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Chuzi S, Manning K. Integration of palliative care across the spectrum of heart failure care and therapies: considerations, contemporary data, and challenges. Curr Opin Cardiol 2024; 39:218-225. [PMID: 38567949 DOI: 10.1097/hco.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is characterized by significant symptoms, compromised quality of life, frequent hospital admissions, and high mortality, and is therefore well suited to palliative care (PC) intervention. This review elaborates the current PC needs of patients with HF across the spectrum of disease, including patients who undergo advanced HF surgical therapies, and reviews the current data and future directions for PC integration in HF care. RECENT FINDINGS Patients with chronic HF, as well as those who are being evaluated for or who have undergone advanced HF surgical therapies such as left ventricular assist device or heart transplantation, have a number of PC needs, including decision-making, symptoms and quality of life, caregiver support, and end-of-life care. Available data primarily supports the use of PC interventions in chronic HF to improve quality of life and symptoms. PC skills and teams may also help address preparedness planning, adverse events, and psychosocial barriers in patients who have had HF surgeries, but more data are needed to determine association with outcomes. SUMMARY Patients with HF have tremendous PC needs across the spectrum of disease. Despite this, more data are needed to determine the optimal timing and structure of PC interventions in patients with chronic HF, left ventricular assist device, and heart transplantation. Future steps must be taken in clinical, research, and policy domains in order to optimize care.
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Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katharine Manning
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center
- Section of Palliative Medicine, Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Murakami N, Reich AJ, He K, Gelfand SL, Leiter RE, Sciacca K, Adler JT, Lu E, Ong SC, Concepcion BP, Singh N, Murad H, Anand P, Ramer SJ, Dadhania DM, Lentine KL, Lakin JR, Alhamad T. Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study. Am J Kidney Dis 2024; 83:173-182.e1. [PMID: 37726050 PMCID: PMC11360225 DOI: 10.1053/j.ajkd.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS Potential selection bias. CONCLUSIONS Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine He
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samantha L Gelfand
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joel T Adler
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Song C Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | - Haris Murad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Prince Anand
- Medical University of South Carolina, Greenville, South Carolina
| | | | | | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St Louis, Missouri
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri.
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3
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McClung JA, Frishman WH, Aronow WS. The Role of Palliative Care in Cardiovascular Disease. Cardiol Rev 2024:00045415-990000000-00182. [PMID: 38169299 DOI: 10.1097/crd.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.
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Affiliation(s)
- John Arthur McClung
- From the Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
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Chou PL, Lin PC, Lin CC, Lee HC, Huang YT. Trends and Changes in Intensive Care Use for Patients With Heart Failure in the Last Month of Life. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241239143. [PMID: 38506439 PMCID: PMC10956157 DOI: 10.1177/00469580241239143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
A good death is a human right. Unfortunately, patients with chronic heart failure (CHF) in the terminal stage still receive inappropriate life-sustaining treatment before death. There is limited understanding of the status of intensive care unit (ICU) admission, mechanical ventilation (MV), cardiopulmonary resuscitation (CPR), and even extracorporeal membrane oxygenation (ECMO) for patients with CHF before death, as well as their use of hospice-related services. This study investigated the trends and trend changes in intensive procedures and hospice-related services for patients with CHF in the last month of life. This population-based retrospective observational study included 25 375 patients with CHF from the National Health Insurance research database in Taiwan and collected information on their intensive treatments during the last month of life. We computed intensive treatment utilization rates and analyzed the trends and trend changes via joinpoint regression. The average percentage of patients with CHF admitted to ICUs was 53.27% (n = 13 516). A total of 327 (1.29%) patients with CHF received ECMO. The percentages of patients receiving MV (54.3%'41.5%) and CPR (41.5%'17%) decreased over time. Conversely, the percentage of ECMO use (0.52%'1.78%) increased. However, only 222 (0.87%) patients with CHF received hospice care in the last month of life between 2001 and 2013. The rates of ICU admission and life-sustaining treatment among patients with CHF in the month before death remain high, and hospice-related services remain inadequate. This study highlights the need for research and training in providing palliative and hospice care for patients with CHF.
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Affiliation(s)
- Pi-Ling Chou
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Chao Lin
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Hsiang-Chun Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan
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Barrett TA, MacEwan SR, Melnyk H, Di Tosto G, Rush LJ, Shiu-Yee K, Volney J, Singer J, Benza R, McAlearney AS. The Role of Palliative Care in Heart Failure, Part 3: Facilitators and Barriers to Cardiac Palliative Care Clinic Development. J Palliat Med 2023; 26:1685-1690. [PMID: 37878332 DOI: 10.1089/jpm.2022.0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
Background: Patients with heart failure frequently have significant disease burden and complex psychosocial needs. The integration of palliative care into the management of these patients can decrease symptom burden throughout their course of illness. Therefore, in 2009, we established a cardiac palliative care clinic colocated with heart failure providers in a large academic heart hospital. Objective: To better understand the facilitators and barriers to integrating palliative care into our heart failure management service. Design: Qualitative study using a semistructured interview guide. Setting, Subjects: Between October 2020 and January 2021, we invited all 25 primary cardiac providers at our academic medical center in the midwestern United States to participate in semistructured qualitative interviews to discuss their experiences with the cardiac palliative care clinic. Measurements: Interview transcripts were analyzed using a deductive-dominant thematic analysis approach to reveal emerging themes. Results: Providers noted that the integration of palliative care into the treatment of patients with heart failure was helped and hindered primarily by issues related to operations and communications. Operational themes about clinic proximity and the use of telehealth as well as communication themes around provider-provider communication and the understanding of palliative care were particularly salient. Conclusions: The facilitators and barriers identified have broad applicability that are independent of the etiological nature (e.g., cancer, pulmonary, neurological) of any specialty or palliative care clinic. Moreover, the strategies we used to implement improvements in our clinic may be of benefit to other practice models such as independent and embedded clinics.
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Affiliation(s)
- Todd A Barrett
- Division of Palliative Medicine, Department of Internal Medicine, Richard M. Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sarah R MacEwan
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Division of General Internal Medicine, Department of Internal Medicine, and College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Halia Melnyk
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Gennaro Di Tosto
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Laura J Rush
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Karen Shiu-Yee
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jaclyn Volney
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jonathan Singer
- Department of Psychology, The Ohio State University, Columbus, Ohio, USA
| | - Raymond Benza
- Division of Cardiology, Heart, and Vascular Institute/Richard M. Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ann Scheck McAlearney
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Deng LX, Sharma A, Gedallovich SM, Tandon P, Hansen L, Lai JC. Caregiver Burden in Adult Solid Organ Transplantation. Transplantation 2023; 107:1482-1491. [PMID: 36584379 PMCID: PMC10993866 DOI: 10.1097/tp.0000000000004477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.
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Affiliation(s)
- Lisa X. Deng
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Arjun Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Seren M. Gedallovich
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Puneeta Tandon
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, AB, Canada
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, OR
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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7
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Valleggi A, Passino C, Emdin M, Murante AM. Differences in family caregiver experiences and expectations of end-of-life heart failure care across providers and settings: a systematic literature review. BMC Health Serv Res 2023; 23:429. [PMID: 37138363 PMCID: PMC10155156 DOI: 10.1186/s12913-023-09241-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/03/2023] [Indexed: 05/05/2023] Open
Abstract
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.
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Affiliation(s)
| | - Claudio Passino
- Fondazione Gabriele Monasterio, Pisa, Italy
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Michele Emdin
- Fondazione Gabriele Monasterio, Pisa, Italy
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Anna Maria Murante
- Management and Health Lab - Institute of Management, Scuola Superiore San'Anna, Pisa, Italy.
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Cousino MK, Yu S, Blume ED, Henderson H, Hollander SA, Khan S, Parent J, Schumacher KR. Circumstances surrounding end-of-life in pediatric patients pre- and post-heart transplant: a report from the Pediatric Heart Transplant Society. Pediatr Transplant 2022; 26:e14196. [PMID: 34820983 PMCID: PMC10466174 DOI: 10.1111/petr.14196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although mortality has decreased considerably in pediatric heart transplantation, waitlist and post-transplant death rates remain notable. End-of-life focused research in this population, however, is very limited. This Pediatric Heart Transplant Society study aimed to describe the circumstances surrounding death of pediatric heart transplant patients. METHODS A retrospective analysis of the multi-institutional, international, Pediatric Heart Transplant Society registry was conducted. Descriptive statistics and univariate analyses were performed to 1) describe end-of-life in pediatric pre- and post-heart transplant patients and 2) examine associations between location of death and technological interventions at end-of-life with demographic and disease factors. RESULTS Of 9217 patients (0-18 years) enrolled in the registry between 1993 and 2018, 2804 (30%) deaths occurred; 1310 while awaiting heart transplant and 1494 post-heart transplant. The majority of waitlist deaths (89%) occurred in the hospital, primarily in ICU (74%) with most receiving mechanical ventilation (77%). Fewer post-transplant deaths occurred in the hospital (22%). Out-of-hospital death was associated with older patient age (p < .01). CONCLUSIONS ICU deaths with high use of technological interventions at end-of-life were common, particularly in patients awaiting heart transplant. In this high mortality population, findings raise challenging considerations for clinicians, families, and policy makers on how to balance quality of life amidst high risk for hospital-based death.
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Affiliation(s)
- Melissa K. Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
- University of Michigan Congenital Heart Center, Ann Arbor, MI
- University of Michigan Transplant Center, Ann Arbor, MI
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
- University of Michigan Congenital Heart Center, Ann Arbor, MI
| | | | - Heather Henderson
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Seth A. Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA
| | - Sairah Khan
- Division of Cardiology, Children’s National Hospital, Washington, DC
| | - John Parent
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Kurt R. Schumacher
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
- University of Michigan Congenital Heart Center, Ann Arbor, MI
- University of Michigan Transplant Center, Ann Arbor, MI
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Strangl F, Ullrich A, Oechsle K, Bokemeyer C, Blankenberg S, Knappe D, Reichenspurner H, Bernhardt AM, Barten MJ, Rybczynski M. Assessing palliative care need in left ventricular assist device patients and heart transplant recipients. Interact Cardiovasc Thorac Surg 2020; 31:874-880. [PMID: 33155042 DOI: 10.1093/icvts/ivaa211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/14/2020] [Accepted: 08/25/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Palliative care (PC) has gained rising attention in a holistic treatment approach to chronic heart failure (HF). It is unclear whether there is a need for PC in left ventricular assist device (LVAD) patients or heart transplant recipients. METHODS In a cross-sectional explorative pilot study, outpatients after heart transplantation (HTx, n = 69) or LVAD implantation (n = 21) underwent screening for palliative care (PC) need and evaluation of symptom burden and psychological distress using tools that emanated from palliative cancer care. RESULTS The 'Palliative Care Screening Tool for Heart Failure Patients' revealed scores of 4.3 ± 2.2 in HTx and 6.0 ± 2.1 in LVAD patients (max. 12 points, P = 0.003), indicating the need for PC (≥5 points) in 32% of HTx and 67% of LVAD patients. Symptom burden, as assessed by MIDOS ('Minimal Documentation System for Palliative Care') scores was substantial in both groups (4.9 ± 4.7 in HTx vs 6.6 ± 5.3 in LVAD, max. 30 points, P = 0.181). 'Fatigue', 'weakness' and 'pain' were the most frequent symptoms. Using the 'Distress-Thermometer', 'clinically relevant' distress was detected in 57% of HTx and 47% of LVAD patients (P = 0.445). In the PHQ-4 ('4-Item Patient Health Questionnaire'), 45% of LVAD patients, compared to only 10% of HTx patients, reported mild symptoms of anxiety and depression. CONCLUSIONS Findings reveal substantial need for PC in LVAD patients and, to a lesser extent, in heart transplant recipients, suggesting that multi-disciplinary PC should be introduced into routine aftercare.
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Affiliation(s)
- Felix Strangl
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Ullrich
- Department of Oncology, Hematology and Bone Marrow Transplantation, Palliative Care Unit, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Department of Oncology, Hematology and Bone Marrow Transplantation, Palliative Care Unit, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation, Palliative Care Unit, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dorit Knappe
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Herrmann Reichenspurner
- Department of Cardiac Surgery, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiac Surgery, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus J Barten
- Department of Cardiac Surgery, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Meike Rybczynski
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
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Vieira Silva S, Freire E, Pessegueiro Miranda H. Palliative Care in End-Stage Liver Disease Patients Awaiting Liver Transplantation: Review. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:417-428. [PMID: 33251291 DOI: 10.1159/000507336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/17/2020] [Indexed: 01/15/2023]
Abstract
Introduction End-stage liver disease (ESLD) is the advanced phase of most liver diseases. The cure is liver transplantation (LT), only available for a minority of patients. This review summarizes the evidence regarding palliative care (PC) in ESLD patients awaiting LT. Methods Review of the literature available in Medline, Scopus and Web of Knowledge, with keywords ESLD and PC. Results Fifteen of the 230 articles reviewed met the inclusion criteria. Ten main themes were addressed: symptom burden; perspectives of life-sustaining treatment and comfort for patients, families and health professionals; goals of care discussions; patient and family needs; quality of life; PC and survival; referral to PC, barriers and opportunities; integration of PC; outpatient care and cost-effectiveness analysis. The referral of patients to PC was only evaluated in a few studies, all of which reported low referral rates. Better knowledge of how PC professionals can support other professionals was considered important, and also better ways to integrate PC were considered essential. Conclusion ESLD patients awaiting LT have a significant need for PC and, despite the insufficient response, were reported to benefit from this type of care. Future research is essential to determine the means to overcome barriers and better integrate PC for ESLD patients awaiting LT.
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Affiliation(s)
- Sara Vieira Silva
- Equipa Intra-Hospitalar de Suporte de Cuidados Paliativos, Serviço de Medicina, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Elga Freire
- Equipa Intra-Hospitalar de Suporte de Cuidados Paliativos, Serviço de Medicina, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Helena Pessegueiro Miranda
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal.,Unidade de Transplantação Hepato-bilio-pancreática, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Saúde Publica da Universidade do Porto (ISPUP), Universidade do Porto, Porto, Portugal
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13
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Gustafson C, Song MK. State of the Science of Palliative Care in Solid Organ Transplantation. Prog Transplant 2020; 30:382-395. [PMID: 32930042 DOI: 10.1177/1526924820958156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Both solid organ transplant candidates and recipients and their family caregivers have complex care needs and may benefit from palliative care. But palliative care is not often considered as part of transplant care despite palliative care being promoted as an important component of transplant care both before and after solid organ transplantation. Further, the current state of the science of palliative care in solid organ transplantation has not been well-documented. OBJECTIVE To describe the state of the science of palliative care in solid organ transplant and identify gaps in the literature. METHODS Four electronic databases were searched using controlled vocabulary words and synonymous free text to find articles on palliative care and solid organ transplant. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist were also used. RESULTS Twenty articles were included in the final review for synthesis, 18 of which involved transplants for adults only. Twelve articles described palliative care for patients before transplant, four articles examined palliative care for patients after transplant, primarily at the end-of-life, and four articles described transplant provider perspectives on palliative care. The reviewed evidence suggested that patients could be benefited by palliative care both pre and posttransplant, particularly for symptom management and advance care planning and that transplant providers faced many barriers to implementing palliative care in practice. DISCUSSION There is limited research on palliative care following solid organ transplantation, particularly outside of hospice care. Much of the prior research on this topic has described adult patients.
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Affiliation(s)
- Carolina Gustafson
- Nell Hodgson Woodruff School of Nursing, 15792Emory University, Atlanta, GA, USA
| | - Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing, 15792Emory University, Atlanta, GA, USA
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14
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Chang YK, Kaplan H, Geng Y, Mo L, Philip J, Collins A, Allen LA, McClung JA, Denvir MA, Hui D. Referral Criteria to Palliative Care for Patients With Heart Failure: A Systematic Review. Circ Heart Fail 2020; 13:e006881. [PMID: 32900233 DOI: 10.1161/circheartfailure.120.006881] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with heart failure have significant symptom burden, care needs, and often a progressive course to end-stage disease. Palliative care referrals may be helpful but it is currently unclear when patients should be referred and by whom. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with heart failure. METHODS We searched Ovid, MEDLINE, Ovid Embase, and PubMed databases for articles in the English language from the inception of databases to January 17, 2019 related to palliative care referral in patients with heart failure. Two investigators independently reviewed each citation for inclusion and then extracted the referral criteria. Referral criteria were then categorized thematically. RESULTS Of the 1199 citations in our initial search, 102 articles were included in the final sample. We identified 18 categories of referral criteria, including 7 needs-based criteria and 10 disease-based criteria. The most commonly discussed criterion was physical or emotional symptoms (n=51 [50%]), followed by cardiac stage (n=46 [45%]), hospital utilization (n=38 [37%]), prognosis (n=37 [36%]), and advanced cardiac therapies (n=36 [35%]). Under cardiac stage, 31 (30%) articles suggested New York Heart Association functional class ≥III and 12 (12%) recommended New York Heart Association class ≥IV as cutoffs for referral. Prognosis of ≤1 year was mentioned in 21 (21%) articles as a potential trigger; few other criteria had specific cutoffs. CONCLUSIONS This systematic review highlighted the lack of consensus regarding referral criteria for the involvement of palliative care in patients with heart failure. Further research is needed to identify appropriate and timely triggers for palliative care referral.
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Affiliation(s)
- Yuchieh Kathryn Chang
- Department of Palliative Care, Rehabilitation and Integrative Medicine (Y.K.C., H.K., L.M., D.H.), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Holland Kaplan
- Department of Palliative Care, Rehabilitation and Integrative Medicine (Y.K.C., H.K., L.M., D.H.), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yimin Geng
- Research Medical Library (Y.G.), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Li Mo
- Department of Palliative Care, Rehabilitation and Integrative Medicine (Y.K.C., H.K., L.M., D.H.), The University of Texas MD Anderson Cancer Center, Houston, TX.,Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China (L.M.)
| | - Jennifer Philip
- Department of Medicine, St Vincent's Hospital Campus, University of Melbourne, Fitzroy, Australia (J.P., A.C.).,Royal Melbourne Hospital, Parkville, Australia (J.P.)
| | - Anna Collins
- Department of Medicine, St Vincent's Hospital Campus, University of Melbourne, Fitzroy, Australia (J.P., A.C.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A.)
| | - John A McClung
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York (J.A.M.)
| | - Martin A Denvir
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (M.A.D.)
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine (Y.K.C., H.K., L.M., D.H.), The University of Texas MD Anderson Cancer Center, Houston, TX
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15
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Butler CR, Reese PP, Perkins JD, Hall YN, Curtis JR, Kurella Tamura M, O'Hare AM. End-of-Life Care among US Adults with ESKD Who Were Waitlisted or Received a Kidney Transplant, 2005-2014. J Am Soc Nephrol 2020; 31:2424-2433. [PMID: 32908000 DOI: 10.1681/asn.2020030342] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/22/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The care of patients in the United States who have ESKD is often shaped by their hopes and prognostic expectations related to kidney transplant. Little is known about how patients' engagement in the transplant process might relate to patterns of end-of-life care. METHODS We compared six measures of intensity of end-of-life care among adults in the United States with ESKD who died between 2005 and 2014 after experiencing differing exposure to the kidney transplant process. RESULTS Of 567,832 decedents with ESKD, 27,633 (5%) had a functioning kidney transplant at the time of death, 14,653 (3%) had a failed transplant, 16,490 (3%) had been removed from the deceased donor waitlist, 17,010 (3%) were inactive on the waitlist, 11,529 (2%) were active on the waitlist, and 480,517 (85%) had never been waitlisted for or received a transplant (reference group). In adjusted analyses, compared with the reference group, patients exposed to the transplant process were significantly more likely to have been admitted to an intensive care unit and to have received an intensive procedure in the last 30 days of life; they were also significantly more likely to have died in the hospital. Those who died on the transplant waitlist were also less likely than those in the reference group to have been enrolled in hospice and to have discontinued dialysis before death. CONCLUSIONS Patients who had engaged in the kidney transplant process received more intensive patterns of end-of-life care than other patients with ESKD. These findings support the relevance of advance care planning, even for this relatively healthy segment of the ESKD population.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine and Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Manjula Kurella Tamura
- Division of Nephrology, Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington.,Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Heath Care System, Seattle, Washington
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16
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Affiliation(s)
- Ernst R von Schwarz
- Southern California Hospital Heart Institute, Southern California Hospital, Culver City
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mingyue He
- Southern California Hospital Heart Institute, Southern California Hospital, Culver City
| | - Parag Bharadwaj
- Southern California Hospital Heart Institute, Southern California Hospital, Culver City
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17
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Sobanski PZ, Alt-Epping B, Currow DC, Goodlin SJ, Grodzicki T, Hogg K, Janssen DJA, Johnson MJ, Krajnik M, Leget C, Martínez-Sellés M, Moroni M, Mueller PS, Ryder M, Simon ST, Stowe E, Larkin PJ. Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement. Cardiovasc Res 2019; 116:12-27. [DOI: 10.1093/cvr/cvz200] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 04/19/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Abstract
Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Waldeggstrasse 10, 6430 Schwyz, Switzerland
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Medical Center Göttingen Georg August University, Robertkochstrasse 40, 37075 Göttingen, Germany
| | - David C Currow
- University of Technology Sydney, Broadway, Ultimo, Sydney, 2007 New South Wales, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Sydney, New South Wales, Australia
| | - Sarah J Goodlin
- Department of Medicine-Geriatrics, Portland Veterans Affairs Medical Center and Patient-cantered Education and Research, 3710 SW US Veterans Rd, Portland, 97239 OR, USA
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, 31-531 Kraków, Śniadeckich 10, Poland
| | | | - Daisy J A Janssen
- Department of Research and Education, CIRO, Hornerheide 1, 6085 NM Horn, The Netherlands
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Allam Medical Building University of Hull, Cottingham Road, Hull, HU6 7RX, UK
| | - Małgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Carlo Leget
- University of Humanistic Studies, Chair Care Ethics, Kromme Nieuwegracht 29, Utrecht, The Netherlands
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Matteo Moroni
- S.S.D. Cure Palliative, sede di Ravenna, AUSL Romagna, Via De Gasperi 8, 48121 Ravenna, Italy
| | - Paul S Mueller
- Mayo Clinic Health System, Mayo Clinic Collage of Medicine and Science, 700 West Avennue South, La Crosse, 54601 Wisconsin, USA
| | - Mary Ryder
- School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland St. Vincent’s University Hospital Dublin,Belfield, Dublin 4, Ireland
| | - Steffen T Simon
- Department of Palliative Medicine, Medical Faculty of the Universityof Cologne, Köln, Germany
- Centre for Integrated Oncology Cologne/Bonn (CIO), Medical Faculty ofthe University of Cologne, Kerpener Strasse 62, 50924 Köln, Germany
| | | | - Philip J Larkin
- Service des soins palliatifs Lausanne University Hospital, CHUV, Centre hospitalier univeritaire vaudois, Lausanne Switzerland
- Institut universitaire de formation et de recherche en soins – IUFRS, Faculté de viologie et de medicine – FBM, Lausanne, Switzerland
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18
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Kennedy R, Abdullah N, Bhadra R, Bonsu NO, Fayezizadeh M, Ickes H. Barriers to Effective use of Palliative Care Services in the Acute Care Setting with Emphasis on Terminal Noncancer Diseases. Indian J Palliat Care 2019; 25:203-209. [PMID: 31114104 PMCID: PMC6504735 DOI: 10.4103/ijpc.ijpc_201_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction: This study assessed the views of nurses, resident doctors, and attending physicians of the use of a readily available pain and palliative care specialty at their institution while assessing their ability to recognize terminal noncancer illnesses. Methodology: In community hospital consisting of an in-patient pain and palliative specialty, attending physicians, residents, and nurses participate in a survey highlighting the following: parameters for referral/consultation, definition of noncancer-related terminal illnesses, role of pain and palliative care in acute care, consult/referral delay, barriers to effective referral, recognition and withdrawal of futile care, and opioid prescription. Patterns of responses by each professional group were compared and contrasted. Results: The most common accepted reasons for referral were that of hospice care, terminal cancer, and uncontrolled pain, while reasons related to terminal noncancer illnesses were less accepted. A majority of approved physical and social parameters to define terminal noncancer illnesses were not universally accepted among the groups-especially among attendings and residents. While most participants agreed that the best time to refer to palliative care specialty was at the point of diagnosis of a terminal illness, >25% of participants from each group felt that referrals should be done later in the course of the illness. The most highlighted reasons expressed by attendings and residents for the delay in consult were either that of excessive withdrawal of modalities of care or interference with ongoing management that may benefit the patient. Most residents and nurses agreed that attendings' reluctance to consult is a major barrier to its utilization. Conclusion: Barriers to effective utilization are multifactorial, mostly relating to perceptions of the specialty as well as ineffective communication within specialties.
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Affiliation(s)
- Randol Kennedy
- Department of Internal Medicine, Internal Medicine Residency Program of St Vincent Charity Medical Center, Cleveland, OH, USA
| | - Nabilah Abdullah
- Department of Internal Medicine, Internal Medicine Residency Program of St Vincent Charity Medical Center, Cleveland, OH, USA
| | - Rhajarshi Bhadra
- Department of Internal Medicine, Internal Medicine Residency Program of St Vincent Charity Medical Center, Cleveland, OH, USA
| | - Nana Osei Bonsu
- Department of Internal Medicine, Internal Medicine Residency Program of St Vincent Charity Medical Center, Cleveland, OH, USA
| | - Mojtaba Fayezizadeh
- Department of Internal Medicine, Internal Medicine Residency Program of St Vincent Charity Medical Center, Cleveland, OH, USA
| | - Harold Ickes
- Department of Internal Medicine, Internal Medicine Residency Program of St Vincent Charity Medical Center, Cleveland, OH, USA
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19
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Abstract
PURPOSE OF REVIEW The unmet palliative care needs of patients with chronic heart failure (CHF) are well known. Palliative care needs assessment is paramount for timely provision of palliative care. The present review provides an overview of palliative care needs assessment in patients with CHF: the role of prognostic tools, the role of the surprise question, and the role of palliative care needs assessment tools. RECENT FINDINGS Multiple prognostic tools are available, but offer little guidance for individual patients. The surprise question is a simple tool to create awareness about a limited prognosis, but the reliability in CHF seems less than in oncology and further identification and assessment of palliative care needs is required. Several tools are available to identify palliative care needs. Data about the ability of these tools to facilitate timely initiation of palliative care in CHF are lacking. SUMMARY Several tools are available aiming to facilitate timely introduction of palliative care. Focus on identification of needs rather than prognosis appears to be more fitting for people with CHF. Future studies are needed to explore whether and to what extent these tools can help in addressing palliative care needs in CHF in a timely manner.
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20
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Janssen DJ, Boyne J, Currow DC, Schols JM, Johnson MJ, La Rocca HPB. Timely recognition of palliative care needs of patients with advanced chronic heart failure: a pilot study of a Dutch translation of the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF). Eur J Cardiovasc Nurs 2019; 18:375-388. [PMID: 30760021 DOI: 10.1177/1474515119831510] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF) was developed to identify and triage palliative care needs in patients with chronic heart failure. A Dutch version is currently lacking. AIMS The aim of this study was to investigate the feasibility and acceptability of a Dutch NAT:PD-HF in chronic heart failure outpatients; and to gain preliminary data regarding the effect of the NAT:PD-HF on palliative care referral, symptoms, health status, care dependency, caregiver burden and advance directives. METHODS A mixed methods study including 23 outpatients with advanced chronic heart failure and 20 family caregivers was performed. Nurses conducted patient consultations using a Dutch translation of the NAT:PD-HF and rated acceptability. Before this visit and 4 months later, symptoms, health status, performance status, care dependency, caregiver burden and recorded advance directives were assessed. A focus group with participating nurses discussed barriers and facilitators towards palliative care needs assessment. RESULTS Acceptability was rated as 7 (interquartile range 6-7 points) on a 10-point scale. All patients had palliative care needs. In 48% actions were taken, including two patients referred to palliative care. Symptoms, performance status, care dependency, caregiver burden and advance directives were unchanged at 4 months, while health status deteriorated in patients completing follow-up ( n=17). Barriers towards palliative care needs assessment included feeling uncomfortable to initiate discussions and concerns about the ability to address palliative care needs. CONCLUSIONS The NAT:PD-HF identified palliative care needs in all participants, and triggered action to address these in half. However, training in palliative care communication skills as well as palliative care interventions should accompany the introduction of a palliative care needs assessment tool. NETHERLANDS NATIONAL TRIAL REGISTER (NTR) 5616. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5616.
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Affiliation(s)
- Daisy Ja Janssen
- 1 Department of Research and Education, CIRO, The Netherlands.,2 Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), The Netherlands
| | - Josiane Boyne
- 3 Department of Patient and Care, Maastricht University Medical Centre (MUMC+), The Netherlands
| | - David C Currow
- 4 IMPACCT, Faculty of Health, University of Technology Sydney, Australia
| | - Jos Mga Schols
- 5 Department of Health Services Research and Department of Family Medicine, Maastricht University, The Netherlands
| | - Miriam J Johnson
- 6 Wolfson Palliative Care Research Centre, University of Hull, UK
| | - H-P Brunner- La Rocca
- 7 Department of Cardiology, Maastricht University Medical Centre (MUMC+), The Netherlands
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21
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Kurozumi Y, Oishi S, Sugano Y, Sakashita A, Kotooka N, Suzuki M, Higo T, Yumino D, Takada Y, Maeda S, Yamabe S, Washida K, Takahashi T, Ohtani T, Sakata Y, Sato Y. Possible associations between palliative care conferences and positive outcomes when performing palliative care for patients with end-stage heart failure: a nationwide cross-sectional questionnaire survey. Heart Vessels 2018; 34:452-461. [PMID: 30238352 DOI: 10.1007/s00380-018-1261-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 09/14/2018] [Indexed: 01/06/2023]
Abstract
Palliative care for end-stage heart failure should be provided by a multidisciplinary team. However, the influence of each occupational category on patients receiving palliative care for end-stage heart failure remains unclear. Thus, this study investigated the relationships between palliative care conferences and positive outcomes of palliative care for end-stage heart failure patients. We sent questionnaires to all cardiology training hospitals authorized by the Japanese Circulation Society (n = 1004); of these, responses from the directors at 554 institutions were analyzed. We divided the responding institutions into two groups according to their implementation of palliative care conferences for patients with end-stage heart failure. The institutions that had held such conferences (n = 223) had a larger number of hospital beds, beds in the cardiovascular department, and patients admitted to the cardiovascular department, compared with institutions that had not held these conferences (n = 321). The usage rates of opioids, non-steroidal anti-inflammatory drugs, and sedatives were significantly higher in institutions that held these conferences. Multivariate analysis revealed that nutritionists and medical social workers had greater involvement in the improvement of mental symptoms and ensuring that patients could stay where they wished, respectively. The presence of palliative care physicians, physical therapists, or pharmacists was associated with multiple positive outcomes. This study indicated that there are possible associations between palliative care conferences and positive outcomes when performing palliative care for patients with end-stage heart failure.
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Affiliation(s)
- Yuma Kurozumi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, 660-8550, Hyogo, Japan.
| | - Shogo Oishi
- Department of Cardiology, Himeji Cardiovascular Center, Himeji, Japan
| | - Yasuo Sugano
- Department of Cardiology, Keiyu Hospital, Yokohama, Japan.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihiro Sakashita
- Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Norihiko Kotooka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Makoto Suzuki
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | | | - Yasuko Takada
- Department of Nursing, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Seiko Maeda
- Department of Nursing, Nagoya Heart Center, Nagoya, Japan
| | - Saori Yamabe
- Department of Nursing, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Koichi Washida
- Department of Nursing, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | | | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, 660-8550, Hyogo, Japan
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22
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Abstract
It is currently estimated that 5.7 million Americans live with heart failure. Of these, less than 3000 will receive a heart transplant this year, according to the US Department of Health and Human Services Organ Procurement and Transplantation Network. With successful transplantation can come significant emotional and physical symptoms that are not always addressed. Although palliative care is an interdisciplinary subspecialty designed to alleviate multiple domains of suffering in serious illness, many mistakenly associate it solely with the end of life. Traditionally associated with cancer, research into the role of palliative care in other chronic illnesses and complex life-changing therapies such as solid organ transplantation remains scarce but is nonetheless developing. Here, we try to investigate a potential role for palliative care for heart transplant recipients. Early research thus far has demonstrated importance of early involvement of palliative care teams and the significant improvement of physical and emotional symptoms in the pre- and post-transplant period. Nevertheless, more research is warranted to determine the ideal timing of palliative care integration, the effects on health care resource utilization, and whether improving quality of life can affect morbidity and mortality. By understanding these critical elements and others we may be able to develop a model for the role of palliative care for heart transplant patients.
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23
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Klinedinst R, Kornfield ZN, Hadler RA. Palliative Care for Patients With Advanced Heart Disease. J Cardiothorac Vasc Anesth 2018; 33:833-843. [PMID: 29793760 DOI: 10.1053/j.jvca.2018.04.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Indexed: 11/11/2022]
Abstract
Over the past 2 decades, the discipline of palliative care has evolved and expanded such that it is now the standard of care for a variety of acute and chronic processes. Although there are recommendations encouraging incorporation of palliative care into the routine management of patients with chronic cardiac processes, such as congestive heart failure, implementation has been challenging, and nowhere more so than in the cardiac surgical population. However, as the boundaries of surgical care have expanded to include progressively more complex cases, increasing attention has been given to the integration of palliative care into their management. In this review article, the authors describe the existing evidence for palliative care team involvement in patients with non-operative and surgical cardiac diseases and examine future directions for growth in this field.
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Affiliation(s)
- Rachel Klinedinst
- Division of Palliative Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Z Noah Kornfield
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel A Hadler
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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24
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Palliative care in heart failure. Trends Cardiovasc Med 2018; 28:445-450. [PMID: 29735287 DOI: 10.1016/j.tcm.2018.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/04/2018] [Accepted: 02/15/2018] [Indexed: 12/31/2022]
Abstract
Palliative care (PC) is now recommended by all major cardiovascular societies for advanced heart failure (HF). PC is a philosophy of care that uses a holistic approach to address physical, psychosocial, and spiritual needs in patients with a terminal disease process. In HF, PC has been shown to improve symptoms and quality of life, facilitate advanced care planning, decrease hospital readmissions, and decrease hospital-associated healthcare costs. Although PC is still underutilized in HF, uptake is increasing. Specific strategies for successfully implementing PC in HF include early PC involvement, multidisciplinary collaboration, exploring patient values for end-of-life care, medical therapy (including both the addition of symptom-directed medications, as well as the removal of life-prolonging medications), and considerations regarding device therapy and mechanical support. Barriers to PC in HF include difficulties predicting the disease trajectory, patient and physician misconceptions, and lack of PC-trained physicians. Moving forward, PC will continue to be a key part of advanced HF care as our knowledge of this area grows.
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Phongtankuel V, Meador L, Adelman RD, Roberts J, Henderson CR, Mehta SS, del Carmen T, Reid M. Multicomponent Palliative Care Interventions in Advanced Chronic Diseases: A Systematic Review. Am J Hosp Palliat Care 2018; 35:173-183. [PMID: 28273750 PMCID: PMC5879777 DOI: 10.1177/1049909116674669] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions. OBJECTIVES To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes. DESIGN Systematic review. STUDY SELECTION English-language articles analyzing multicomponent palliative care interventions. OUTCOMES MEASURED Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life). RESULTS Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes. CONCLUSIONS While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.
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Affiliation(s)
- Veerawat Phongtankuel
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Lauren Meador
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Ronald D. Adelman
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | | | | | - Sonal S. Mehta
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Tessa del Carmen
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - M.C. Reid
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
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26
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Wentlandt K, Weiss A, O'Connor E, Kaya E. Palliative and end of life care in solid organ transplantation. Am J Transplant 2017; 17:3008-3019. [PMID: 28976070 DOI: 10.1111/ajt.14522] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 09/17/2017] [Accepted: 09/22/2017] [Indexed: 01/25/2023]
Abstract
Palliative care is an interprofessional approach that focuses on quality of life of patients who are facing life-threatening illness. Palliative care is consistently associated with improvements in advance care planning, patient and caregiver satisfaction, quality of life, symptom burden, and lower healthcare utilization. Most transplant patients have advanced chronic disease, significant symptom burden, and mortality awaiting transplant. Transplantation introduces new risks including perioperative death, organ rejection, infection, renal insufficiency, and malignancy. Numerous publications over the last decade identify that palliative care is well-suited to support these patients and their caregivers, yet access to palliative care and research within this population are lacking. This review describes palliative care and summarizes existing research supporting palliative intervention in advanced organ failure and transplant populations. A proposed model to provide palliative care in parallel with disease-directed therapy in a transplant program has the potential to improve symptom burden, quality of life, and healthcare utilization. Further studies are needed to elucidate specific benefits of palliative care for this population. In addition, there is a tremendous need for education, specifically for clinicians, patients, and families, to improve understanding of palliative care and its benefits for patients with advanced disease.
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Affiliation(s)
- K Wentlandt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - A Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - E O'Connor
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - E Kaya
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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27
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Palliative Care in Older Adults with Cardiovascular Disease: Addressing Misconceptions to Advance Care. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0530-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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28
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O’Mahony S, Levine S, Baron A, Johnson TJ, Ansari A, Leyva I, Marschke M, Szmuilowicz E, Deamant C. Palliative Workforce Development and a Regional Training Program. Am J Hosp Palliat Care 2016; 35:138-143. [DOI: 10.1177/1049909116685046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aims: Our primary aims were to assess growth in the local hospital based workforce, changes in the composition of the workforce and use of an interdisciplinary team, and sources of support for palliative medicine teams in hospitals participating in a regional palliative training program in Chicago. Methods: PC program directors and administrators at 16 sites were sent an electronic survey on institutional and PC program characteristics such as: hospital type, number of beds, PC staffing composition, PC programs offered, start-up years, PC service utilization and sources of financial support for fiscal years 2012 and 2014. Results: The median number of consultations reported for existing programs in 2012 was 345 (IQR 109 – 2168) compared with 840 (IQR 320 – 4268) in 2014. At the same time there were small increases in the overall team size from a median of 3.2 full time equivalent positions (FTE) in 2012 to 3.3 FTE in 2013, with a median increase of 0.4 (IQR 0-1.0). Discharge to hospice was more common than deaths in the acute care setting in hospitals with palliative medicine teams that included both social workers and advanced practice nurses ( p < .0001). Conclusions: Given the shortage of palliative medicine specialist providers more emphasis should be placed on training other clinicians to provide primary level palliative care while addressing the need to hire sufficient workforce to care for seriously ill patients.
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Affiliation(s)
| | | | | | | | - Aziz Ansari
- Loyola University Hospital, Maywood, IL, USA
| | - Ileana Leyva
- Cadence Health Central Dupage Hospital, Winfield, IL, USA
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29
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Wentlandt K, Dall'Osto A, Freeman N, Le LW, Kaya E, Ross H, Singer LG, Abbey S, Clarke H, Zimmermann C. The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant 2016; 30:1591-1596. [PMID: 27910190 DOI: 10.1111/ctr.12838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 12/20/2022]
Abstract
Although patients within a transplant program are awaiting or have received disease modifying or curative treatment, they are also facing advanced illness and the possibility of death. The involvement of specialized palliative care services for these patients may improve symptom management and facilitate advance care planning. However, patients in organ transplantation programs have difficulty accessing palliative care resources and often do so only sporadically in the inpatient setting. Currently, there is little access to ambulatory palliative care for these patients and there have been no descriptions of programs delivering such care in the medical literature. We outline the development and structure of a Transplant Palliative Care Clinic within the University Health Network's Multi-Organ Transplant Program, in Toronto, Canada. This information may be helpful for others aiming to provide early, integrated palliative care to patients awaiting and receiving organ transplantation.
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Affiliation(s)
- Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Angela Dall'Osto
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Nicole Freeman
- Department of Family Medicine [Windsor Program], Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ebru Kaya
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Lianne G Singer
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan Abbey
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Pain Research Unit and the Transitional Pain Service, Department of Anaesthesia, University Health Network, Toronto, ON, Canada.,Department of Anaesthesia, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Campbell Family Cancer Research Institute, Ontario Cancer Institute, Toronto, ON, Canada
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30
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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31
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Braun LT, Grady KL, Kutner JS, Adler E, Berlinger N, Boss R, Butler J, Enguidanos S, Friebert S, Gardner TJ, Higgins P, Holloway R, Konig M, Meier D, Morrissey MB, Quest TE, Wiegand DL, Coombs-Lee B, Fitchett G, Gupta C, Roach WH. Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association. Circulation 2016; 134:e198-225. [DOI: 10.1161/cir.0000000000000438] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.
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32
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Luo N, Rogers JG, Dodson GC, Patel CB, Galanos AN, Milano CA, O'Connor CM, Mentz RJ. Usefulness of Palliative Care to Complement the Management of Patients on Left Ventricular Assist Devices. Am J Cardiol 2016; 118:733-8. [PMID: 27474339 DOI: 10.1016/j.amjcard.2016.06.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 12/25/2022]
Abstract
Within the last decade, advancements in left ventricular assist device therapy have allowed patients with end-stage heart failure (HF) to live longer and with better quality of life. Like other life-saving interventions, however, there remains the risk of complications including infections, bleeding episodes, and stroke. The candidate for left ventricular assist device therapy faces complex challenges going forward, both physical and psychological, many of which may benefit from the application of palliative care principles by trained specialists. Despite these advantages, palliative care remains underused in many advanced HF programs. Here, we describe the benefits of palliative care, barriers to use within HF, and specific applications to the integrated care of patients on mechanical circulatory support.
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Affiliation(s)
- Nancy Luo
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Joseph G Rogers
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gwen C Dodson
- Palliative Medicine Section, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Anthony N Galanos
- Palliative Medicine Section, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher M O'Connor
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Robert J Mentz
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
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33
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Meyers DE, Goodlin SJ. End-of-Life Decisions and Palliative Care in Advanced Heart Failure. Can J Cardiol 2016; 32:1148-56. [DOI: 10.1016/j.cjca.2016.04.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/14/2016] [Accepted: 04/25/2016] [Indexed: 12/21/2022] Open
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Palliative care for patients with heart failure: facilitators and barriers - a cross sectional survey of German health care professionals. BMC Health Serv Res 2016; 16:361. [PMID: 27503510 PMCID: PMC4977661 DOI: 10.1186/s12913-016-1609-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/30/2016] [Indexed: 11/22/2022] Open
Abstract
Background Compared to patients with cancer, heart failure patients are seldom candidates for palliative care. Numerous studies have investigated reasons why heart failure patients do not receive palliative care; however, none of these studies have ever evaluated the situation in the German health care setting. This study aims to identify German healthcare providers’ (HCP) perception of barriers and facilitators to palliative care of patients with chronic heart failure. Methods We conducted an online-survey with 315 nurses and physicians of different medical disciplines. Results Even though heart failure patients’ need of palliative care and its advantages has been recognized, HCP see potential for development and improvement. A lack of knowledge about the content and measures of palliative care, poor communication and unclear responsibilities between medical disciplines, difficulties to determine the right time to initiate palliative care, and the feeling not to be prepared to discuss end-of-life issues with the patient has been identified as barriers. Further, HCP believe that patients and relatives do not possess adequate knowledge about the disease and its progression and are therefore unprepared in asking questions regarding palliative care. They rather tend to demand everything possible to be done in order prolong life, and are reluctant to accept that life is limited. Overall, HCP perceive that dying is a taboo subject within our society placing palliative care on the same level as assisted dying. In addition, results indicate that HCP have an inappropriate notion of ideal medicine fearing to lose patient and are worried about the appropriateness of PC remuneration. Conclusions In order to overcome the described barriers, HCP, patients, and relatives need to be educated in palliative care. Information and education encompassing the aim, content and measures of palliative care needs to be provided for all parties in order to optimize patient care, to foster communication between healthcare professionals, patients, and relatives, and to overcome perceived barriers. Trial registration DRKS00007119 Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1609-x) contains supplementary material, which is available to authorized users.
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Kane PM, Murtagh FEM, Ryan K, Mahon NG, McAdam B, McQuillan R, Ellis-Smith C, Tracey C, Howley C, Raleigh C, O'Gara G, Higginson IJ, Daveson BA. The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure. Heart Fail Rev 2016; 20:673-87. [PMID: 26435042 PMCID: PMC4608978 DOI: 10.1007/s10741-015-9508-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II–IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included ‘patient-centred care’, ‘quality of life’ and ‘shared decision making’. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations.
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Affiliation(s)
- P M Kane
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.
| | - F E M Murtagh
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - K Ryan
- St. Francis Hospice, Dublin, Ireland.,Mater Misericordiae University Hospital, Dublin, Ireland
| | - N G Mahon
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - B McAdam
- Beaumont Hospital, Dublin, Ireland
| | - R McQuillan
- St. Francis Hospice, Dublin, Ireland.,Beaumont Hospital, Dublin, Ireland
| | - C Ellis-Smith
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - C Tracey
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - C Howley
- Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - G O'Gara
- Beaumont Hospital, Dublin, Ireland
| | - I J Higginson
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - B A Daveson
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
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Pak E, Wald J, Kirkpatrick JN. Multimorbidity and End of Life Care in Patients with Cardiovascular Disease. Clin Geriatr Med 2016; 32:385-97. [DOI: 10.1016/j.cger.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.
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Affiliation(s)
- Timothy J Fendler
- Division of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, 4401 Wornall Road, SLNI, CV Research, Suite 5603, Kansas City, MO 64111, USA.
| | - Keith M Swetz
- Section of Palliative Medicine, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, 12605 East 16th Avenue, 3rd Floor, Aurora, CO 80045, USA
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Initiating pain and palliative care outpatient services for the suburban underserved in Montgomery County, Maryland: Lessons learned at the NIH Clinical Center and MobileMed. Palliat Support Care 2015; 14:381-6. [PMID: 26373835 DOI: 10.1017/s1478951515001030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE With the ongoing expansion of palliative care services throughout the United States, meeting the needs of socioeconomically marginalized populations, as in all domains of healthcare, continues to be a challenge. Our specific aim here was to help meet some of these needs through expanding delivery of pain and palliative care services by establishing a new clinic for underserved patients and collecting descriptive data about its operation. METHOD In November of 2014, the National Institutes of Health Clinical Center's Pain and Palliative Care Service (PPCS) launched a bimonthly offsite pain and palliative care outpatient clinic in collaboration with Mobile Medical Care Inc. (MobileMed), a private not-for-profit primary care provider in Montgomery County, Maryland, serving underserved area residents since 1968. Staffed by NIH hospice and palliative medicine clinical fellows and faculty, the clinic provides specialty pain and palliative care consultation services to patients referred by their primary care healthcare providers. A patient log was maintained, charts reviewed, and referring providers surveyed on their satisfaction with the service. RESULTS The clinic had 27 patient encounters with 10 patients (6 males, 4 females, aged 23-67) during its first 7 months of operation. The reason for referral for all but one patient was chronic pain of multiple etiologies. Patients had numerous psychosocial stressors and comorbidities. All primary care providers who returned surveys (n = 4) rated their level of satisfaction with the consultation service as "very satisfied" or "extremely satisfied." SIGNIFICANCE OF RESULTS This brief descriptive report outlines the steps taken and logistical issues addressed to launch and continue the clinic, the characteristics of patients treated, and the results of quality-improvement projects. Lessons learned are highlighted and future directions suggested for the clinic and others that may come along like it.
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Abstract
Heart failure (HF) is increasingly common in the United States and is associated with a high degree of morbidity and mortality. As patients approach the end of life there is a significant increase in health care resource use. Patients with end-stage HF have a unique set of needs at the end of life, including symptoms such as dyspnea, uremia, and depression, as well as potentially deactivating implantable defibrillators and mechanical circulatory support devices. Improved palliative care services for patients with HF may improve quality of life and decrease health care resource use near the end of life.
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Affiliation(s)
- Jonathan Buggey
- Department of Medicine, Duke University Medical Center, Duke Medical Hospital, Medical Residency Office/Room 8254DN, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27710, USA
| | - Anthony N Galanos
- Division of Palliative Care, Department of Medicine, Duke University Medical Center, PO Box 3003, DUMC, Durham, NC 27710, USA
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Köberich S, Ziehm J, Farin E, Becker G. Barriers and Facilitators to Palliative Care of Patients with Chronic Heart Failure in Germany: A Study Protocol. J Public Health Res 2015; 4:556. [PMID: 26425500 PMCID: PMC4568429 DOI: 10.4081/jphr.2015.556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/19/2015] [Indexed: 12/03/2022] Open
Abstract
Background Despite its high prevalence, similar symptoms and symptom burden, people suffering from chronic heart failure receive less palliative care than patients with malignant diseases. Internationally, numerous barriers to palliative care of patients with chronic heart failure are known, however, there are no credible data regarding barriers and facilitators to palliative care of people suffering from chronic heart failure available for Germany. Design and Methods Tripartite study. First part of this study evaluates health care providers’ (physicians and nurses) perceived barriers and facilitators to palliative care of patients with chronic heart failure using a qualitative approach. At least 18 persons will be interviewed. In the second part, based on the results of part one, a questionnaire about barriers and facilitators to palliative care of patients with chronic heart failure will be designed and applied to at least 150 physicians and nurses. In the last part a classic Delphi method will be used to develop specific measures to improve the palliative care for chronic heart failure patients. Expected Impact for Public Health The results of this study will help to understand why patients with heart failure are seldom referred to palliative care and will provide solutions to overcome these barriers. Developed solutions will be the first step to improve palliative care in patients with heart failure in Germany. In addition, the results will help health care providers in other countries to take action to improve palliative care situations for heart failure patients. Significance for public health Patients with chronic heart failure suffer from similar symptoms and symptom burden than patients with malignant diseases. However, palliative care differs between these groups in a quantitative and qualitative way. This study will help to understand why patients with chronic heart failure receive less palliative care than patients with malignant disease. In addition, measures to overcome barriers and to promote facilitators of palliative care in patients with chronic heart failure will be developed. These recommendations could provide a basis for quality improvement projects or studies aiming at improving symptoms and symptom burden of heart failure patients. The recommended measures could also be used to reduce caregiver burden.
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Affiliation(s)
- Stefan Köberich
- Institute for Quality Management and Social Medicine, Medical Centre - University of Freiburg , Germany ; Heart Centre, University of Freiburg , Germany
| | - Jeantte Ziehm
- Institute for Quality Management and Social Medicine, Medical Centre - University of Freiburg , Germany
| | - Erik Farin
- Institute for Quality Management and Social Medicine, Medical Centre - University of Freiburg , Germany
| | - Gerhild Becker
- Department of Palliative Care, Medical Centre, University of Freiburg , Germany
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Jorgenson A, Sidebottom AC, Richards H, Kirven J. A Description of Inpatient Palliative Care Actions for Patients With Acute Heart Failure. Am J Hosp Palliat Care 2015; 33:863-870. [PMID: 26126817 DOI: 10.1177/1049909115593064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In a recent randomized trial, inpatient palliative care (PC) visits were associated with improved quality of life and symptom burden for patients with heart failure. To better understand what actions by PC providers may have led to those outcomes, we conducted chart reviews of 101 patients in the intervention group (who received PC). Palliative care actions are described for all patients and for those with higher symptoms. Orders were written for 24% of patients, most frequently for pain. Recommendations to change current care were made for 40% of patients. At least 1 element of future care planning was documented for 99% of patients. Palliative care for inpatients with HF led to additive actions beyond standard care, especially for pain, and promoted HF-specific goals of care discussions.
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Affiliation(s)
- Ann Jorgenson
- Division of Applied Research, Allina Health, Minneapolis, MN, USA
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Fowler A, Freiberger D, Moonan M. Palliative and end-of-life care in pediatric solid organ transplantation. Pediatr Transplant 2015; 19:11-7. [PMID: 25422076 DOI: 10.1111/petr.12387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 11/30/2022]
Abstract
End-of-life care is a component of palliative care and takes a holistic, individualized approach to patients, focusing on the assessment of quality of life and its maintenance until the end of life, and beyond, for the patient's family. Transplant teams do not always make timely referrals to palliative care teams due to various clinician and perceived family barriers, an important one being the simultaneous, active care plan each patient would have alongside an end-of-life plan. Application of findings and further research specific to the pediatric solid organ population would be of significant benefit to guide transplant teams as to the most effective time to introduce end-of-life care, who to involve in ongoing discussions, and important ethical and cultural considerations to include in care planning. Attention must also be paid to clinician training and support in this challenging area of health care.
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Affiliation(s)
- Amy Fowler
- Freeman Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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Sidebottom AC, Jorgenson A, Richards H, Kirven J, Sillah A. Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial. J Palliat Med 2014; 18:134-42. [PMID: 25479182 DOI: 10.1089/jpm.2014.0192] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Heart failure (HF) is associated with a high symptom burden and reduced quality of life (QOL). Models integrating palliative care (PC) into HF care have been proposed, but limited research is available on the outcomes of such models. OBJECTIVE Our aim was to assess if inpatient PC for HF patients is associated with improvements in symptom burden, depressive symptoms, QOL, or differential use of services. METHODS Patients hospitalized with acute HF were randomized to receive a PC consult with follow-up as determined by provider or standard care. Two hundred thirty-two patients (116 intervention/116 control) from a large tertiary-care urban hospital were recruited over a 10-month period. Primary outcomes were symptom burden, depressive symptoms, and QOL measured at baseline, 1, and 3 months. Secondary outcomes included advance care planning (ACP), inpatient 30-day readmission, hospice use, and death. RESULTS Improvements were greater at both 1 and 3 months in the intervention group for primary outcome summary measures after adjusting for age, gender, and marital status differences between study groups. QOL scores increased by 12.92 points in the intervention and 8 points in the control group at 1 month (difference+4.92, p<0.001). Improvement in symptom burden was 8.39 in the intervention group and 4.7 in the control group at 1 month (+3.69, p<0.001). ACP was the only secondary outcome associated with the intervention (hazard ratio [HR] 2.87, p=0.033). CONCLUSION An inpatient PC model for patients with acute HF is associated with short-term improvement in symptom burden, QOL, and depressive symptoms.
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Mentz RJ, Tulsky JA, Granger BB, Anstrom KJ, Adams PA, Dodson GC, Fiuzat M, Johnson KS, Patel CB, Steinhauser KE, Taylor DH, O’Connor CM, Rogers JG. The palliative care in heart failure trial: rationale and design. Am Heart J 2014; 168:645-651.e1. [PMID: 25440791 DOI: 10.1016/j.ahj.2014.07.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/24/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The progressive nature of heart failure (HF) coupled with high mortality and poor quality of life mandates greater attention to palliative care as a routine component of advanced HF management. Limited evidence exists from randomized, controlled trials supporting the use of interdisciplinary palliative care in HF. METHODS PAL-HF is a prospective, controlled, unblinded, single-center study of an interdisciplinary palliative care intervention in 200 patients with advanced HF estimated to have a high likelihood of mortality or rehospitalization in the ensuing 6 months. The 6-month PAL-HF intervention focuses on physical and psychosocial symptom relief, attention to spiritual concerns, and advanced care planning. The primary end point is health-related quality of life measured by the Kansas City Cardiomyopathy Questionnaire and the Functional Assessment of Chronic Illness Therapy with Palliative Care Subscale score at 6 months. Secondary end points include changes in anxiety/depression, spiritual well-being, caregiver satisfaction, cost and resource utilization, and a composite of death, HF hospitalization, and quality of life. CONCLUSIONS PAL-HF is a randomized, controlled clinical trial that will help evaluate the efficacy and cost effectiveness of palliative care in advanced HF using a patient-centered outcome as well as clinical and economic end points.
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Poonja Z, Brisebois A, van Zanten SV, Tandon P, Meeberg G, Karvellas CJ. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol 2014; 12:692-8. [PMID: 23978345 DOI: 10.1016/j.cgh.2013.08.027] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/22/2013] [Accepted: 08/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis who are receiving palliative care and are not eligible for liver transplantation (LT) are often hospitalized multiple times, with lack of expectations or understanding of death and dying. We evaluated how frequently these patients received appropriate and palliative care. METHODS We performed a retrospective study of 102 consecutive adult patients (67% men; mean age, 55 years) who were removed from the list for or declined LT from January 2005 through December 2010 at the University of Alberta, Canada. Patients' medical records were reviewed to determine their access to palliative care and relief of symptoms, the appropriateness of the goals for their care, and their requirements for acute care services. RESULTS The patients' median Model for End-stage Liver Disease score was 20, and median time from denial of LT to death was 52 days (range, 10-332 days). The most common reasons that patients were removed from the transplant wait list were noncompliance or substance abuse (26%) and severe illness or organ dysfunction (25%). After patients were removed from the list, 17% received renal replacement therapy, and 48% were subsequently admitted to the intensive care unit. Patients spent a median of 14 days (range, 6-33 days) in the hospital after they were removed from the transplant wait list. On the basis of the Edmonton Symptom Assessment System, 65% of patients had evidence of pain, 58% had evidence of nausea, 10% had depression, 36% had anxiety, 48% had dyspnea, and 49% had symptoms of anorexia. Twenty-eight percent of all the patients had documentation of do not resuscitate status on their charts, and only 11% were referred for palliative care. CONCLUSIONS Patients with cirrhosis who have been removed from the wait list for LT are infrequently referred for palliative care (∼ 10% of cases), although a high percentage have pain or nausea. Goals of care and do not resuscitate status are rarely discussed. Improved planning of goals of care and access to palliative services are required for these patients.
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Affiliation(s)
- Zafrina Poonja
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Division of General Internal Medicine and Palliative Care, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sander Veldhuyzen van Zanten
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Glenda Meeberg
- Liver Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - Constantine J Karvellas
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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46
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Lindvall C, Hultman TD, Jackson VA. Overcoming the barriers to palliative care referral for patients with advanced heart failure. J Am Heart Assoc 2014; 3:e000742. [PMID: 24584742 PMCID: PMC3959710 DOI: 10.1161/jaha.113.000742] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Boothroyd LJ, Lambert LJ, Ducharme A, Guertin JR, Sas G, Charbonneau É, Carrier M, Cecere R, Morin JE, Bogaty P. Challenge of informing patient decision making: what can we tell patients considering long-term mechanical circulatory support about outcomes, daily life, and end-of-life issues? CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2014; 7:179-87. [PMID: 24425705 DOI: 10.1161/circoutcomes.113.000243] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lucy J Boothroyd
- Institut National d'Excellence en Santé et en Services Sociaux, Montreal, Quebec, Canada
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48
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Kim S, Hwang WJ. Palliative care for those with heart failure: nurses' knowledge, attitude, and preparedness to practice. Eur J Cardiovasc Nurs 2014; 13:124-33. [PMID: 24399844 DOI: 10.1177/1474515113519521] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Palliative care is an important element of holistic care but has received little attention in cardiac disease patients. The purpose of the paper is (a) to investigate nurses' knowledge of palliative care, attitudes toward care of the dying, coping with death, and preparedness to practice palliative care for those with heart failure, and (b) to evaluate influencing factors on preparedness to practice on palliative care. METHODS A cross-sectional descriptive design employed a structured questionnaire that tested nurses' knowledge, attitude, coping, and preparedness to practice on palliative care for patients with heart failure. Ninety nurses in two tertiary university hospitals in South Korea participated in the survey. Data were analyzed with descriptive statistics, correlation, and multiple regression. RESULTS Results showed low levels of knowledge reported (an average of 48.3% correct answers), attitude (134.8±110.1), coping (117.2±24.3), and preparedness to practice (17.3±4.7) relating to palliative care. The extent of knowledge was related to both attitudes and coping. These attitudes and coping skills were related to preparedness to practice. The multiple regression analysis showed that preparedness to practice was explained by coping and attitude (R (2) =0.46, F=6.1, p<0.001). CONCLUSIONS Palliative care training is urgently needed to improve knowledge, attitude, coping, and preparedness to practice. Guidance to assist healthcare professionals involved in palliative care for those with cardiac disease needs to be developed and provided.
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Affiliation(s)
- Sanghee Kim
- 1Nursing Policy Research Institute, College of Nursing, Yonsei University, South Korea
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49
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Kavalieratos D, Mitchell EM, Carey TS, Dev S, Biddle AK, Reeve BB, Abernethy AP, Weinberger M. "Not the 'grim reaper service'": an assessment of provider knowledge, attitudes, and perceptions regarding palliative care referral barriers in heart failure. J Am Heart Assoc 2014; 3:e000544. [PMID: 24385453 PMCID: PMC3959712 DOI: 10.1161/jaha.113.000544] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 11/17/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although similar to cancer patients regarding symptom burden and prognosis, patients with heart failure (HF) tend to receive palliative care far less frequently. We sought to explore factors perceived by cardiology, primary care, and palliative care providers to impede palliative care referral for HF patients. METHODS AND RESULTS We conducted semistructured interviews regarding (1) perceived needs of patients with advanced HF; (2) knowledge, attitudes, and experiences with specialist palliative care; (3) perceived indications for and optimal timing of palliative care referral in HF; and (4) perceived barriers to palliative care referral. Two investigators analyzed data using template analysis, a qualitative technique. We interviewed 18 physician, nurse practitioner, and physician assistant providers from 3 specialties: cardiology, primary care, and palliative care. Providers had limited knowledge regarding what palliative care is, and how it can complement traditional HF therapy to decrease HF-related suffering. Interviews identified several potential barriers: the unpredictable course of HF; lack of clear referral triggers across the HF trajectory; and ambiguity regarding what differentiates standard HF therapy from palliative care. Nevertheless, providers expressed interest for integrating palliative care into traditional HF care, but were unsure of how to initiate collaboration. CONCLUSIONS Palliative care referral for HF patients may be suboptimal due to limited provider knowledge and misperceptions of palliative care as a service reserved for those near death. These factors represent potentially modifiable targets for provider education, which may help to improve palliative care referral for HF patients with unresolved disease-related burden.
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Affiliation(s)
- Dio Kavalieratos
- Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (D.K.)
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
| | - Emma M. Mitchell
- School of Nursing and Health Studies, University of Miami, FL (E.M.M.)
| | - Timothy S. Carey
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill,
| | - Sandesh Dev
- Phoenix Veterans Affairs Medical Center, Phoenix, AZ (S.D.)
| | - Andrea K. Biddle
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
| | - Bryce B. Reeve
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
| | - Amy P. Abernethy
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.P.A.)
- Division of Medical Oncology, Duke University School of Medicine, Duke University, Durham, NC (A.P.A.)
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill,
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC (M.W.)
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Sheppard KD, Brown CJ, Hearld KR, Roth DL, Sawyer P, Locher JL, Allman RM, Ritchie CS. Symptom burden predicts nursing home admissions among older adults. J Pain Symptom Manage 2013; 46:591-7. [PMID: 23218806 PMCID: PMC3748255 DOI: 10.1016/j.jpainsymman.2012.10.228] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 10/11/2012] [Accepted: 10/17/2012] [Indexed: 10/27/2022]
Abstract
CONTEXT Symptom burden has been associated with functional decline in community-dwelling older adults and may be responsive to interventions. Known predictors of nursing home (NH) admission are often nonmodifiable. OBJECTIVES To determine if symptom burden independently predicted NH admission among community-dwelling older adults over an eight and a half-year follow-up period. METHODS A random sample of community-dwelling Medicare beneficiaries in Alabama, stratified by race, gender, and rural/urban residence had baseline in-home assessments of sociodemographic measurements, Charlson comorbidity count, and symptoms. Symptom burden was derived from a count of 10 patient-reported symptoms. Nursing home admissions were determined from telephone interviews conducted every six months over the eight and a half years of study. Cox proportional hazard modeling was used to examine the significance of symptom burden as a predictor for NH admission after adjusting for other variables. RESULTS The mean ± SD age of the sample (N = 999) was 75.3 ± 6.7 years, and the sample was 51% rural, 50% African American, and 50% male. Thirty-eight percent (n = 380) had symptom burden scores ≥2. Seventy-five participants (7.5%) had confirmed dates for NH admission during the eight and a half years of follow-up. Using Cox proportional hazard modeling, symptom burden remained an independent predictor of time to NH placement (hazard ratio = 1.11; P = 0.02), even after adjustment for comorbidity count, race, sex, and age. CONCLUSION Symptom burden is an independent risk factor for NH admission. Aggressive management of symptoms in older adults may reduce or delay NH admission.
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Affiliation(s)
- Kendra D Sheppard
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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