Psychosocial needs and interventions for heart failure patients and families receiving palliative care support: a systematic review

Home symptom management training programme: carer evaluation

OBJECTIVES

Most people say if they had a terminal illness, they would prefer to be cared for at home and, if possible, to die there. Often this is not possible without a carer to assist with on-going practical care and symptom management. If breakthrough symptoms are not treated in a timely manner, symptoms can escalate quickly causing increased suffering resulting in unwanted hospital transfers. Many carers report feeling motivated but uneducated for the task of medicine management, especially if it involves preparation and/or administration of subcutaneous medicines This study assesses the impact of an education and resource package, caring@home, on carers' confidence, knowledge, and skills in managing palliative symptoms at home using subcutaneous medicines.

METHODS

Nurses trained volunteer carers on the use of the package. Carers were invited to complete a 10 min written evaluation survey and to consider consenting to a 30 min semistructure phone interview.

RESULTS

Fifty carers returned surveys and 12 were interviewed. Most carers agreed or strongly agreed that the package provided them with the necessary knowledge, skills and confidence to safely and confidently manage breakthrough symptoms using subcutaneous medicines, further, they would recommend the package to others. Interview analysis revealed three main themes: (1) hesitation and motivation to adopt expanded carer role; (2) the importance of a layered approach to support; and (3) avoiding perceived unnecessary contact with nurses.

CONCLUSION

The programme can be used by clinical services to empower carers to help enable a person to be cared for, and to die at home.

A randomized trial of a nurse-led educational intervention in patients with heart failure and their caregivers: impact on caregiver outcomes

AIMS

Psychoeducational interventions focusing on self-management of heart failure (HF) patients may improve patient health knowledge and reduce hospitalizations, but data regarding the effects on caregiver outcomes are inconclusive.

METHODS AND RESULTS

We conducted a single-centre, randomized controlled study to evaluate the effect of a nurse-led educational intervention in dyads of recently hospitalized HF patients and their caregivers on caregiver burden, feelings of guilt and health-related quality of life (HR-QoL). Dyads were randomized to usual care plus intervention group 1 (IG-1) or 2 (IG-2) or usual care only (control group, CG). Educational sessions in IG-1 and IG-2 were initiated before hospital discharge and continued with combination of home visits and telephone sessions in IG-1, or telephone sessions only in IG-2, delivered on regular intervals for 6 months. Caregiver burden was assessed by Heart Failure Caregiver Questionnaire (HF-CQ v5.0), guilt by Caregiver Guilt Questionnaire (CGQ), and QOL by EuroQol EQ-5D. Fifty-seven patient/caregiver dyads were included: 12 in IG-1, 18 in IG-2, and 27 in CG, of whom 11, 16, and 20, respectively, completed the study. All domains of HF-CQ and CGQ improved in IG-1 and IG-2 at 6 months, whereas deteriorated in CG (all P < 0.01). EQ-5D improved in IG-1 and IG-2 only in visual analogue scale part (P = 0.002), but not in the descriptive part.

CONCLUSION

A nurse-led, 6-month educational intervention on recently hospitalized HF patients/caregiver dyads, delivered through either combined home visits and telephone sessions or telephone sessions only, reduced caregiver burden and feelings of guilt, with lesser effect on HR-QoL.

REGISTRATION

ClinicalTrials.gov: NCT05480969.

The association between psychological factors and self-care in patients with heart failure: an integrative review

AIMS

This integrative review aims to describe the current evidence concerning the relationship between a broad range of psychological factors (depression, depressive symptoms, anxiety, stress, and type-D personality) and self-care in patients with heart failure.

METHODS AND RESULTS

Six electronic databases were searched and keywords were used to identify potential eligible studies published within the last 10 years. To be eligible, individuals with heart failure aged 18 years or older and who were included in any type of observational study that examined the association between psychological factors and self-care were considered. Twenty articles were included, and 16 of them reported that depression/depressive symptoms were associated with poorer self-care, after controlling for age, sex, education level, cardiac history, or comorbidities. Five studies found that self-care confidence/self-efficacy mediates the relationship between depression/depressive symptoms and self-care. The association between depression/depressive symptoms and self-care varied in assessment methods and statistical approaches. Seven studies showed an inverse association between anxiety and self-care. Four studies found a stronger association between self-care and depression compared with the relationship between self-care and other psychological factors. Stress and type-D personality were both associated with self-care in four studies.

CONCLUSION

Depression/depressive symptoms and anxiety were found to be inversely associated with self-care in patients with heart failure. Depression exhibited a stronger impact on self-care than other psychological factors. Limited studies assessed stress and type-D personality; the results should be considered with caution. Further studies are warranted on different psychological factors and their underlying mechanisms in individuals with heart failure.

Portuguese adaptation of the Chronic Heart Failure Knowledge Questionnaire (KQCHF)

BACKGROUND

A patient's knowledge of heart failure (HF) is associated with better outcomes. The more information patients have about their illness, the less likely they are to be readmitted to the hospital. Such knowledge includes the cause, symptoms, probable duration, and expected evolution of the clinical picture. In Portugal, a tool for testing patient knowledge is an unmet need. Therefore, this study aimed to adapt and test the Chronic Heart Failure Knowledge Questionnaire (KQCHF) for the Portuguese context.

METHODS

This work includes three cross-sectional studies. In Study 1, subjects were divided between before and after receiving information about HF. In Study 2, participants answered the questionnaire before and after reading the brochure. In Study 3, KQCHF was applied to patients with HF. Studies 1 and 2 were carried out in the general population. Study 3 was carried out with HF outpatients. Convenience sampling was applied to participants in the three studies.

RESULTS

In Study 1 (n = 45), those who received information had better scores (9.2 ± 1.9) than those who did not (6.0 ± 2.3). In Study 2 (n = 21), the scores were higher after reading the brochure (10.4 ± 1.7 vs. 6.5 ± 2.9). In Study 3 (n = 169), women had better scores than men (9.1 ± 2.1 vs. 8.3 ± 2.2, overall: 8.5 ± 2.2), and knowledge was correlated with education (r = .340, p < .001) and age (r = -.170, p = .030).

CONCLUSION

The Portuguese adaptation of KQCHF captured relevant knowledge about HF and has shown promising results for clinical and research purposes. The questionnaire can be useful in assessing HF patients' knowledge of their disease and as a basis for the implementation of general and personalised educational strategies to improve HF knowledge and, therefore, promote health literacy and self-care.

Multidisciplinary Care in Heart Failure Services

The American College of Cardiology/American Heart Association/Heart Failure Society of American 2022 guidelines for heart failure (HF) recommend a multidisciplinary team approach for patients with HF. The multidisciplinary HF team-based approach decreases the hospitalization rate for HF and health care costs and improves adherence to self-care and the use of guideline-directed medical therapy. This article proposes the optimal multidisciplinary team structure and each team member's delineated role to achieve institutional goals and metrics for HF care. The proposed HF-specific multidisciplinary team comprises cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians. A standardized multidisciplinary HF team-based approach should be incorporated to optimize the structure, minimize the redundancy of clinical responsibilities among team members, and improve clinical outcomes and patient satisfaction in their HF care.

Palliative Care Interventions Effects on Psychological Distress: A Systematic Review & Meta-Analysis

BACKGROUND

Managing psychological distress is an objective of palliative care. No meta-analysis has evaluated whether palliative care reduces psychological distress.

OBJECTIVES

Examine the effects of palliative care on depression, anxiety, and general psychological distress for adults with life-limiting illnesses and their caregivers.

DESIGN

We searched PubMed, PsycInfo, Embase, and CINAHL for randomized clinical trials (RCTs) of palliative care interventions. RCTs were included if they enrolled adults with life-limiting illnesses or their caregivers, reported data on psychological distress at 3 months after study intake, and if authors had described the intervention as "palliative care."

RESULTS

We identified 38 RCTs meeting our inclusion criteria. Many (14/38) included studies excluded participants with common mental health conditions. There were no statistically significant improvements in patient or caregiver anxiety (patient SMD: -0.008, P = 0.96; caregiver SMD: -0.21, P = 0.79), depression (patient SMD: -0.13, P = 0.25; caregiver SMD -0.27, P = 0.08), or psychological distress (patient SMD: 0.26, P = 0.59; caregiver SMD: 0.04, P = 0.78).

CONCLUSIONS

Psychological distress is not likely to be reduced in the context of a typical palliative care intervention. The systemic exclusion of patients with common mental health conditions in more than 1/3 of the studies raises ethical questions about the goals of palliative care RCTS and could perpetuate inequalities.

Differences in family caregiver experiences and expectations of end-of-life heart failure care across providers and settings: a systematic literature review

Heart failure impacts patients' quality of life and life expectancy and significantly affects the daily behaviours and feelings of family caregivers. At the end-of-life, the burden for family caregivers depends on their emotional and sentimental involvement, as well as social costs.

OBJECTIVES

The aim of this work is to determine whether and how family caregivers' experiences and expectations vary in relation to the places of care and teams involved in heart failure management.

METHODS

A systematic literature review was conducted, by screening manuscripts dealing with the experience of Family Care Givers' (FCGs) of patients with Advanced Heart failure. Methods and results were reported following the PRISMA rules. Papers were searched through three databases (PubMed, Scopus and Web of Science). Seven topics were used to synthetize results by reporting qualitative information and quantitative evidence about the experience of FCGs in places of care and with care teams.

RESULTS

Thirty-one papers, dealing with the experience of 814 FCGs, were selected for this systematic review. Most manuscripts came from the USA (N = 14) and European countries (N = 13) and were based on qualitative methods. The most common care setting and provider profile combination at the end of life was home care (N = 22) and multiprofessional teams (N = 27). Family caregivers experienced "psychological issues" (48.4%), impact of patients' condition on their life (38,7%) and "worries for the future" (22.6%). Usually, when family caregivers were unprepared for the future, the care setting was the home, and there was a lack of palliative physicians on the team.

DISCUSSION

At the end-of-life, the major needs of chronic patients and their relatives are not health related. And, as we observed, non-health needs can be satisfied by improving some key components of the care management process that could be related to care team and setting of care. Our findings can support the design of new policies and strategies.

Spiritual care needs among Chinese elders hospitalized for severe chronic heart failure: An observational study

OBJECTIVES

To investigate the spiritual care needs and their attributes among Chinese elders hospitalized for severe chronic heart failure (CHF) based on the Kano model, in order to provide a reference for improving the quality and satisfaction of spiritual care.

METHODS

An observational design was implemented, and the STROBE Checklist was used to ensure quality reporting of the study. The demographic characteristics questionnaire, the Nurse Spiritual Therapeutics Scale, and the Kano model-based Nurse Spiritual Therapeutics Attributes Scale were used. A convenience sample of 451 patients were selected from 2 hospitals. Descriptive statistics, and Kano model were used to analyze the data.

RESULTS

The total score of spiritual care needs was 29.95 ± 7.51. Among the 12 items, 3 items were attractive attributes, all of which were located in Reserving Zone IV; 5 items were one-dimensional attributes, of which 3 were located in Predominance Zone I and 2 were located in Improving Zone II; 2 items were must-be attributes, all of which were located in Improving Zone II; and 2 items were indifference attributes, all of which were located in Secondary Improving Zone III.

SIGNIFICANCE OF RESULTS

The spiritual care needs among Chinese elders hospitalized for severe CHF were moderate. The must-be and one-dimensional attributes mainly focus on "creating a good atmosphere" and "sharing self-perception" dimensions, while attractive attributes mainly focus on "sharing self-perception" and "helping thinking" dimensions. It is suggested that hospital authority should develop and innovate attractive attributes on the basis of maintaining and perfecting must-be and one-dimensional attributes, and objectively analyze and optimize indifference attributes.

Palliative Care in Heart Failure: An Integrative Review of Nurse Practice

Introduction: Because it is a chronic disease of progressive evolution, heart failure requires nursing attitudes and practices that are articulated with palliative care, implemented in an interdisciplinary team along with patients and their families. Objective: Identifying nurses' attitudes and practices in palliative care in cardiology. Method: Integrative literature review. The searches were carried out in the following bases: Google Scholar, Virtual Health Library, LILACS, SciELO, Embase, MEDLINE, CINAHL, and Scopus; through the terms Palliative Care AND Cardiology AND Nursing. Results: We identified 1298 studies published in the last five years, 14 of which have been selected for the scope of this review. Nurse attitudes and practices were characterized as: approach to symptom control; promotion of comfort and well-being; integrality of care and family orientation; effective communication among patients, family members and nursing team; timely evaluation for palliative care. Most of the studies included in this review have evidence level 2C (n = 7) and 2B (n = 4). Therefore, the results can be interpreted as reliable. Conclusions: This study makes important contributions to the practice of nurses in palliative care for heart failure. Based on the evidence collected, nurses can develop actions with the nursing team and with the interdisciplinary team related to direct patient and family care, as well as professional training. However, the field lacks studies showing the practices and actions implemented by the nursing team.

What are the needs and experiences of caregivers of people with heart failure? A qualitative study

BACKGROUND

The global burden of heart failure is estimated to be around 64 million people, with many needing care and support for daily living activities. These needs are usually filled by close relatives, often a spouse, and therefore someone of a similar age to the person for whom they care.

OBJECTIVES

The aim of this study was to explore the needs and experiences of caregivers caring for a person with heart failure through a qualitative interview approach.

METHODS

A qualitative study was conducted in a large region in South England. 17 caregivers were interviewed using a semi-structured approach and the data analysed using thematic analysis.

RESULTS

Four themes were identified from the data: a) Taking on the role of caregiver with the sub-themes of: acceptance and life changes; b) Getting to grips with being a caregiver with sub-themes: carrying out the care and coping with the care; c) Impact on own health and wellbeing: sub-themes of physical health and mental and emotional health and finally: d) Need for information and Support with sub-themes: trying to get knowledge and making sense.

CONCLUSIONS

This study has shown that heart failure caregiving can have a negative impact on caregivers' own health and wellbeing and involves complex care delivery for which they receive little support. Caregivers of people with heart failure report having significant information needs in order to understand the reasons for the care they provide yet feel marginalised by health care professionals.

Comprehensive Palliative Care Needs in Outpatients with Chronic Heart Failure: A Japanese Cross-Sectional Study

Background:

The type and frequency of palliative care needs of chronic heart failure (CHF) patients have not been determined in Japan.

Objectives:

The aim of this study was to comprehensively assess the prevalence and characteristics of palliative care needs of CHF outpatients.

Methods:

Patients were recruited for this cross-sectional study from June 1 to August 31, 2020, at the Kobe University Hospital. An Integrated Palliative care Outcome Scale (IPOS) and an original questionnaire developed by multidisciplinary experts were answered once by patients themselves or with the assistance of their family.

Results:

A total of 101 patients (63 males and 38 females) were included. The most common distressing symptoms were dyspnea (29%; 95% confidence interval [CI] 21–39]), drowsiness (29%; 95% CI 21–39), poor mobility (25%; 95% CI 17–35), insomnia (25%; 95% CI 17–35), and anxiety (24%; 95% CI 17–35). Eighty percent (95% CI 70–87) of patients were willing to have an end-of-life (EOL) discussion. When we compared New York Heart Association class I/II with III/IV patients, the frequency of distressing symptoms was associated with the severity of the disease, but both groups exhibited a willingness for having an EOL discussion or knowing the future course of their diseases.

Conclusions:

Dyspnea, drowsiness, insomnia, and anxiety were frequent symptoms in CHF outpatients in Japan. Beyond distressing symptoms, most ambulatory heart failure patients have a need for EOL discussion, which was not associated with disease stage. Assessing comprehensive and multidimensional palliative care needs, including needs for EOL discussion, is advisable among outpatients with CHF.

How Do We Start Palliative Care for Patients With End-Stage Liver Disease?

Patients with end-stage liver disease undergo repetitive patterns of recovery and deterioration and are burdened with uncertainty. Although quality of life is low in patients with end-stage liver disease and their family members, few studies have been conducted to identify what palliative care should be provided for them. This integrative review aimed to explore palliative care for patients with end-stage liver disease, focusing on the components and outcome measurements for further research. After searching for studies on palliative care for end-stage liver disease published between 1995 and 2017, 12 studies that met the inclusion criteria were analyzed. The common components of palliative care for patients with liver disease were: (a) an interdisciplinary approach, (b) early palliative care, (c) discussion goals of care with patient and family members, (d) symptom management, and (e) psychosocial support. It was reported that patients who were provided palliative care had improved itching, well-being, appetite, anxiety, fatigue, and depression, increased the number of do-not-resuscitate orders, palliative care consultations, and decreased length of stay. These findings could guide the development of palliative care for end-stage liver disease patients.

The impact of sources of perceived social support on readmissions in patients with heart failure

BACKGROUND

Lower levels of perceived social support have been known as an independent predictor of hospital readmissions in patients with heart failure (HF). However, the impact of sources of perceived social support on readmissions remain unexplored.

PURPOSE

The main purpose of this study was to investigate and compare the relative importance of social support from significant other, family, and friends on all-cause readmission and cardiac readmission in patients with HF.

METHODS

The prospective cohort study was used to recruit a total of 299 patients with HF in Taiwan between May 2012 and December 2014. Demographic and clinical characteristics, Multidimensional Perceived Social Support Scale (MPSSS), and 18-month follow-up readmissions were recorded during the hospital stay. Univariate and multivariate logistic regressions were constructed to determine the impact of levels and sources of perceived social support with all-cause readmission and cardiac readmission.

RESULTS

A total of 158 patients (52.8%) and 118 patients (39.5%), respectively, had all-cause readmission and cardiac readmissions within 18 months. Multivariate logistic regression yielded inverse associations between levels of perceived social support and readmissions by 18-months. Importantly, social support from significant other was significantly associated with a lower risk of readmissions, both of all-cause readmission and cardiac readmission, in patients with HF, even after controlling for possible covariates, social support from family and friends.

CONCLUSIONS

Social support from significant other, rather than from family and friends, was relatively and inversely associated with 18-month all-cause readmission and cardiac readmission in patients with HF, which is consistent with the hierarchical compensatory model.

Mind-Body Interventions in Patients With Heart Failure: State of the Science

Complementary and alternative medicine are broadly considered mind-body interventions (MBIs) that support physical and mental wellness in patients with heart failure (HF). The aims of this review were to integrate and summarize current evidence from MBIs in patients with HF and to identify gaps for future research. We used PRISMA guideline and conducted a literature search through six databases. Fifteen publications met the criteria, published between 2013 and 2021. This review stipulated that MBIs included yoga, Tai Chi, meditation, reflexology, massage, relaxation, and breathing interventions. The findings emphasized that MBIs could reduce physical and psychological symptoms and improve health outcomes in patients with HF. MBIs had encouraging results for patients with HF on selected physiological and behavioral outcomes. Despite the early state of the evidence in this field, it seems that MBIs will play an essential role in the future for alleviating the symptoms of patients with HF.

Spiritual care needs and their associated influencing factors among elderly patients with moderate-to-severe chronic heart failure in China: A cross-sectional study

Background

The significance of spiritual care needs among chronic diseases patients has been emphasized across countries and cultures in many studies. However, there were few studies on spiritual care needs among elderly patients with moderate-to-severe chronic heart failure (CHF) in China.

Objective

To investigate spiritual care needs and associated influencing factors among elderly patients with moderate-to-severe CHF, and to examine the relationships among spiritual care needs, self-perceived burden, symptom management self-efficacy, and perceived social support.

Methods

A cross-sectional design was implemented, and the STROBE Checklist was used to report the study. A convenience sample of 474 elderly patients with moderate-to-severe CHF were selected from seven hospitals in Tianjin, China. The sociodemographic characteristics questionnaire, the Spiritual Needs Questionnaire Scale, the Self-Perceived Burden Scale, the Self-efficacy for Symptom Management Scale, and the Perceived Social Support Scale were used. Descriptive statistics, univariate, multiple linear regression, and Pearson's correlation analysis were used to analyze data.

Results

The total score of spiritual care needs among 474 elderly patients with moderate-to-severe CHF was 37.95 ± 14.71, which was moderate. Religious belief, educational background, self-perceived burden, symptom management self-efficacy, and perceived social support were the main factors affecting spiritual care needs, and spiritual care needs were negatively correlated with self-perceived burden (r = −0.637, p < 0.01) and positively correlated with symptom management self-efficacy (r = 0.802, p < 0.01) and social support (r = 0.717, p < 0.01).

Significance of results

The spiritual care needs of elderly patients with moderate-to-severe CHF were moderate, which were influenced by five factors. It is suggested that clinical nurses, families, and society should take targeted spiritual care measures to improve patients’ symptom management self-efficacy and perceived social support from many aspects, and reduce self-perceived burden to meet their spiritual care needs and improve the quality and satisfaction of spiritual care in nursing practice.

Toward a socio-spiritual approach? A mixed-methods systematic review on the social and spiritual needs of patients in the palliative phase of their illness

BACKGROUND

Patients express a variety of needs, some of which are labeled social and spiritual. Without an in-depth exploration of patients' expressions of these needs, it is difficult to differentiate between them and allocate appropriate healthcare interventions.

AIM

To gain insight into the social and spiritual needs of patients with a life-limiting illness and the distinction between these needs, as found in the research literature.

DESIGN

A mixed-methods systematic review and meta-aggregation were conducted following the Joanna Briggs Institute (JBI) approach to qualitative synthesis and the PALETTE framework and were reported according to the PRISMA statement. This review was registered in PROSPERO (CRD42019133571).

DATA SOURCES

The search was conducted in PubMed, EMBASE, CINAHL, Scopus, and PsycInfo. Eligible studies reported social and spiritual needs from the patients' perspective and were published between January 1st 2008 and October 2020. The quality of evidence was assessed using JBI Critical Appraisal Tools.

RESULTS

Thirty-four studies (19 qualitative, 1 mixed-methods, and 14 quantitative) were included. The five synthesized findings encompassing social and spiritual needs were: being autonomous, being connected, finding and having meaning, having a positive outlook, and dealing with dying and death.

CONCLUSION

What literature labels as social and spiritual needs shows great similarities and overlap. Instead of distinguishing social from spiritual needs based on patients' linguistic expressions, needs should always be explored in-depth. We propose a socio-spiritual approach that honors and preserves the multidimensionality of patients' needs and enables interdisciplinary teamwork to allocate patient-tailored care.

Mutual support between patients and family caregivers in palliative care: A systematic review and narrative synthesis

BACKGROUND

Patients in palliative care are usually conceptualised as recipients of support from family caregivers. Family caregivers in palliative care are typically defined as providers of support to patients. Little is known about reciprocal dimensions of support provision between patients and family caregivers in palliative care.

AIM

To identify processes of mutual support between patients and family caregivers in palliative care and factors that contribute to or obstruct mutual support between patients and family caregivers in palliative care.

DESIGN

Systematic review and narrative synthesis of original peer-reviewed research published between January 2000 and March 2020.

DATA SOURCES

Medline, CINAHL, Embase, AMED, PsycINFO and PsycARTICLES.

RESULTS

After full-text screening, 10 studies were included. We identified that patients and family caregivers in palliative care can support one another by mutually acknowledging the challenges they face, by remaining positive for one another and by jointly adapting to their changing roles. However, patients and family caregivers may not routinely communicate their distress to each other or reciprocate in distress disclosure. A lack of mutual disclosure pertaining to distress can result in conflict between patients and family caregivers.

CONCLUSIONS

Few studies have focused in whole or in part, on reciprocal dimensions of support provision between patients with advancing non-curable conditions, and their family caregivers in palliative care. Further research is required to identify key domains of mutual support between patients and family caregivers in palliative care.

Development of a Nostalgic Remembering Intervention: Feeling Safe in Dyads Receiving Palliative Care for Advanced Heart Failure

BACKGROUND

Dyads receiving palliative care for advanced heart failure are at risk for the loss of feeling safe, experienced as a fractured sense of coherence, discontinuity in sense of self and relationships, and strained social connections and altered roles. However, few theory-based interventions have addressed feeling safe in this vulnerable population.

PURPOSE

The purpose of this article is to describe the development of the Nostalgic Remembering Intervention to strengthen feeling safe and promote adaptive physiological and psychological regulation in dyads receiving palliative care for heart failure.

CONCLUSIONS

Systematic intervention development is essential to understand what, for whom, why, and how an intervention works in producing outcomes. Program theory provided a systematic approach to the development of the Nostalgic Remembering Intervention, including conceptualization of the problem targeted by the intervention, specification of critical inputs and conditions that operationalize the intervention, and understanding the mediating processes leading to expected outcomes.

CLINICAL IMPLICATIONS

Creating a foundation for cardiovascular nursing research and practice requires continued, systematic development of theory-based interventions to best meet the needs of dyads receiving palliative care for heart failure. The development of the Nostalgic Remembering Intervention to strengthen feeling safe in dyads provides a novel and relevant approach.

The need for palliative and support care services for heart failure patients in the community

BACKGROUND

Palliative care is a care option considered appropriate for those with heart failure, but is uncommon partially due to a lack of timely identification of those needing palliative care. A standard mechanism that triggers which heart failure patients should receive palliative care is not available. The Gold Standards Framework (GSF) identifies those needing palliative care but has not been investigated with heart failure patients.

OBJECTIVES

To describe palliative care provided in the community and determine whether the GSF can identify heart failure patients in need of palliative care.

METHODS

Descriptive study. A total of 252 heart failure patients in the community completed a demographic characteristics questionnaire, the Edmonton symptom assessment scale-revised and the Minnesota living with heart failure questionnaire. Clinical data were collected from the medical chart and the primary physician completed the GSF prognostic indicator guidance.

RESULTS

Participants had a mean age of 76.9 years (standard deviation 10.9), most at New York Heart Association level III (n=152, 60%). Fewer than half received pain medications (n=76, 30%), anxiolytics (n=35, 14%), antidepressants (n=64, 25%) or sleep medications (n=65, 26%). Eight patients spoke with a psychologist or psychologist (3%). One had an advanced directive and 16 (6%) had a record of discussions with their family caregivers. Three (1%) had end-of-life discussions with their healthcare providers. Most healthcare providers responded 'no' to the 'surprise question' (n=160, 63%). Sensitivity and specificity of the gold standards framework was poor.

CONCLUSIONS

Few community dwelling heart failure patients received most aspects of palliative care. The gold standards framework was not a good indicator of those who should receive palliative care.

Tools to help healthcare professionals recognize palliative care needs in patients with advanced heart failure: A systematic review

BACKGROUND

The delivery of palliative care interventions is not widely integrated in chronic heart failure care as the recognition of palliative care needs is perceived as difficult. Tools may facilitate healthcare professionals to identify patients with palliative care needs in advanced chronic heart failure.

AIM

To identify tools to help healthcare professionals recognize palliative care needs in patients with advanced chronic heart failure.

DESIGN

This systematic review was registered in the PROSPERO database (CRD42019131896). Evidence of tools' development, evaluation, feasibility, and implementation was sought and described.

DATA SOURCES

Electronic searches to identify references of tools published until June 2019 were conducted in MEDLINE, CINAHL, and EMBASE. Hand-searching of references and citations was undertaken. Based on the identified tools, a second electronic search until September 2019 was performed to check whether all evidence about these tools in the context of chronic heart failure was included.

RESULTS

Nineteen studies described a total of seven tools. The tools varied in purpose, intended user and properties. The tools have been validated to a limited extent in the context of chronic heart failure and palliative care. Different health care professionals applied the tools in various settings at different moments of the care process. Guidance and instruction about how to apply the tool revealed to be relevant but may be not enough for uptake. Spiritual care needs were perceived as difficult to assess.

CONCLUSION

Seven tools were identified which showed different and limited levels of validity in the context of palliative care and chronic heart failure.

Health-Related Quality of Life and Use of Hospital Services by Patients with Heart Failure and Their Family Caregivers: A Multicenter Case-Control Study

BACKGROUND

Heart failure (HF) causes high rates of hospital admissions. It is known that disease progression impacts the health-related quality of life (HRQoL) of both patients and caregivers, yet to date, this finding is based on cross-sectional studies with limited samples.

OBJECTIVES

The study aim is to analyze the relationship between HF patients' use of hospital services (a proxy for disease progression) and the HRQoL of their family caregivers.

METHODS

This work is a multicenter nested case-control study on a population of patients admitted to hospitals in southern Spain due to heart failure. The sample comprised 530 patient-caregiver dyads. Hospital admission data were retrospectively collected for the 5 years prior to inclusion in the study. Bivariate analyses and multivariate logistic regression were used to determine associations between patient deterioration and caregivers' quality of life.

RESULTS

Patients' use of hospital services was associated with worsened quality of life for family caregivers, with an overall OR of 1.48 (95% CI: 1.23-1.79). A positive correlation was found between patients' perceptions of their physical health and the perceived mental health of caregivers (r = 0.127, p = 0.004) and between the perceived mental health of both (r = 0.291; p <0.0001).

CONCLUSIONS

Greater use of hospital services by patients with HF is an independent predictor of deterioration of family caregivers' HRQoL. The physical and mental components of patients' and their family caregivers' HRQoL interact and influence each other. Additional factors, such as the nature and intensity of care provided, also determine the worsening of a family caregiver's HRQoL.

CLINICAL RELEVANCE

These results can be used to identify family caregivers of people with heart failure at risk of suffering a deterioration in their health-related quality of life. Increased use of hospital services is an independent predictor of the deterioration of the family caregivers' health-related quality of life. Since clinical nurses are the main provider who gives support and education to family caregivers, they should be alert to this situation and individualize interventions to prevent this deterioration.

Social work involvement in palliative care heart failure research: a review of recent literature

PURPOSE OF REVIEW

The aim of the review is to examine the findings of empirical studies of palliative care interventions for patients with heart failure in which a social worker was identified as a key member of the interprofessional clinical team.

RECENT FINDINGS

Our systematic review of the empirical literature from January 2016 to August 2019 found five palliative care interventions with heart failure patients that cited involvement of a social worker as a key team member. The reviewed studies highlighted social workers' roles in the areas of psychosocial assessments and support, advance care planning, and patient-medical team communication.

SUMMARY

Palliative social workers possess the knowledge and skills to provide expertise in psychological, social, and cultural care within palliative care domains of practice. Given this primary and critical role, more studies that include the assessment of outcomes linked to the social worker's role should be pursued. Our review unearthed several important studies that highlight the role of the palliative social workers in heart failure models of care.

Palliative Care in Heart Failure: A Public Health Emergency

BACKGROUND

Palliative care (PC) is the holistic care of patients with life-limiting illnesses focused on relief of suffering and maximizing quality of life for patients and their families. Patients with heart failure (HF) are the largest group eligible for PC services, but only a small percentage of them receive PC.

AREAS OF UNCERTAINTY

The optimal content and method of delivery of PC interventions to HF patients in resource-limited countries remain unknown. The integration of PC into existing HF disease management continues to be a challenge.

DATA SOURCES

PUBMED was searched to identify articles on the topic published in the last 5 years (2014-April 2019). One hundred thirty-six articles were identified-14 articles out of were included in the revision.

THERAPEUTIC ADVANCES

Research concerning PC in HF is still scarce and comes predominantly from developed countries. PC in HF improves patients' and caregivers' outcomes in terms of dyspnea, sleep, depression, communication, coping, and care-giving burden. Specialized home-based PC services have a positive impact on patients' physical and emotional wellbeing while decreasing utilization of medical services. Fatigue, dyspnea, and pain are frequent symptoms. Evidence concerning use of opioids for dyspnea is increasing. Family caregivers offer a considerable amount of care during the disease trajectory. There is often incongruence between the carer's and the patient's wishes in terms of treatment decisions and preferences. Carers should be assessed for risk and supported in their roles in care management and care coordination.

CONCLUSIONS

Because of the unpredictability of the disease and difficulty in prognostication, PC should be introduced at the point of diagnosis of HF. Basic education in PC needs to be introduced early in the training of cardiology staff, focused on concept definition, differencing PC and terminal care, symptom management, communication, and decision-making.

Rethinking the Meaning of Palliation in Heart Failure

PURPOSE OF REVIEW

Palliative care follows a philosophy of care that focuses upon the quality of life in patients with chronic or life-threatening illness. It also focuses upon the needs of their families which is a wider scope of care. Cardiovascular disease, and specifically heart failure, affects millions of patients and family members who have a symptom burden that exceeds that of many cancers and other chronic diseases.

RECENTLY FINDINGS

Historically palliative care has been viewed as an alternative to curative therapies, but over time, it is now recognized that it should be implemented earlier in the course of chronic diseases. Although non-oncologic patients now comprise over half of the patient seen by palliative care, patients with cardiovascular disease are still not being referred to palliative care. Palliative care goes beyond advance directives and end of life planning. There is a need to continue to expand the view of palliative care to encompass interventions that help improve the overall health of these patients, including their psychosocial well-being and quality of life. The collection of papers in this journal provides insight into the breadth of palliative care for patients with heart failure and other cardiovascular diseases.

Palliative care needs-assessment and measurement tools used in patients with heart failure: a systematic mixed-studies review with narrative synthesis

Patients with heart failure have comparable illness burden and palliative care needs to those with cancer. However, few of them are offered timely palliative care. One main barrier is the difficulty in identifying those who require palliative care. Several palliative care needs-assessment/measurement tools were used to help identify these patients and assess/measure their needs, but it is not known which one is the most appropriate for this population. This review aimed to identify the most appropriate palliative care needs-assessment/measurement tools for patients with heart failure. Cochrane Library, MEDLINE Complete, AMED, PsycINFO, CINAHL Complete, EMBASE, EThOS, websites of the identified tools, and references and citations of the included studies were searched from inception to 25 June 2020. Studies were included if they evaluated palliative care needs-assessment/measurement tools for heart failure populations in terms of development, psychometrics, or palliative care patient/needs identification. Twenty-seven papers were included regarding nineteen studies, most of which were quantitative and observational. Six tools were identified and compared according to their content and context of use, development, psychometrics, and clinical applications in identifying patients with palliative care needs. Despite limited evidence, the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF) is the most appropriate palliative care needs-assessment tool for use in heart failure populations. It covers most of the patient needs and has the best psychometric properties and evidence of identification ability and appropriateness. Psychometric testing of the tools in patients with heart failure and evaluating the tools to identify those with palliative care needs require more investigation.

Health and Well-Being in the Year before Death: The Association with Quality of Life and Care at the End-of-Life

Objective: We examined whether older adults' health and well-being during their final year of life predicts end-of-life (EOL) quality of life (QOL) and quality of care (QOC). Methods: Using data from deceased participants (n = 1125) in the 2011-2015 National Health and Aging Trends Study, we performed latent class analysis to identify profiles of health and well-being, and we examined the association between these classes and EOL QOL and QOC. Results: Four classes were identified: healthy/happy (20%), frail/happy (37%), cognitively impaired/moderately distressed (27%), and highly impaired/highly distressed (16%). Persons in the highly impaired/highly distressed class showed a poorer QOL at the EOL, whereas those in the healthy/happy class reported a lower level of QOC at the EOL. Discussion: The benefits of maintaining health and well-being often carry forward to EOL. Older adults with high impairment and distress merit greater attention such as assuring care and advance care plans.

Family Caregiving for Individuals With Heart Failure: A Scientific Statement From the American Heart Association

Many individuals living with heart failure (HF) rely on unpaid support from their partners, family members, friends, or neighbors as caregivers to help manage their chronic disease. Given the advancements in treatments and devices for patients with HF, caregiving responsibilities have expanded in recent decades to include more intensive care for increasingly precarious patients with HF—tasks that would previously have been undertaken by healthcare professionals in clinical settings. The specific tasks of caregivers of patients with HF vary widely based on the patient’s symptoms and comorbidities, the relationship between patient and caregiver, and the complexity of the treatment regimen. Effects of caregiving on the caregiver and patient range from physical and psychological to financial. Therefore, it is critically important to understand the needs of caregivers to support the increasingly complex medical care they provide to patients living with HF. This scientific statement synthesizes the evidence pertaining to caregiving of adult individuals with HF in order to (1) characterize the HF caregiving role and how it changes with illness trajectory; (2) describe the financial, health, and well-being implications of caregiving in HF; (3) evaluate HF caregiving interventions to support caregiver and patient outcomes; (4) summarize existing policies and resources that support HF caregivers; and (5) identify knowledge gaps and future directions for providers, investigators, health systems, and policymakers.

Utility of the integrated palliative care outcome scale (IPOS): a cross-sectional study in hospitalised patients with heart failure

AIM

The aim of this study was to evaluate the suitability and comprehensibility of the integrated palliative care outcome scale for the evaluation of palliative care needs in patients with heart failure.

METHODS AND RESULTS

This cross-sectional study investigated 100 heart failure patients (40 women, 60 men; median age 79 years) within the first few days of their hospitalisation by applying the integrated palliative care outcome scale (3-day recall period) and two additional self-developed questions about the suitability and comprehensibility of the integrated palliative care outcome scale. Clinically relevant somatic and psycho-emotional symptoms were reported very frequently (approximately 75% each), followed by communicational needs or practical issues. Ninety-five per cent of patients thought the integrated palliative care outcome scale very easy to understand, and 91% judged the integrated palliative care outcome scale suitable to assess palliative care needs.

CONCLUSION

The integrated palliative care outcome scale was well accepted by hospitalised patients with heart failure and identified a high burden of both physical and psycho-emotional symptoms. Screening for palliative care has to consider patients and their relatives alike, and should be part of a comprehensive care concept jointly integrated into clinical routine by primary and specialised palliative care teams.

"I'd Have to Basically Be on My Deathbed": Heart Failure Patients' Perceptions of and Preferences for Palliative Care

Objectives: To identify patient perceptions of how and when palliative care (PC) could complement usual heart failure (HF) management. Background: Despite guidelines calling for the integration of PC into the management of HF, PC services remain underutilized by this population. Patient preferences regarding delivery of and triggers for PC are unknown. Setting/subjects: Individuals with New York Heart Association Class II-IV disease were recruited from inpatient and outpatient settings at an academic quaternary care hospital. Measurements: Participants completed semistructured interviews discussing perceptions, knowledge, and preferences regarding PC. They also addressed barriers and facilitators to PC delivery. Two investigators independently analyzed data using template analysis. Results: We interviewed 27 adults with HF (mean age 63, 85% white, 63% male, 30% Class II, 48% Class III, and 22% Class IV). Participants frequently conflated PC with hospice; once corrected, they expressed variable preferences for primary versus specialist services. Proponents of primary PC cited continuity in care, HF-specific expertise, convenience, and cost, whereas advocates for specialist care highlighted expertise in symptom management and caregiver support, reduced time constraints, and a comprehensive approach to care. Triggers for specialist PC focused on late-stage manifestations of disease such as loss of independence and absence of disease-directed therapies. Conclusions: Patients with HF demonstrated variable conceptions of PC and its relevance to their disease management. Although preferences for delivery model were based on a variety of logistical and relational factors, triggers for initiation remained focused on late-stage disease, suggesting that patients with HF may misconceive PC is an option of last resort.

Informational needs of family caregivers of people with intellectual disability who require palliative care: a two-phase integrative review of the literature

BACKGROUND:

People with intellectual disabilities are living longer, with increasingly complex needs and their family caregivers may have a broad scope of unmet needs.

AIMS:

To identify the most common needs of family caregivers, to identify gaps in the literature, and distinguish the information needs of family caregivers of people with intellectual disabilities who require palliative care.

METHODS:

This two phase literature review used five electronic databases (CINAHL, PsycINFO, Medline, Cochrane and Pubmed). Phase 1 involved a review of systematic reviews of the needs of family caregivers across healthcare settings. Phase 2 explored the commonly reported information needs from phase 1, in relation to family caregivers of people with intellectual disability who require palliative care. There was no research explicit to the information needs of these family caregivers.

FINDINGS:

This review reveals potential information needs which may exist, guided by the palliative caregiving literature; alluding to information needs surrounding the disease, finances, and psychological or practical support.

CONCLUSION:

It is surmised that a greater scope of informational need exists for this population and further research is pertinent for international healthcare settings.

A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition

CONTEXT

Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers.

OBJECTIVES

The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

METHODS

Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel.

RESULTS

We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews).

CONCLUSION

A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association

Introduction:

In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035.

Methods:

We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers’ wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant.

Results:

The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD.

Conclusions:

The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.

Exploring the Challenges that Family Caregivers Faced When Caring for Hospice Patients with Heart Failure

Although patients with heart disease comprise the second largest diagnostic group in hospice care, the challenges faced by family caregivers of hospice patients with heart failure are poorly understood and often go unaddressed. This study explored the challenges and needs of family caregivers of adults with advanced heart failure receiving hospice care in the home. The baseline quantitative and qualitative data from 28 family caregivers' participation in a large-scale hospice clinical trial of a problem-solving therapy intervention were analyzed. The quantitative data showed that family caregivers were mildly anxious and had worse financial and physical quality of life than their social and emotional quality of life. The qualitative data showed that caregiver challenges were related to patient care and symptom management, inadequate social support, communication issues, and financial concerns. The results provide insight to hospice social workers and researchers to develop practical tools that can be used in routine care to evaluate family caregivers' needs comprehensively.

Problems experienced by informal caregivers of individuals with heart failure: An integrative review

OBJECTIVES

The purpose of this review was to examine and synthesize recent literature regarding problems experienced by informal caregivers when providing care for individuals with heart failure in the home.

DESIGN

Integrative literature review.

DATA SOURCES

A review of current empirical literature was conducted utilizing PubMed, CINAHL, Embase, Sociological Abstracts, Social Sciences Full Text, PsycARTICLES, PsycINFO, Health Source: Nursing/Academic Edition, and Cochrane computerized databases. 19 qualitative, 16 quantitative, and 2 mixed methods studies met the inclusion criteria for review.

REVIEW METHODS

Computerized databases were searched for a combination of subject terms (i.e., MeSH) and keywords related to informal caregivers, problems, and heart failure. The title and abstract of identified articles and reference lists were reviewed. Studies were included if they were published in English between January 2000 and December 2016 and examined problems experienced by informal caregivers in providing care for individuals with heart failure in the home. Studies were excluded if not written in English or if elements of caregiving in heart failure were not present in the title, abstract, or text. Unpublished and duplicate empirical literature as well as articles related to specific end-stage heart failure populations also were excluded. Methodology described by Cooper and others for integrative reviews of quantitative and qualitative research was used. Quality appraisal of the included studies was evaluated using the Joanna Briggs Institute critical appraisal tools for cross-sectional quantitative and qualitative studies.

RESULTS

Informal caregivers experienced four key problems when providing care for individuals with heart failure in the home, including performing multifaceted activities and roles that evolve around daily heart failure demands; maintaining caregiver physical, emotional, social, spiritual, and financial well-being; having insufficient caregiver support; and performing caregiving with uncertainty and inadequate knowledge.

CONCLUSIONS

Informal caregivers of individuals with heart failure experience complex problems in the home when providing care which impact all aspects of their lives. Incorporating advice from informal caregivers of individuals with heart failure will assist in the development of interventions to reduce negative caregiver outcomes. Given the complex roles in caring for individuals with heart failure, multicomponent interventions are potentially promising in assisting informal caregivers in performing these roles.

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

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

Ginsenoside Rb1 improves cardiac function and remodeling in heart failure

We investigated the effect of ginsenoside Rb1 on cardiac function and remodeling in heart failure (HF). Four weeks after HF induction, the rats were administrated with ginsenoside Rb1 (35 and 70 mg/kg) and losartan (4.5 mg/kg) for 8 weeks. Losartan was used as a positive control. Cardiac function was assessed by measuring hemodynamic parameters. Histological changes were analyzed by HE and Masson’s trichrome staining. Cardiac hypertrophy, fibrosis, mitochondrial membrane potential and glucose transporter type 4 (GLUT4) levels were evaluated. In the present study, high dose of (H−) ginsenoside Rb1 decreased heart rate, improved cardiac function and alleviated histological changes induced by HF. H-ginsenoside Rb1 attenuated cardiac hypertrophy and myocardial fibrosis by decreasing left ventricular (LV) weight/heart weight ratio and cardiomyocyte cross-sectional area and reducing the levels of atrial natriuretic factor (ANF), β-myosin heavy chain (β-MHC), periostin, collagen I, Angiotensin II (Ang II), Angiotensin converting enzyme (ACE) and Ang II type 1 (AT1) receptor. Moreover, H-ginsenoside Rb1 decreased mitochondrial membrane potential and enhanced the translocation of GLUT4 to plasma membrane. The TGF-β1/Smad and ERK signaling pathways were inhibited and the Akt pathway was activated. These findings suggest that ginsenoside Rb1 might restore cardiac/mitochondrial function, increase glucose uptake and protect against cardiac remodeling via the TGF-β1/Smad, ERK and Akt signaling pathways.