Elements of Integrated Palliative Care in Chronic Heart Failure Across the Care Continuum: A Scoping Review

Barriers and Facilitators of Palliative Care in Older Adults With Heart Failure: A Qualitative Content Analysis

Objectives: The progressive and unpredictable course of heart failure (HF) has made the provision of palliative care (PC) services to older adults with HF a serious challenge. This study aimed to explain the barriers and facilitators of PC in older adults with HF. Methods: This qualitative study was conducted using the content analysis approach. A sample of 15 participants, including 6 patients, 2 family caregivers, and 7 healthcare team members (4 nurses, a psychiatric nurse, a nutritionist, and a PC physician) were selected by purposive sampling over 10 months (November 21, 2020 to September 1, 2021). The data were collected using semistructured in-person interviews until data saturation and analyzed with conventional qualitative content analysis. Results: The findings revealed the main category of "neglecting the provision of PC," with 4 subcategories of "weak organizational structure," "poor social support," "older adults' and healthcare teams' poor knowledge," and "limited financial resources" as the barriers of PC and the main category of "enjoying support potentials" with 3 subcategories of "the cooperation of the government, benefactors, and nongovernmental organizations," "empathy from the family and relatives," and "benefiting from the presence of healthcare workers" as PC facilitators. Conclusions: The findings of this study explained the barriers and facilitators of PC in older adults with HF. Removing the barriers and supporting the facilitators give older adults with HF better access to PC. Therefore, to expand PC centers for older adults with HF, health system officials, and policy-makers should pay attention to organizational infrastructures and remove the barriers at organizational, social, educational, and economic levels with the cooperation of governmental organizations, benefactors, and nongovernmental organizations.

CICARE communication model and hierarchical responsibility nursing coordination in the application research of elderly patients with chronic heart failure

The aim of this study was to evaluate the efficacy of implementing the CICARE communication model and hierarchical responsibility nursing coordination in managing chronic heart failure among elderly patients. From June 2021 to June 2023, 120 elderly patients diagnosed with chronic heart failure were admitted to our hospital. They were divided into 2 groups according to different treatment methods: the regular group and the observation group. Both groups of patients received nursing interventions for 3 months. Before and after the intervention, we assessed the levels of cardiac function indicators (left ventricular end-diastolic diameter, left ventricular ejection fraction, and B-type natriuretic peptide levels) and exercise tolerance (6-minute walk test) in both groups of patients. The time to clinical symptom relief, self-efficacy, and quality of life scores were compared between the 2 groups of patients. Before the intervention, there were no significant differences in cardiac function indicators between the 2 groups (P > .05). However, after the intervention, both groups exhibited improvements in left ventricular end-diastolic diameter and B-type natriuretic peptide levels, with the observation group demonstrating greater reductions compared to the control group. Furthermore, both groups showed increased left ventricular ejection fraction levels, with the observation group experiencing a significantly higher improvement. Although exercise tolerance did not differ significantly between the groups before the intervention, post-intervention analysis revealed a greater increase in 6-minute walk test distance in the observation group compared to the control group (P < .05). The time to relief of breathlessness and edema did not significantly differ between the groups (P > .05). Similarly, there were no significant differences in self-efficacy and quality of life scores between the groups before the intervention (P > .05); however, post-intervention analysis showed higher self-efficacy scores in the observation group. Application of the CICARE communication model and hierarchical responsibility nursing coordination in elderly patients with chronic heart failure can effectively improve the patients' cardiac function levels and significantly enhance their exercise tolerance, self-efficacy, and quality of life.

Integrating Palliative Care and Heart Failure: the PalliatHeartSynthesis realist synthesis

Background

Cardiovascular disease is the most common cause of death worldwide, highlighting the need for studies to determine options for palliative care within the management of patients with heart failure. Although there are promising examples of integrated palliative care and heart failure interventions, there is heterogeneity in terms of countries, healthcare settings, multidisciplinary team delivery, modes of delivery and intervention components. Hence, this review is vital to identify what works, for whom and in what circumstances when integrating palliative care and heart failure.

Objectives

To (1) develop a programme theory of why, for whom and in what contexts desired outcomes occur; and (2) use the programme theory to co-produce with stakeholders key implications to inform best practice and future research.

Design

A realist review of the literature underpinned by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Searches of bibliographic databases were conducted in November 2021 using the following databases: EMBASE, MEDLINE, PsycInfo, AMED, HMIC and CINAHL. Further relevant documents were identified via alerts and the stakeholder group.

Review methods

Realist review is a theory-orientated and explanatory approach to the synthesis of evidence. A realist synthesis was used to synthesise the evidence as successful implementation of integrated palliative care and heart failure depends on the context and people involved. The realist synthesis followed Pawson's five iterative stages: (1) locating existing theories; (2) searching for evidence; (3) document selection; (4) extracting and organising data; and (5) synthesising the evidence and drawing conclusions. We recruited an international stakeholder group (n = 32), including National Health Service management, healthcare professionals involved in the delivery of palliative care and heart failure, policy and community groups, plus members of the public and patients, to advise and give us feedback throughout the project, along with Health Education England to disseminate findings.

Results

In total, 1768 documents were identified, of which 1076 met the inclusion criteria. This was narrowed down to 130 included documents based on the programme theory and discussions with stakeholders. Our realist analysis developed and refined 6 overarching context-mechanism-outcome configurations and 30 sub context-mechanism-outcome configurations. The realist synthesis of the literature and stakeholder feedback helped uncover key intervention strategies most likely to support integration of palliative care into heart failure management. These included protected time for evidence-based palliative care education and choice of educational setting (e.g. online, face to face or hybrid), and the importance of increased awareness of the benefits of palliative care as key intervention strategies, the emotive and intellectual need for integrating palliative care and heart failure via credible champions, seeing direct patient benefit, and prioritising palliative care and heart failure guidelines in practice. The implications of our findings are further outlined in the capability, opportunity, motivation, behaviour model.

Limitations

The realist approach to analysis means that findings are based on our interpretation of the data.

Future work

Future work should use the implications to initiate and optimise palliative care in heart failure management.

Conclusion

Ongoing refinement of the programme theory at each stakeholder meeting allowed us to co-produce implications. These implications outline the required steps to ensure the core components and determinants of behaviour are in place so that all key players have the capacity, opportunity and motivation to integrate palliative care into heart failure management.

Study registration

This study is registered as PROSPERO CRD42021240185.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131800) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 34. See the NIHR Funding and Awards website for further award information.

The Use of Person-Centered Outcome Measures to Support Integrated Palliative Care for Older People: A Systematic Review

OBJECTIVES

The aim was to synthesize evidence on the use of person-centered outcome measures to facilitate integrated palliative care for older people and build a logic model depicting the mechanisms through which person-centered outcome measures support integrated care.

DESIGN

Mixed methods systematic review using a data-based convergent synthesis design.

SETTING AND PARTICIPANTS

Older people aged ≥60 years who are approaching the end of their lives in multiple settings.

METHODS

The study was underpinned by a conceptual framework of integrated palliative care, which informed the search strategy, data extraction, analysis, and synthesis. A hybrid search strategy was implemented, with database searches (PsycINFO, MEDLINE, CINAHL, and ASSIA) complemented by snowball searches. Qualitative and quantitative data were analyzed by narrative synthesis to summarize and explain the findings. The findings informed a logic model depicting the mechanisms of using person-centered outcome measures to support integrated palliative care.

RESULTS

Twenty-six studies were included. Three mixed methods studies, 2 qualitative studies, and 21 quantitative studies were included. There was evidence that person-centered outcome measures could support integrated palliative care through informing palliative care policy development (n = 4), facilitating joint working across settings (n = 5), enabling close collaboration of multidisciplinary teams (n = 14), promoting joint education (n = 1), facilitating timing and specialist referral (n = 6), and enhancing patient-centered care (n = 3).

CONCLUSIONS AND IMPLICATIONS

This review makes an important, novel, and theoretically informed contribution to the delivery of scalable and sustainable integrated palliative care into the care of older people using person-centered outcome measures. The constructed logic model provides a conceptual framework and practical approach to how person-centered outcome measures support multilevel integration. A future area of research is the development of person-centered outcome measure interventions informed by the logic model to meet clinical needs.

miR-182-5p combined with brain-derived neurotrophic factor assists the diagnosis of chronic heart failure and predicts a poor prognosis

Objective

Chronic heart failure (CHF) is a general progressive disorder with high morbidity and poor prognosis. This study analyzed the serum expression and clinical value of miR-182-5p and brain-derived neurotrophic factor (BDNF) in CHF patients.

Methods

A total of 82 CHF patients were selected as the study subjects (15 cases in NYHA stage I, 29 cases in stage II, 27 cases in stage III, and 11 cases in stage IV), with another 78 healthy people as the controls. The expression of serum miR-182-5p was detected by RT-qPCR. BDNF expression was measured by ELISA. Furthermore, the Pearson coefficient was used to analyze the correlation of miR-182-5p/BDNF with BNP and LVEF. ROC curve was employed to assess the potential of miR-182-5p or/and BDNF for the diagnosis of CHF. Kaplan–Meier survival curve was implemented to evaluate the prognostic value of miR-182-5p and BDNF.

Results

Serum miR-182-5p level was elevated and BDNF expression was lowered in CHF patients. Serum miR-182-5p in CHF patients was positively-related with BNP and inversely-correlated with LVEF, while serum BDNF was negatively-linked with BNP and positively-correlated with LVEF. ROC curve indicated the diagnostic value of serum miR-182-5p and BDNF for CHF and the diagnostic accuracy of miR-182-5p combined with BDNF was improved. Kaplan–Meier analysis unveiled that miR-182-5p low expression and BDNF high expression could predict the overall survival in CHF patients.

Conclusion

miR-182-5p expression is increased and BDNF level is decreased in CHF patients. miR-182-5p combined with BDNF can assist the diagnosis of CHF and predict a poor prognosis.

Integrating palliative care and heart failure: a protocol for a realist synthesis (PalliatHeartSynthesis)

INTRODUCTION

Heart failure affects over 26 million people worldwide with prevalence expected to grow due to an ageing global population. Palliative care can address the holistic needs of patients with heart failure, and integrated palliative care in heart failure management has been indicated to improve outcomes for patients. Despite known benefits for integrated palliative care in heart failure management, implementation is poor across the majority of global health services. Recent systematic reviews have identified the benefits of integrating palliative care into heart failure management and highlighted barriers to implementation. However, there was heterogeneity in terms of countries, healthcare settings, delivery by differing staff across multidisciplinary teams, modes of delivery and different intervention components.

METHODS AND ANALYSIS

The aim of this study is to identify how integrated palliative care and heart failure interventions produce desired outcomes, in which contexts, and for which patients. We will undertake a realist synthesis to identify this, using Pawson's five iterative steps. We will recruit an international stakeholder group comprised of healthcare providers and patients with heart failure to advise and provide feedback throughout the review. Our initial realist programme theory sets out the necessary steps needed to accomplish the final intended outcome(s) from the implementation of integrated palliative care and heart failure. This initial programme theory will be shaped through an iterative process of testing and refinement.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. With our stakeholder group, we will coproduce a user guide that outlines practical advice to optimise, tailor and implement interventions designed to integrate palliative care and heart failure, taking into consideration local context, alongside user-friendly summaries of the synthesis findings using short animations to convey complex findings. We will draw on the expertise within the stakeholder group to identify key stakeholders for disseminating to relevant audiences, ensuring outputs are tailored for their respective needs.

PROSPERO REGISTRATION NUMBER

CRD42021240185.