONCLUSIONS Among ambulatory patients with advanced HF, a lower INTERMACS profile was associated with a greater burden of HF across multiple dimensions and a higher composite risk of durable MCS, urgent transplant, or death. These profiles may assist in risk assessment and triaging ambulatory patients to advanced therapies.
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Affiliation(s)
- Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Palak Shah
- Department of Medicine, Inova Heart and Vascular Institute, Falls Church, Virgina, USA
| | - Anuradha Lala
- Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Rhondalyn C McLean
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Salpy Pamboukian
- Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Douglas A Horstmanshof
- Interagency Autism Coordinating Committee Advanced Cardiac Care Deptartment, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Jennifer Thibodeau
- Department of Internal Medicine, University of Texas Southwest Medical Center, Dallas, Texas, USA
| | - Keyur Shah
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Jeffrey Teuteberg
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Nisha A Gilotra
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Neal Jeffries
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Douglas Mann
- Department of Internal Medicine, Washington University, St. Louis, Missouri, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Garrick C Stewart
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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230
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Sandhu A, Levy A, Varosy PD, Matlock D. Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in Older Adults With Heart Failure. J Am Geriatr Soc 2019; 67:2193-2199. [PMID: 31403714 DOI: 10.1111/jgs.16099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/04/2019] [Accepted: 06/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are cardiac implantable electronic devices that may improve morbidity and mortality in select patients with heart failure. Although the benefits of these devices have been well defined, competing mortality risks, comorbid conditions, and frailty pose difficulty in determining risk-benefit trade-offs when these options are considered for older adults. CONCLUSION In this review, we focus on the benefit, risk, and use of ICD and CRT in older adults, particularly because the goals of care for many older adults include a shift away from life-prolonging interventions. Additionally, we discuss periprocedural risk, cost, and maintenance in older populations. Finally, we introduce a framework for helping clinicians and older adults make these challenging decisions collectively. J Am Geriatr Soc 67:2193-2199, 2019.
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Affiliation(s)
- Amneet Sandhu
- Section of Electrophysiology, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado.,Section of Electrophysiology, University of Colorado School of Medicine, Aurora, Colorado.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Andrew Levy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Paul D Varosy
- Section of Electrophysiology, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado.,Section of Electrophysiology, University of Colorado School of Medicine, Aurora, Colorado.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Veterans Affairs (VA) Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado.,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado
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231
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Walter JK, Arnold RM, Curley MAQ, Feudtner C. Teamwork When Conducting Family Meetings: Concepts, Terminology, and the Importance of Team-Team Practices. J Pain Symptom Manage 2019; 58:336-343. [PMID: 31051202 PMCID: PMC6800049 DOI: 10.1016/j.jpainsymman.2019.04.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/19/2019] [Accepted: 04/22/2019] [Indexed: 11/18/2022]
Abstract
Family meetings, which bring together members of a seriously ill patient's family and the interprofessional team (IPT), have been widely recognized as promoting shared decision-making for hospitalized patients, particularly those in intensive care units. The planning and conducting of interprofessional family meetings are hampered, however, by a lack of clarity about who is doing what and when, which in turn can lead to inefficiencies and uncoordinated efforts. This article describes how members of the IPT interact with one another (what we have termed team-team practices), distinguishing these interactions from how the IPT engages directly with family members (team-family practices) in preparing for and conducting family meetings. Although most research and guidelines have focused on team-family practices that directly affect patient- and family-level outcomes (e.g., safety and satisfaction), team-team practices are needed to coordinate team contributions and optimize the skills of the diverse team. Team members' knowledge and attitudes also contribute to patient and family outcomes as well as team outcomes. Yet without attention to team-team practices before, during, and after a family meeting, the family-level outcomes are less likely to be achieved as are team well-being outcomes (e.g., reduced burnout and staff retention). Drawing upon team theory, we present a set of key concepts and corresponding terms that enable a more precise description of team-team practices and team-family practices, aiming to help with team training and evaluation and to enable future research of these distinct yet inter-related practices.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Robert M Arnold
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Martha A Q Curley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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232
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Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Larry A. Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Shannon M. Dunlay
- Division of Cardiology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Haider J. Warraich
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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233
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Nguyen LA. Draw me your disease: Obstacles to palliative intervention for patients with noncancer diagnoses. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e370-e371. [PMID: 31413043 PMCID: PMC6693603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Laurie-Anne Nguyen
- Completed the Enhanced Skills in Palliative Care Program at the University of Montreal in Quebec in June 2019, and will begin a family medicine group practice in the fall that includes palliative home care
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234
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Nguyen LA. Dessine-moi ta maladie. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:583-584. [PMID: 31413030 PMCID: PMC6693616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Laurie-Anne Nguyen
- Terminé le programme de compétences avancées en soins palliatifs à l'Université de Montréal (Québec) en juin 2019, et elle commence à l'automne une pratique en groupe de médecine de famille qui inclut des soins palliatifs à domicile
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235
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Hauptman PJ. How Much Validation Do We Need? J Card Fail 2019; 25:493. [PMID: 31345282 DOI: 10.1016/j.cardfail.2019.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Paul J Hauptman
- University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Knoxville, TN 37920. Tel.: 865 305 9290.
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Miller JL, Chung ML, Etaee F, Hammash M, Thylén I, Biddle MJ, Elayi SC, Czarapata MM, McEvedy S, Cameron J, Haedtke CA, Ski CF, Thompson DR, Moser DK. Missed opportunities! End of life decision making and discussions in implantable cardioverter defibrillator recipients. Heart Lung 2019; 48:313-319. [DOI: 10.1016/j.hrtlng.2019.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/06/2019] [Accepted: 04/12/2019] [Indexed: 12/29/2022]
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237
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Validation and Recalibration of Seattle Heart Failure Model in Japanese Acute Heart Failure Patients. J Card Fail 2019; 25:561-567. [DOI: 10.1016/j.cardfail.2018.07.463] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/22/2022]
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238
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Family caregiving for persons with advanced heart failure: An integrative review. Palliat Support Care 2019; 17:720-734. [DOI: 10.1017/s1478951519000245] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AbstractObjectiveThe unique needs of caregivers of those with advanced heart failure (HF) are not effectively being met, and reports of physical and mental health challenges are common. The objective is to identify the current state of the literature related to family caregivers of persons with advanced HF, ascertain gaps that require further exploration, and provide preliminary practice recommendations based on the results.MethodSystematic review of quantitative and qualitative literature. A search of CINAHL, Medline, EMBASE, and PubMed identified 24 articles that met inclusion criteria. Data were analyzed using the constant comparison method and coded. Thematic analysis was used to develop themes.ResultSixteen qualitative and seven quantitative studies met inclusion criteria. Analysis of these studies identified six key areas: (1) undertaking a journey in a state of flux, (2) gaining strength, (3) forgetting oneself along the way, (4) seeking out sources of support, (5) preparing for end of life, and (6) finding closure.Significance of resultsThe healthcare system currently struggles to meet the care demands of patients with chronic conditions such as advanced HF; as such, informal caregivers are undertaking key roles in the management of symptoms and promotion of the health of those with advanced HF. When caregivers are not adequately prepared for their role, both patient and caregiver well-being is compromised; therefore, a deeper understanding of the caregiving experience could assist in identifying the cause of caregiver anxiety and result in the development of strategies to minimize its effects. Overall, this review will also contribute to improving the current practice when working with caregivers of persons with advanced HF and serve as a basis for development of evidence informed interventions in the future.
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239
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Schichtel M, Wee B, Perera R, Onakpoya I, Albury C, Barber S. Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis. Heart 2019; 105:1316-1324. [PMID: 31118199 DOI: 10.1136/heartjnl-2019-314758] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Advance care planning (ACP) is widely advocated to contribute to better outcomes for patients suffering from heart failure. But clinicians appear hesitant to engage with ACP. Our aim was to identify interventions with the greatest potential to engage clinicians with ACP in heart failure. METHODS A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO for randomised controlled trials (RCTs) from inception to January 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (GRADE) and intervention synergy according to Template for Intervention Description and Replication. ORs were calculated for pooled effects. RESULTS Of 14 175 articles screened, we assessed the full text of 131 studies. 13 RCTs including 3709 participants met all of the inclusion criteria. The intervention categories of patient-mediated interventions (OR 5.23; 95% CI 2.36 to 11.61), reminder systems (OR 3.65; 95% CI 1.47 to 9.04) and educational meetings (OR 2.35; 95% CI 1.29 to 4.26) demonstrated a favourable effect to engage clinicians with the completion of ACP. CONCLUSION The review provides evidence from 13 published RCTs and suggests that interventions that involve patients to change clinical practice, reminder systems and educational meetings have the greatest effect in improving the implementation of ACP in heart failure.
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Affiliation(s)
- Markus Schichtel
- Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Bee Wee
- Sir Michael Sobell House Study Centre, Oxford University Hospital Trust NHS, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Barber
- Oxford Health NHS, Broadshires Health Centre, Carterton, Oxfordshire, UK
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240
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Morell E, Moynihan K, Wolfe J, Blume ED. Palliative care and paediatric cardiology: current evidence and future directions. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:502-510. [PMID: 31126897 DOI: 10.1016/s2352-4642(19)30121-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/20/2019] [Accepted: 02/27/2019] [Indexed: 12/24/2022]
Abstract
Although outcomes for children with heart disease have improved substantially over the past several decades, heart disease remains one of the leading causes of paediatric mortality. For children who progress to advanced heart disease, disease morbidity is high, with many children requiring multiple surgical interventions and long-term intensive care hospitalisations. Care for children with advanced heart disease requires a multidisciplinary approach, and opportunities for earlier integration of palliative care are being explored. This Viewpoint summarises the relevant literature over the past decade. We also identify gaps in parent and provider understanding of prognosis and communication, propose indications for palliative care consultation in paediatric advanced heart disease, and summarise attitudes and perceived barriers to palliative care consultation. Areas for additional research that we identify include paediatric cardiologist education, parental distress, socioeconomic disparities, and patient-reported outcomes. Interdisciplinary clinical and research efforts are required to further advance the field and improve integration of palliative care in the care of children with heart disease.
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Affiliation(s)
- Emily Morell
- Division of Pediatric Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Pediatric Palliative Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
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Stewart GC, Cascino T, Richards B, Khalatbari S, Mann DL, Taddei-Peters WC, Baldwin JT, Jeffries NO, Spino C, Stevenson LW, Aaronson KD. Ambulatory Advanced Heart Failure in Women: A Report From the REVIVAL Registry. JACC-HEART FAILURE 2019; 7:602-611. [PMID: 31078480 DOI: 10.1016/j.jchf.2019.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/15/2019] [Accepted: 02/17/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study sought to explore clinical characteristics and outcomes in women and men with ambulatory advanced heart failure (HF). BACKGROUND Women have been underrepresented in studies of advanced HF and have an increased mortality on the transplant waiting list and early after mechanical circulatory support (MCS). An increased understanding of the differential burden of HF between women and men is required to inform the use of mechanical circulatory support in ambulatory advanced HF patients. METHODS REVIVAL (Registry Evaluation for Vital Information on Ventricular Assist Devices in Ambulatory Life) is a prospective, observational study of 400 outpatients with chronic systolic HF, New York Heart Association functional class II to IV, and 1 additional high-risk feature. Clinical characteristics, quality of life, and functional capacity were compared between women and men, as was a primary composite endpoint of death, durable MCS, or urgent heart transplantation at 1 year. RESULTS REVIVAL enrolled 99 women (25% of the cohort) who had similar age, ejection fraction, INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles, medication use, and willingness to consider MCS as the men enrolled; however, women reported significantly greater limitations in quality of life with respect to physical limitation, reduced 6-min walk distance, and more frequent symptoms of depression. Nevertheless, 1-year combined risk of death, durable MCS, or urgent transplantation did not differ between women and men (24% vs. 22%; p = 0.94). CONCLUSIONS This study represents the largest report to date of women with ambulatory advanced HF receiving contemporary therapies. Systematic elicitation of patient-reported outcome measures uncovered an added burden of HF in women and may be an appropriate target of augmented support and intervention.
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Affiliation(s)
| | | | - Blair Richards
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan
| | - Shokoufeh Khalatbari
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan
| | - Douglas L Mann
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Catherine Spino
- University of Michigan School of Public Health, Ann Arbor, Michigan
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Responding to Ventricular Assist Device Recalls: An Ethical Guide for Mechanical Circulatory Support Programs. ASAIO J 2019; 66:363-366. [PMID: 31045923 DOI: 10.1097/mat.0000000000001005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We discuss the ethical responsibilities of mechanical circulatory support (MCS) programs in the context of cardiac device recalls, particularly the near-simultaneous recalls of Abbott HeartMate 3 left ventricular assist device (VAD) and Medtronic HVAD devices in 2018. We consider MCS programs' ethical responsibilities toward patients who already have VADs and their caregivers, as well as the impact of recalls on informed consent and shared decision-making in patients under consideration for new VADs. Timely communication to affected patients is imperative throughout the recall process. MCS programs are required to notify existing VAD patients about the nature and likelihood of risk. A press release from the device manufacturer or other press reports may occur before MCS teams learn about the recall. This leads to a disclosure gap, where the programs are actively deciding on an appropriate action plan while simultaneously fielding patient concerns. From an ethics standpoint, if all device users are owed the recall information from the manufacturer, all patients are owed the information from their treating team. The question is what to disclose specifically, and how.
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243
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Kaufman BD, Hollander SA, Zhang Y, Chen S, Bernstein D, Rosenthal DN, Almond CS, Murray JM, Burgart AM, Cohen HJ, Kirkpatrick JN, Blume ED. Compassionate deactivation of ventricular assist devices in children: A survey of pediatric ventricular assist device clinicians' perspectives and practices. Pediatr Transplant 2019; 23:e13359. [PMID: 30734422 DOI: 10.1111/petr.13359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study's objective was to investigate compassionate ventricular assist device deactivation (VADdeact) in children from the perspective of the pediatric heart failure provider. BACKGROUND Pediatric VAD use is a standard therapy for advanced heart failure. Serious adverse events may affect relative benefit of continued support, leading to consideration of VADdeact. Perspectives and practices regarding VADdeact have been studied in adults but not in children. METHODS A web-based anonymous survey of clinicians for pediatric VAD patients (<18 years) was sent to list-serves for the ISHLT Pediatric Council, the International Consortium of Circulatory Assist Clinicians Pediatric Taskforce, and the Pediatric Cardiac Intensivist Society. RESULTS A total of 106 respondents met inclusion criteria of caring for pediatric VAD patients. Annual VAD volume per clinician ranged from <4 (33%) to >9 (20%). Seventy percent of respondents had performed VADdeact of a child. Response varied to VADdeact requests by parent or patient and was influenced by professional degree and region of practice. Except for the scenario of intractable suffering, no consensus on VADdeact appropriateness was reported. Age of child thought capable of making informed requests for VADdeact varied by subspecialty. The majority of respondents (62%) do not feel fully informed of relevant legal issues; 84% reported that professional society supported guidelines for VADdeact in children had utility. CONCLUSION There is limited consensus regarding indications for VADdeact in children reported by pediatric VAD provider survey respondents. Knowledge gaps related to legal issues are evident; therefore, professional guidelines and educational resources related to pediatric VADdeact are needed.
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yulin Zhang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sharon Chen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jenna M Murray
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Burgart
- Anesthesiology, Perioperative and Pain Medicine, Stanford Center for Biomedical Ethics, Stanford University, Palo Alto, California
| | - Harvey J Cohen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - James N Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center, Seattle, Washington
| | - Elizabeth D Blume
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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244
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Palliative care needs of heart failure patients in China: putting people first. Curr Opin Support Palliat Care 2019; 12:10-15. [PMID: 29206703 DOI: 10.1097/spc.0000000000000315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recognizing the rising prevalence of heart failure in China, patients with heart failure have substantial palliative needs. This review highlights recent evidence on the epidemic of heart failure, identifies needs and potential benefit of palliative care in heart failure, and sets future strategic policy and research directions in China. RECENT FINDINGS Epidemiological studies demonstrate the prevalence of heart failure among women is higher than men in China and increases substantially with age. However, few studies have addressed the palliative needs of Chinese heart failure patients. The main themes from this review include: Healthcare providers should be culturally sensitive whenever assessing symptoms and needs. Locally validated, brief outcome measures are called for to identify symptoms and needs of Chinese heart failure patients. Palliative care should be better integrated into the management of heart failure through increased training for healthcare providers, policy development, financial support, and cultural acceptance of palliative care. SUMMARY Large-scale epidemiological studies are urgently needed to assess the current situation of heart failure in China, alongside interventional studies to drive the development of innovative palliative care services to address the needs of Chinese heart failure patients.
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245
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Birriel B, Alonso W, Kitko LA, Hupcey JE. Family caregiver-reported outcomes regarding decision-making for left ventricular assist device implantation. Heart Lung 2019; 48:308-312. [PMID: 30981423 DOI: 10.1016/j.hrtlng.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/05/2019] [Accepted: 03/12/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Family caregivers (FCGs) often participate in the decision for their loved one to receive a left ventricular assist device (LVAD). Little is known about the contribution of FCGs to this complex decision. OBJECTIVES To investigate family caregiver-reported outcomes related to decision-making for LVAD implantation and their experiences post-implantation. METHODS Descriptive thematic analysis was used to analyze longitudinal data. Thematic saturation was achieved. RESULTS Three key themes emerged from the data. The main theme in the pre-implantation period was: Not a decision. The two themes in the post-implantation period were: More satisfaction than regret and Unanticipated situational change. CONCLUSIONS Family caregiver-reported outcomes inform clinical practice and future research. FCGs of LVAD recipients did not see viable alternatives to LVAD implantation, were generally satisfied with post-implantation outcomes, and experienced unexpected life changes in the post-implantation period despite feeling prepared preoperatively. Education of both LVAD recipients and their FCGs must be optimized.
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Affiliation(s)
- Barbara Birriel
- The Pennsylvania State University, College of Nursing, 90 Hope Drive, 1300 Academic Support Building / A110, Hershey, PA 17033, United States.
| | - Windy Alonso
- The Pennsylvania State University, College of Nursing, 90 Hope Drive, 1300 Academic Support Building / A110, Hershey, PA 17033, United States; University of Nebraska Medical Center, College of Nursing, 985330 Nebraska Medical Center, Omaha, NE 68198-5330, United States
| | - Lisa A Kitko
- The Pennsylvania State University, College of Nursing, 90 Hope Drive, 1300 Academic Support Building / A110, Hershey, PA 17033, United States; The Pennsylvania State University, College of Nursing, 307H Nursing Sciences Building, University Park, PA 16802, United States
| | - Judith E Hupcey
- The Pennsylvania State University, College of Nursing, 90 Hope Drive, 1300 Academic Support Building / A110, Hershey, PA 17033, United States
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Akita K, Kohno T, Kohsaka S, Shiraishi Y, Nagatomo Y, Goda A, Mizuno A, Sujino Y, Fukuda K, Yoshikawa T. Prognostic Impact of Previous Hospitalization in Acute Heart Failure Patients. Circ J 2019; 83:1261-1268. [PMID: 30944274 DOI: 10.1253/circj.cj-18-1087] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The natural course of heart failure (HF) is typically associated with repeated hospitalizations, and subsequently, patient prognosis deteriorates. However, the precise relationship between repeated admissions for HF and long-term prognosis remains unknown. Methods and Results: We analyzed data from 1,730 consecutive acute HF patients registered in the West Tokyo Heart Failure (WET-HF) registry between June 2005 and April 2014 (median age, 76 years). Patients were divided into 3 groups according to the number of previous HF admissions at the time of the index admission (0, n=876 [55.4%]; 1, n=425 [26.9%]; ≥2, n=279 [17.7%] previous admissions). A history of multiple previous admissions was an independent predictor for all-cause death and HF readmission in reference to a history of a single previous admission (hazard ratio (HR), 1.53; 95% confidence interval (CI) 1.10-2.13; HR, 1.90 95% CI, 1.47-2.44, respectively) or no previous admissions (HR, 1.37, 95% CI, 1.01-1.85; HR, 2.83, 95% CI, 2.19-3.65, respectively). On the other hand, a history of a single previous admission was an independent predictor for HF readmission in reference to a history of no previous admissions (HR, 1.51, 95% CI, 1.18-1.92), but not for all-cause death (HR, 0.89, 95% CI, 0.66-1.20). CONCLUSIONS Based on a contemporary multicenter HF registry, a history of multiple previous HF admissions was revealed as an independent, strong risk factor of adverse events following the index admission. The number of hospitalizations could be a simple and important surrogate indicating subsequent adverse events in patients with HF.
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Affiliation(s)
- Keitaro Akita
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Takashi Kohno
- Division of Cardiology, Department of Medicine, Keio University School of Medicine
| | - Shun Kohsaka
- Division of Cardiology, Department of Medicine, Keio University School of Medicine
| | - Yasuyuki Shiraishi
- Division of Cardiology, Department of Medicine, Keio University School of Medicine
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College
| | - Ayumi Goda
- Department of Cardiology, Kyorin University School of Medicine
| | - Atsushi Mizuno
- Department of Cardiology, St. Lukes International Hospital
| | - Yasumori Sujino
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Keiichi Fukuda
- Division of Cardiology, Department of Medicine, Keio University School of Medicine
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247
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Masterson Creber R, Russell D, Dooley F, Jordan L, Baik D, Goyal P, Hummel S, Hummel EK, Bowles KH. Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Fail 2019; 6:371-378. [PMID: 30835970 PMCID: PMC6437549 DOI: 10.1002/ehf2.12398] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/23/2018] [Indexed: 01/14/2023] Open
Abstract
AIMS Estimating survival is challenging in the terminal phase of advanced heart failure. Patients, families, and health-care organizations would benefit from more reliable prognostic tools. The Palliative Performance Scale Version 2 (PPSv2) is a reliable and validated tool used to measure functional performance; higher scores indicate higher functionality. It has been widely used to estimate survival in patients with cancer but rarely used in patients with heart failure. The aim of this study was to identify prognostic cut-points of the PPSv2 for predicting survival among patients with heart failure receiving home hospice care. METHODS AND RESULTS This retrospective cohort study included 1114 adult patients with a primary diagnosis of heart failure from a not-for-profit hospice agency between January 2013 and May 2017. The primary outcome was survival time. A Cox proportional-hazards model and sensitivity analyses were used to examine the association between PPSv2 scores and survival time, controlling for demographic and clinical variables. Receiver operating characteristic curves were plotted to quantify the diagnostic performance of PPSv2 scores by survival time. Lower PPSv2 scores on admission to hospice were associated with decreased median (interquartile range, IQR) survival time [PPSv2 10 = 2 IQR: 1-5 days; PPSv2 20 = 3 IQR: 2-8 days] IQR: 55-207. The discrimination of the PPSv2 at baseline for predicting death was highest at 7 days [area under the curve (AUC) = 0.802], followed by an AUC of 0.774 at 14 days, an AUC of 0.736 at 30 days, and an AUC of 0.705 at 90 days. CONCLUSIONS The PPSv2 tool can be used by health-care providers for prognostication of hospice-enrolled patients with heart failure who are at high risk of near-term death. It has the greatest utility in patients who have the most functional impairment.
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Affiliation(s)
- Ruth Masterson Creber
- Division of Health Informatics, Department of Healthcare Policy and ResearchWeill Cornell Medicine425 East Street, Suite 301New YorkNY10065USA
| | - David Russell
- Visiting Nurse Service of New YorkNew YorkNY10021USA
- Appalachian State UniversityBooneNC28608USA
| | | | | | - Dawon Baik
- Columbia University School of NursingNew YorkNY10032USA
| | - Parag Goyal
- Department of MedicineWeill Cornell MedicineNew YorkNY10065USA
| | - Scott Hummel
- Department of MedicineUniversity of Michigan, Ann Arbor Veterans Affairs Health SystemAnn ArborMI48105USA
| | - Ellen K. Hummel
- Department of MedicineUniversity of Michigan, Ann Arbor Veterans Affairs Health SystemAnn ArborMI48105USA
| | - Kathryn H. Bowles
- University of Pennsylvania School of NursingPhiladelphiaPA19104USA
- Center for Home Care Policy and ResearchVisiting Nurse Service of New YorkNew YorkNY10021USA
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248
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Bagcivan G, Bakitas M, Palmore J, Kvale E, Nichols AC, Howell SL, Dionne-Odom JN, Mancarella GA, Osisami O, Hicks J, Huang CHS, Tucker R. Looking Back, Moving Forward: A Retrospective Review of Care Trends in an Academic Palliative and Supportive Care Program from 2004 to 2016. J Palliat Med 2019; 22:970-976. [PMID: 30855204 DOI: 10.1089/jpm.2018.0410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To examine a rural-serving HBPC program's 12-year experience and historical trends to inform future program direction and expansion. Background: There is limited information about longitudinal trends in mature hospital-based palliative care (HBPC) programs serving racially diverse rural populations. Methods: This is a retrospective cross-sectional study of operational and patient-reported outcomes from the University of Alabama at Birmingham (UAB) Center for Palliative and Supportive Care (CPSC) inpatient (n=11,786) and outpatient (n=315) databases from October 2004 to March 2016. Results: Inpatients were a mean age of 63.7 years, male (50.1%), white (62.3%), general medicine referred (19.5%), primarily for goals of care (84.4%); 47.1% had "do not resuscitate/do not intubate" status and 46.9% were transferred to the Palliative Care and Comfort Unit (PCCU) after consultation. Median time from admission to consultation was three days, median PCCU length of stay (LOS) was four days, and median hospital LOS was nine days. Increased emergency department and cardiology referrals were notable in later years. Outpatients' mean age was 53.02 years, 63.5% were female, 76.8% were white, and 75.6% had a cancer diagnosis. Fatigue, pain, and disturbed sleep were the most common symptoms at the time of the visit; 34.6% reported mild-to-moderate depressive symptoms. Of patients reporting pain (64.8%), one-third had 50% or less relief from pain treatment. Discussion: The CPSC, which serves a racially diverse rural population, has demonstrated robust growth. We are poised to scale and spread our lessons learned to underserved communities.
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Affiliation(s)
- Gulcan Bagcivan
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama.,2Koc University School of Nursing, İstanbul, Turkey
| | - Marie Bakitas
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama.,3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jackie Palmore
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Kvale
- 5Division of Geriatrics and Palliative Care, Department of Medicine, University of Texas, Austin, Texas
| | - Ashley C Nichols
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen L Howell
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - J Nicholas Dionne-Odom
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama.,3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gisella A Mancarella
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Oladele Osisami
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Jennifer Hicks
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chao-Hui Sylvia Huang
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rodney Tucker
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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249
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Anscombe R, Middlemiss T. Palliative care in end‐stage heart failure: experience of a collaborative approach in a secondary care setting. Intern Med J 2019; 49:404-407. [DOI: 10.1111/imj.14218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/22/2018] [Accepted: 12/05/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Russell Anscombe
- Cardiology DepartmentHutt Valley District Health Board Lower Hutt New Zealand
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250
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Abstract
Heart failure (HF) affects 2.4% of the adult population in the United States and is associated with high health care costs. Medical and device therapy delay disease progression and improve survival in HF with reduced ejection fraction. Stage D HF is characterized by significant functional limitation, frequent HF hospitalization for decompensation, intolerance of medical therapy, use of inotropes, and high diuretic requirement. Advanced therapies with left ventricular assist devices and cardiac transplantation reduce mortality and improve quality of life, and early referral to specialized centers is imperative for patient selection and success with these therapies.
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Affiliation(s)
- Maya H Barghash
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA.
| | - Sean P Pinney
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
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