The last six months of life for patients with congestive heart failure

Integrating Palliative Care into Disease Management Guidelines

BACKGROUND

Palliative care should not be reserved for those who are close to dying; as a comprehensive approach to minimizing illness-related suffering, it is appropriate for patients with significant illness from the time of diagnosis on.

OBJECTIVE

The American Hospice Foundation Guidelines Committee's initiative aims to provide a practical approach for guideline writers and others to integrate palliative care into disease management and care services whenever it is relevant.

DESIGN

A consensus approach was used to design recommendations for upgrading existing disease management and service guidelines to include palliative care.

RESULTS

A template is described for identifying stages in disease management guidelines when integration of palliative care is appropriate: (1) Introductory sections to disease management guidelines should include prognosis and other disease consequences; (2) Diagnostic sections should include recommendations for conducting a whole patient assessment; (3) Treatment sections should include discernment of patient goals for care, continuous goal reassessment, palliative care interventions to reduce suffering as needed, and treatment decisions should include discussion of the type of expected improvement. Service guidelines should note the role of interdisciplinary team care as well as palliative care consultative or care services; (4) Sections that conclude the care provided to incurable patients should not end without recommendations on grief and bereavement care, and care during the last hours of living.

CONCLUSION

The American Hospice Foundation Guidelines Committee recommends integration of relevant aspects of palliative care in introductory, diagnostic, treatment, and closing sections of management guidelines for all significant illnesses.

End-of-life preferences in elderly patients admitted for heart failure

BACKGROUND

Heart failure is increasing in prevalence and incidence, with considerable mortality among the elderly.

AIM

To determine preferences concerning cardiopulmonary-resuscitation (CPR) and end-of-life care in elderly patients hospitalized for heart failure.

DESIGN

Prospective interview-based survey.

METHODS

Patients >64 years old admitted for acute heart failure were interviewed to address their preferences regarding end-of-life care and cardio-pulmonary resuscitation (CPR) when facing the last stages of their disease.

RESULTS

We interviewed 80 patients (mean age 79 years; 58% women). Thirty-two (40%) expressed a wish not to have CPR. Only two had previously discussed their CPR preferences with their physicians. When recovery from the illness was considered unlikely, 40 (50%) participants preferred to receive treatment at home, 32 (40%) preferred in-hospital management, and 8 (10%) were unsure. Thirty-three patients (41%) expressed a desire for spiritual support, 38 (48%) said not and the remaining 9 (11%) were indifferent.

DISCUSSION

Advance planning of end-of-life procedures and doctor-patient communication regarding these items remains poor and must be improved.

Age, functional capacity, and health-related quality of life in patients with heart failure

BACKGROUND

Although heart failure disproportionately affects older persons and is associated with significant physical disability, existing data on physical limitations and health-related quality of life (HRQL) derive largely from studies of younger subjects. We compared the relationship between functional limitation and HRQL between older and younger patients with heart failure.

METHODS AND RESULTS

We evaluated 546 outpatients with heart failure enrolled in a multicenter prospective cohort study. At baseline and 6 +/- 2 weeks later, functional status was assessed by New York Heart Association (NYHA) classification and 6-minute walk testing. HRQL was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Comparing older (age >65 years, n = 218) and younger patients (n = 328), we assessed baseline HRQL across strata of functional status. In the 484 patients who completed follow-up (194 older and 290 younger patients), we also assessed the changes in HRQL associated with changes in functional status over time. At baseline, older patients had better HRQL than younger patients (mean KCCQ score 60 +/- 25 versus 54 +/- 28, P = .005) in spite of worse NYHA class (mean 2.54 versus 2.35, P < .001) and lower 6-minute walk distances (824 +/- 378 versus 1064 +/- 371 feet, P < .001). After multivariable adjustment including baseline NYHA class, older age was independently correlated with better HRQL (beta = +7.9 points, P < .001). At follow-up, older patients with a deterioration in NYHA class experienced marked declines in HRQL compared with younger patients (mean HRQL change of -14.4 points versus +0.3 points, respectively, P < .001). Analyses using 6-minute walk distance as the functional measure yielded similar results.

CONCLUSIONS

Although older patients with heart failure have relatively good HRQL in spite of significant functional limitations, they are at risk for worsening HRQL with further decline in functional status. These results underscore the importance of treatments aimed at maintaining functional status in older persons with heart failure, including those with significant baseline functional limitations.

Pattern of Care at the End of Life: Does Age Make a Difference in What Happens to Women With Breast Cancer?

Purpose

In the last 40 years, palliative care has become the standard of care at the end of life. However, there are limited data about the degree of access to such care at the population level.

Methods

Using administrative databases, a care-oriented profile score was created to describe the care received during the last 6 months of life for 2,291 women who were dying of breast cancer in the province of Quebec, Canada, during the years 1992 to 1998. The care received was described through indicators of care that would reflect a palliative care philosophy. An ordinal score was developed for comparisons among age groups of women using a proportional odds ordinal regression model.

Results

We found that only 6.9% of women died at home, while 69.6% of them died in acute care beds. While most women (75%) had few indicators indicating provision of palliative care during the last 6 months of life, younger women (< 50 years) were even less likely (odds ratio, 0.70; 95% CI, 0.54 to 0.90) to receive such care compared with middle aged women (50 to 59 years; serving as the reference group), while older women (> 70 years) were more likely (odds ratio, 1.85; 95% CI, 1.49 to 2.29).

Conclusion

Our study indicates that a sizeable proportion of women terminally ill from breast cancer do not have access to palliative care—an issue that health care policy makers may wish to explore further.

Thoughts of patients with advanced heart failure on dying

OBJECTIVE

To explore, over a one-year period, the ideas and attitudes of patients with end-stage cardiac failure concerning dying.

DESIGN

Prospective longitudinal multiple case study using qualitative interview techniques.

PARTICIPANTS

Thirty-one patients from two hospitals who fulfilled one or more of the following criteria: NYHA III or IV, ejection fraction < 25%, at least one hospitalization for heart failure.

MAIN OUTCOMES

Statements of patients with advanced heart failure, expressed in semi-structured interviews, concerning the quality of dying and medical decisions at the end of life.

RESULTS

Many respondents only thought about death during exacerbations. Mentioned aspects of appropriate dying include: a degree of usefulness, prognostic knowledge, appropriate duration and mental awareness. Few respondents were in favour of euthanasia or suicide, but all wanted life-prolonging treatment to be withheld or withdrawn when appropriate.

CONCLUSIONS

Our study found some elements of 'appropriate dying' that differ from other studies and that are relatively specific for advanced heart failure. The tendency of patients not to think about death raises ethical concerns.

Terminal dyspnea and respiratory distress

Dyspnea is a subjective experience that can be reported by the patient. Respiratory distress is an observable corollary, and represents the physical or emotional suffering that results from the experience of dyspnea. Recognizing and understanding this subjective phenomenon poses a challenge to intensive care unit (ICU) clinicians when caring for the patient who is dying in the ICU. Dyspnea and cognitive impairment are highly prevalent in the terminally ill ICU patient. A Respiratory Distress Observation Model may provide a theoretical foundation for the assessment of this phenomenon that is grounded in emotional and autonomic domains of neurologic function. Treatment of dyspnea and respiratory distress relies on nonpharmacologic interventions and opioids and sedatives. As with pain, the treatment of dyspnea and respiratory distress relies on close evaluation of the patient and treatment to satisfactory effect. Empirical evidence suggests that quality care with control of distressing symptoms does not hasten death. Withholding opioids or sedatives in the face of unrelieved dyspnea or respiratory distress has no moral foundation.

Removing the boundaries: palliative care for patients with heart failure

AIM

This study aimed to explore the experiences of patients with severe heart failure and identify their needs for palliative care.

METHOD

A qualitative design was chosen. Semi-structured interviews were used for data collection and patients were interviewed in their homes. The sample consisted of 20 patients with a confirmed diagnosis of heart failure. Patients were between 60 and 83 years.

RESULTS

Patients reported difficulties in walking, extreme fatigue and problems managing daily activities. Having to rely on family, friends and neighbours was common, causing feelings of being a burden, loneliness and isolation. Patients talked about dying as well as their fears and frustrations in living with heart failure. Barriers to accessing information and social services were identified. None of these patients had been referred to specialist palliative care services.

CONCLUSIONS

Patients' experiences were similar to those of patients living with advanced cancer and yet they received little support. Comprehensive routine assessment of the palliative care needs of patients living with severe heart failure is recommended.

Living with advanced heart failure: a prospective, community based study of patients and their carers

BACKGROUND

Services for people with heart failure are under-developed. The perspectives of patients, their informal and professional carers should inform development of service models.

AIM

To describes how patients and carers view health and social care in the last year of life.

METHODS

Qualitative, serial interviews at three monthly intervals with 20 patients (New York Heart Association Grade IV heart failure), their main informal carer, general practitioner and other key professionals in an urban, community setting in SE Scotland. These were tape-recorded, and analysed with the aid of the qualitative data analysis package NVivo and techniques of narrative analysis.

RESULTS

112 interviews comprised; patients (50), informal carers (27), professionals (30), bereavement interviews (5). Patients with heart failure and their carers felt unsupported by services, and had little understanding of their condition, treatment aims or prognosis. Quality of life was severely compromised by physical limitations and psychological morbidity. Psychosocial care, patient and carer education, co-ordination of care between primary and secondary sectors and with social services was generally poor. Many patients had no access to a heart failure nurse specialist. A palliative care approach was rarely apparent.

CONCLUSIONS

Patients with advanced heart failure may benefit from specific models of care with strategic planning across primary and secondary care, and involvement of health and social care services and specialist palliative care providers. Models of care, which focus on quality of life, symptom control, and psychosocial support for patients and their families while continuing active treatment, should be developed.

Hospice as an alternative model of care for older patients with end-stage heart failure

The end of life for patients with end-stage heart failure is often characterized by pain, shortness of breath, and diminished quality of life, indicating a lack of adequate care necessary for patients to experience a good death. The vast majority of those who die from heart failure are 65 or older and potentially eligible for the Medicare Hospice Benefit. Yet, only about 10% of patients with end-stage heart failure actually enroll in hospice programs. Lack of enrollment into hospice has been attributed to a variety of factors including a lack of understanding of the availability of hospice as an option for those with heart failure. While improving models of care for patients with heart failure has been of great interest during the last two decades, little is known about the benefits of hospice as a model for care in patients with end-stage heart failure. Nursing must participate in research that explores options of either improving current models of care or developing new and improved models of care for patients with heart failure.

Patient perceptions of an outpatient palliative care intervention: "It had been on my mind before, but I did not know how to start talking about death..."

Little is known about whether introducing palliative care to seriously ill outpatients continuing to pursue treatment of their disease is acceptable or beneficial to patients. Intervention patients in a trial of outpatient palliative care consultation completed structured exit interviews as part of a qualitative study. Participants had advanced heart or lung disease or cancer, and a life expectancy between 1 to 5 years as estimated by their primary care physician (PCP). Thirty-five of 50 intervention patients (70%) completed the final interview. Twenty-one patients (60%) reported that the team uncovered previously undiagnosed medical problems, 12 patients (34.3%) reported decreased primary care visits, and 8 (22.9%) reported avoiding emergency department visits. Most patients reported improved satisfaction with family caregivers (85.7%), PCPs (80%), and the medical center (65.7%). Most patients (68.6%) would have wanted the intervention even earlier in the course of their illness. Seriously ill outpatients found palliative care acceptable and helpful, reporting increased satisfaction and decreased health care utilization.

Heart Failure in the Elderly

Incidence and prevalence of heart failure are particularly common with advancing age, with notoriously grim prognoses. The absolute number of heart failure patients will undoubtedly surge as the population of older adults continues to escalate. This review emphasizes the importance of factors inherent in aging itself and the resulting predisposition to disease. Physiologic changes associated with cardiovascular aging fundamentally increase susceptibility to heart failure and to complexity of heart failure management. Likewise, typical age-associated diet and lifestyle changes compound risks of heart failure through mechanisms connected to the substrate of disease. In this review, the authors first summarize the demographics of heart failure and the intrinsic aspects of aging and lifestyle that predispose to heart failure. They then expand on related intricacies of diagnosis and therapy. Orientation to heart failure, particularly as a disease of aging, can help critically refine management of acute and chronic disease, as well as foster preventive strategies to reduce incidence of this common malady.

Palliative Care Management: A Veterans Administration Demonstration Project

As part of a Veterans Health Administration (VA) commitment to improve end-of-life care the VA Greater Los Angeles Healthcare System (GLA) implemented Pathways of Caring, a 3-year demonstration project targeting patients with inoperable lung cancer and advanced heart failure and chronic lung disease. The program utilized case-finding for early identification of poor-prognosis patients, interdisciplinary palliative assessment, and intensive nurse care coordination to optimize symptom management, continuity and coordination of services across providers and care settings, and support for families. Program evaluation used patient and family surveys as well as reviews of medical records and administrative databases to assess processes and outcomes of care. Despite significant programmatic challenges including organizational instability and evaluation design issues, the program achieved measurable success including high rates of advance care planning, hospice enrollment, and death at home, and low end-of-life hospital and Intensive Care Unit (ICU) use. As a result of its success, the program will be expanded and its care model extended institution-wide.

CHOICES: Promoting Early Access to End-of-Life Care Through Home-Based Transition Management

CHOICES is a comprehensive home-based care coordination program designed to bridge the gap between home health and hospice for Medicare + Choice enrollees with advanced chronic illness in San Francisco's East Bay region. Key elements of the program include physician education, enrollment of patients with high disease burden who may not be terminally ill, co-management of care with the primary physician, and an advanced practice clinical team that provides comprehensive in-home assessments, a flexible mix of life-prolonging and palliative care that evolves with disease progression, focused education and advance planning, and caregiver support. During a 42-month demonstration, 208 patients were enrolled in the program. Eighty percent had a non-cancer diagnosis; 40% were people of color. After an 8-month follow-up, 44% of the study cohort had died in the program or after transfer to hospice, 51% had been discharged, and 5% remained active. Median length of stay for decedents was 260 days. Preliminary evidence supports the program's feasibility and acceptability to patients, families, physicians, and agency partners. However, the uncertain future of Medicare + Choice and of managed care may jeopardize the program's sustainability. Policymakers and taxpayers will need to determine how to care for the growing number of chronically ill elderly who wish to remain at home as illness advances. The care needs of these patients and their families may overwhelm a health system organized around hospital treatment of acute illness.

Management of heart failure in the elderly

Chronic heart failure is an epidemic disorder in the elderly population. The frequent coexistence of comorbid illnesses and psychosocial issues in older persons often makes diagnosis and management difficult. Physicians must be aware of the current diagnostic modalities and proven therapies as they apply to elderly patients in order to achieve optimal outcomes. This article reviews new approaches to the diagnosis of heart failure, and discusses the latest evidence for both pharmacologic and nonpharmacologic treatment for this condition. Multidisciplinary strategies for the management of heart failure and end-of-life care are also briefly discussed.

The last 2 years of life: functional trajectories of frail older people

OBJECTIVES

To characterize the functional trajectories during the last 2 years of life of patients with progressive frailty, with and without cognitive impairment, and to assess whether it was possible to identify discrete functional indicators that signal the end of life.

DESIGN

A retrospective analysis of functional trajectories during the last 24 months of life.

SETTING

Twelve demonstration sites of the Program of All-inclusive Care for the Elderly (PACE). PACE cares for frail older people who meet criteria for nursing home placement, with the goal of keeping the patient at home.

PARTICIPANTS

Nine hundred seventeen patients who died while enrolled in PACE.

MEASURES

At PACE entry and every 3 months thereafter, data were collected about the degree of dependence (none, partial, or full) in bathing, eating, and walking and the degree of incontinence (none, bladder, or bowel). Cognitive impairment was defined as six or more errors on the Short Portable Mental Status Questionnaire. To describe the end-of-life trajectories of patients, data were analyzed from observational windows of time, beginning with the patients' dates of death and extending backward in time to 24 months before death. Each analytical window was 3 months in duration. For each of the functional measures, the probability of functional deterioration in the last 2 years of life in patients with (64%) and without (36%) cognitive impairment was also compared.

RESULTS

The mean age at death was 84; 69% of patients were women. For patients with and without cognitive impairment, a prolonged, steady increase in the rates of functional dependence that were evident at least 1 year before death, rather than sudden increases in functional dependence shortly before death, characterized the functional trajectories. It was not possible for any of the four measures to detect a time point before death at which there was an abrupt decline in function likely to signal impending death. For each measure, patients with cognitive impairment declined earlier, were more likely than patients without cognitive impairment to have the maximal level of dependence in the 0- to 3-month window before death (e.g., 56% vs 30% for mobility, P <.001), and were more likely to decline in the 2 years before death (e.g., 56% vs 36% for mobility, P <.001).

CONCLUSION

Patients with advanced frailty, with or without cognitive impairment, have an end-of-life functional course marked by slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches. Patients with cognitive impairment have particularly high rates of functional impairment at the time of death. These results suggest that end-of-life care systems that are targeted toward patients with functional trajectories clearly suggesting impending death (such as the Medicare hospice benefit) are poorly suited to older people dying with progressive frailty.

Barriers to hospice care among older patients dying with lung and colorectal cancer

PURPOSE

To identify factors associated with hospice enrollment and length of stay in hospice among patients dying with lung or colorectal cancer.

METHODS

We used the Linked Medicare-Tumor Registry Database to conduct a retrospective analysis of the last year of life among Medicare beneficiaries diagnosed with lung or colorectal cancer at age > or = 66 years between January 1, 1973, and December 31, 1996, in the Surveillance, Epidemiology, and End Results Program who died between January 1, 1988, and December 31, 1998. Our outcomes of interest were time from cancer diagnosis to hospice enrollment and length of stay in hospice care. We used Cox proportional hazards regression to adjust for demographic and clinical information.

RESULTS

We studied elderly patients dying with lung cancer (n = 62,117) or colorectal cancer (n = 57,260). Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death. Median length of stay for hospice patients with lung and colorectal cancer was 25 and 28 days, respectively. Overall, 20% of patients entered hospice within 1 week of death, whereas 6% entered more than 6 months before death. Factors associated with later hospice enrollment include being male; being of nonwhite, nonblack race; having fee-for-service insurance; and residing in a rural community. Many of these factors also were associated with shorter stays in hospice.

CONCLUSION

Although use of hospice care has increased dramatically over time, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance continue to experience delays in hospice enrollment.

Cardiorespiratory Nurses’ Perceptions of Palliative Care in Nonmalignant Disease: Data for the Development of Clinical Practice

Nurses lack a comprehensive body of scientific knowledge to guide the palliative care of patients with nonmalignant conditions. Current knowledge and practice reveal that nurses in many instances are not well prepared to deal with death and dying. Focus groups were used in an exploratory study to examine the perceptions of palliative care among cardiorespiratory nurses (n = 35). Content analysis was used to reveal themes in the data. Four major themes were found: (1) searching for structure and meaning in the dying experience of patients with chronic disease, (2) lack of a treatment plan and a lack of planning and negotiation, (3) discomfort in dealing with death and dying, and (4) lack of awareness of palliative care philosophies and resources. The information derived from this sample of cardiorespiratory nurses represents a complex interplay between personal, professional, and organizational perspectives on the role of palliative care in cardiorespiratory disease. The results of the study suggest a need for nurses to be equipped on both an intellectual and a practical level about the concept of palliative care in nonmalignant disease.

Specialist nurse management programmes: economic benefits in the management of heart failure

Chronic heart failure (CHF) is a modern-day epidemic in most developed countries. As such, it is both common and costly. Contrary to the impression given by clinical trial data, CHF mainly affects older individuals with approximately equal numbers of men and women and concurrent disease profiles likely to complicate or even prohibit the application of proven treatments. It is within this context that there has been an increasing interest in specific CHF-management programmes designed to limit costly hospital use in typically older individuals at high risk for poor quality of life, recurrent readmissions and premature death. This paper examines the evidence to suggest that CHF programmes involving individualised multidisciplinary post-discharge healthcare, with a major focus on specialist nurse management to ensure that the patient receives optimal treatment, are clinically and economically effective in reducing the typical burden imposed by CHF. These programmes appear to be most effective in 'high-risk' patients who typically have recurrent readmissions in high-cost units. Overall, the literature suggests that these programmes are able to reduce recurrent hospital stay by 30-50% relative to usual care (even in the presence of gold-standard treatment) in the short to medium term with comparable cost benefits. Recent data from a management programme involving a cohort of typically older and fragile patients with CHF in Australia showed that at 3 years post index admission, hospital utilisation costs were reduced by one-third relative to usual care. The potential for enormous cost benefits (both in terms of absolute cost savings and in terms of facilitating a more efficient healthcare system) if a specialist nurse programme of care was applied in the form of a UK-wide heart failure service was also recently examined. Based on year 2000 activity levels, it was found that for each specialist heart failure nurse appointed in the UK (with a caseload of 200-250 patients per annum), nominal savings of pound 49 000 per annum could be generated in order to make the healthcare system more efficient.

Deaths from heart failure in general practice: implications for palliative care

Trial and observational research indicates a high one-year mortality with a significant potential for specialist palliative care for patients with heart failure. A community observational study was undertaken in two general practices, with a total population of 21,000. There were three objectives: to determine the prevalence of symptomatic heart failure, to document mortality in the cohort over six and 12 months, and to establish the population in which a palliative care approach was adopted. A search of the computerized medical records yielded 548 patients with symptomatic heart failure (2.6% of the total study population). Over a six-month period, 31 patients (6% of the cohort) died and over a 12-month period 64 patients (12% of the cohort) died. 'Sudden death' was recorded in the records of 14 patients and death from coexisting malignancy was recorded in seven patients. A palliative care approach in patients not dying suddenly or of malignancy was recorded in 21 cases (33% of the total deaths). The findings do not indicate a high mortality in patients with symptomatic heart failure in general practice. The role of specialist palliative care in many cases would appear to be limited by the difficulty in predicting prognosis. In a significant number of cases, general practitioners appear to be aware of the need for a palliative care approach in patients dying of heart failure.

Patients' perspectives on physician skill in end-of-life care: differences between patients with COPD, cancer, and AIDS

OBJECTIVES

Patients' views of physician skill in providing end-of-life care may vary across different diseases, and understanding these differences will help physicians improve the quality of care they provide for patients at the end of life. The objective of this study was to examine the perspectives of patients with COPD, cancer, or AIDS regarding important aspects of physician skill in providing end-of-life care.

DESIGN

Qualitative study using focus groups and content analysis based on grounded theory.

SETTING

Outpatients from multiple medical settings in Seattle, WA.

PATIENTS

Eleven focus groups of 79 patients with three diseases: COPD (n = 24), AIDS (n = 36), or cancer (n = 19).

RESULTS

We identified, from the perspectives of patients, the important physician skills for high-quality end-of-life care. Remarkable similarities were found in the perspectives of patients with COPD, AIDS, and cancer, including the importance of emotional support, communication, and accessibility and continuity. However, each disease group identified a unique theme that was qualitatively more important to that group. For patients with COPD, the domain concerning physicians' ability to provide patient education stood out as qualitatively and quantitatively more important. Patients with COPD desired patient education in five content areas: diagnosis and disease process, treatment, prognosis, what dying might be like, and advance care planning. For patients with AIDS, the unique theme was pain control; for patients with cancer, the unique theme was maintaining hope despite a terminal diagnosis.

CONCLUSIONS

Patients with COPD, AIDS, and cancer demonstrated many similarities in their perspectives on important areas of physician skill in providing end-of-life care, but patients with each disease identified a specific area of end-of-life care that was uniquely important to them. Physicians and educators should target patients with COPD for efforts to improve patient education about their disease and about end-of-life care, especially in the areas defined above. Physicians caring for patients with advanced AIDS should discuss pain control at the end of life, and physicians caring for patients with cancer should be aware of many patients' desires to maintain hope. Physician understanding of these differences will provide insights that allow improvement in the quality of care.

Synergizing acute care and palliative care to optimise nursing care in end-stage cardiorespiratory disease

Advances in the practice of medicine and nursing science have increased survival for patients with chronic cardiorespiratory disease. Parallel to this positive outcome is a societal expectation of longevity and cure of disease. Chronic disease and the inevitability of death creates a dilemma, more than ever before, for the health care professional, who is committed to the delivery of quality care to patients and their families. The appropriate time for broaching the issue of dying and determining when palliative care is required is problematic. Dilemmas occur with a perceived dissonance between acute and palliative care and difficulties in determining prognosis. Palliative care must be integrated within the health care continuum, rather than being a discrete entity at the end of life, in order to achieve optimal patient outcomes. Anecdotally, acute and critical care nurses experience frustration from the tensions that arise between acute and palliative care philosophies. Many clinicians are concerned that patients are denied a good death and yet the moment when care should be oriented toward palliation rather than aggressive management is usually unclear. Clearly this has implications for the type and quality of care that patients receive. This paper provides a review of the extant literature and identifies issues in the end of life care for patients with chronic cardiorespiratory diseases within acute and critical care environments. Issues for refinement of acute and critical care nursing practice and research priorities are identified to create a synergy between these philosophical perspectives.

Therapeutic potential of implantable replacement hearts

In patients hospitalized with decompensated life-threatening heart failure, the impact of newer pharmacologic therapies and mechanical circulatory support has not yet been realized, except for those who are bridged to cardiac transplantation. For long-term support of transplant-ineligible patients who have severe biventricular failure that is refractory to optimized pharmacologic therapy, replacement of the natural heart with a totally implantable mechanical replacement heart, capable of producing blood flow of up to 8 to 10 L/min, may become the most well tolerated and effective treatment. This article summarizes the current status of the first generation implantable replacement heart (AbioCor trade mark, ABIOMED. Inc., Danvers, MA). With regard to optimizing the further enhancement of treatment options for end-stage heart failure and other life-threatening illnesses, the pharmacodynamics-like principle of therapeutic efficiency should play a role in the development of both drugs and devices. In keeping with that principle, we recommend that adjusting a product's design input requirements to maximize the therapeutic effect per exposure and;to separate the cumulative therapeutic effects of the product from the cumulative adverse effects (of the product, and of the comorbid disease processes in the patients treated) should be part of the good product development process for any therapeutic product.

Management of heart failure in the elderly

The management of chronic heart failure in elderly patients is often complicated by the presence of multiple comorbid conditions, polypharmacy, psychosocial and financial concerns, and difficulties with adherence to complex medication and dietary regimens. In addition, few patients over 80 years of age have been enrolled in clinical trials, so that the efficacy of current heart failure therapies remains uncertain in this age group. Taken together, these factors contribute to the persistently high hospitalization and mortality rates as well as the poor quality of life associated with chronic heart failure in the elderly. In this article, nonpharmacologic aspects of care and the pharmacotherapy of systolic heart failure in elderly patients are reviewed. Optimal management requires a systematic approach comprising 5 key elements: coordination of care across disciplines, patient and caregiver education, enhancement of self-management skills, effective followup, and the judicious use of medications. However, it must be recognized that even with "best practice" interventions, the prognosis for established heart failure remains poor. Future research must therefore be directed at developing more effective strategies for the prevention of heart failure in our aging population.

Do not resuscitate orders in different countries

Health care decision making in severely ill patients presents many difficult medical, ethical and legal problems. Physicians, including anaesthesiologists, are frequently confronted with dilemmas regarding the appropriateness of risky interventions and the balance of potential benefits versus risks. The risks include not only death and the pain and suffering that are related to the interventions, but also (and arguably more importantly) the burdens of lingering disability, loss of independence and poor quality of life. This review presents recent findings (focusing on papers published between 1999 and March 2001), and explores the background for the introduction of do not resuscitate policies and their use in clinical practice in different countries. Problems with auditing and implementing do not resuscitate policies are highlighted.

Heart failure in the 21st century: a cardiogeriatric syndrome

Chronic heart failure (CHF) is principally a cardiogeriatric syndrome, and it has become a major public health problem in the 21st century due largely to the aging population. Age-related changes throughout the cardiovascular system in combination with the high prevalence of cardiovascular diseases at older age predispose older adults to the development of CHF. Features that distinguish CHF at advanced age from CHF occurring during middle age include an increasing proportion of women, a shift from coronary heart disease to hypertension as the most common etiology, and the high percentage of cases that occur in the setting of preserved left ventricular systolic function. Although the pharmacotherapy of CHF is similar in older and younger patients, the presence of multiple comorbidities in older patients mandates a multidisciplinary approach to care. Manifest CHF is associated with a poor prognosis, especially in elderly persons, and there is an urgent need to develop more effective strategies for the prevention and treatment of this increasingly common disorder to reduce the individual and societal burden of this devastating illness in the decades ahead.

Dying with cancer: patients' function, symptoms, and care preferences as death approaches

OBJECTIVE

To characterize the dying experience of patients with cancer over the last 6 months of life.

STUDY DESIGN

A retrospective analysis of the last 6 months of life among patients with colon cancer and non-small cell lung cancer enrolled in a prospective cohort study from June 1989 to June 1991 and from January 1992 to January 1994.

SETTING

Five geographically diverse tertiary care academic medical centers participating in the Study to Understand Patient Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) Project.

PARTICIPANTS

All patients enrolled in SUPPORT who had either colon cancer, metastatic to the liver or stage III or stage IV non-small cell lung cancer and died within 1 year of their index hospitalization. This report examines 316 of 520 patients with metastatic colon cancer and 747 of 939 patients with lung cancer enrolled in SUPPORT.

METHODS

Data were collected by interview and chart abstraction at several time points in the SUPPORT Project. To describe progression to death, we constructed four observational windows backward in time beginning with patients' date of death and ending with their date of entry into the SUPPORT Project or 6 months before their death, whichever came first: (1) 3 days before death, (2) 3 days to 1 month before death, (3) 1 month to 3 months before death, and (4) 3 months to 6 months before death. For each outcome, patients contributed information to all windows during which they had data collected. We describe the frequency distributions of each outcome over time and report tests for trend.

OUTCOME MEASURES

We examined several outcomes over time, including: percentage of days spent in a hospital; prognosis as measured by model-based prognostic estimates of 6-month survival; severity of illness as measured by the acute physiology score; functional status as measured by dependencies in activities of daily living (ADLs); severe physical and emotional symptoms, including pain, depression, and anxiety; patients' preferences for care; and the financial impact on patients' families.

RESULTS

The death rate within 1 year of study entry was high among patients with metastatic colon cancer and advanced non-small cell lung cancer enrolled in SUPPORT (61% and 80%, respectively). As patients with cancer progress toward death, their estimated 6-month prognosis decreases significantly and the severity of their disease worsens. Patients' functional status also declines significantly as they approach death, such that most patients have four or more impairments within the 3 days before death. Patients with cancer experience significantly more pain and confusion as death approaches. Severe pain is common; more than one-quarter of patients with cancer experience serious pain 3 to 6 months before death and more than 40% were in serious pain during their last 3 days of life. However, dying patients are only modestly depressed and anxious during their last 3 days of life. As death approaches, patients favor comfort measures over life-extension, and about two-thirds want to forego resuscitation within 3 days of death. Families of patients dying with cancer incurred significant financial burdens during the last 6 months of life, and much of this burden was already experienced by 3 to 6 months before death.

CONCLUSIONS

The last 6 months of life for patients with cancer is characterized by functional decline and poorly controlled severe pain and confusion. Although patients increasingly prefer comfort care as they near death, many die in severe pain. These findings highlight important opportunities to improve the quality of care at the end of life for patients dying with cancer.

Dying with acute respiratory failure or multiple organ system failure with sepsis

BACKGROUND

The dying experience of patients with acute respiratory failure (ARF) or multiple organ system failure with sepsis (MOSF) has not been described.

OBJECTIVES

To describe patients dying from ARF or MOSF, including demographic characteristics, baseline function and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden.

DESIGN

A multicenter prospective study.

SETTING

Five US teaching hospitals, in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

PARTICIPANTS

A total of 1295 adults who died during hospitalization for ARF or MOSF.

MEASUREMENTS

Chart reviews and interviews with patients and surrogates.

RESULTS

SUPPORT enrolled 2956 patients with ARF or MOSF, and 44% died during enrollment hospitalization. Quality of life before hospitalization was reported as fair by 87% of patients. The mean number of impairments in their baseline activities of daily living was 1.6. At the time of death, 79% had a DNR order and 31% had an order to withhold ventilator support. The average time from the DNR order to death was 2 days. Dying patients spent an average of 9 days on a ventilator. Surrogates indicated that one out of four patients died with severe pain and one out of three with severe confusion. Families of 42% of the patients who died reported one or more substantial burden.

CONCLUSIONS

Patients in this study reported substantial functional impairments and reduced quality of life. Limitations to aggressive treatments were usually implemented only when death was imminent. Family impact and physical and emotional suffering were substantial.