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Godfrey S, Steiner JM, Damluji AA, Sampath R, Chuzi S, Warraich H, Krishnaswami A, Bernacki G, Goodlin S, Josephson R, Mulrow J, Doherty C. Palliative Care Education in Cardiovascular Disease Fellowships: A National Survey of Program Directors. J Card Fail 2024:S1071-9164(24)00116-7. [PMID: 38616006 DOI: 10.1016/j.cardfail.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Palliative care (PC) is an essential component of high-quality care for people with cardiovascular disease (CVD). However, little is known about the current state of PC education in CVD training, including attitudes toward integration of PC into training and implementation of PC by the program's leadership. METHODS We developed a nationwide, cross-sectional survey that queried education approaches, perspectives and barriers to PC education in general CVD fellowship training. The survey was distributed to 392 members of the American College of Cardiology Program Director (PD) listserv, representing 290 general CVD fellowships between 1/2023 and 4/2023. We performed descriptive and ꭕ2 analyses of survey data. RESULTS Of the program's representatives, 56 completed the survey (response rate = 19.3%). Respondents identified themselves as current PDs (89%), associate PDs (8.9%) or former PDs (1.8%), representing a diverse range of program sizes and types and regions of the country. Respondents reported the use of informal bedside teaching (88%), formal didactics (59%), online or self-paced modules (13%), in-person simulation (11%), and clinical rotations (16%) to teach PC content. Most programs covered PC topics at least annually, although there was variability by topic. We found no associations between program demographics and type or frequency of PC education. Most respondents reported dissatisfaction with the quantity (62%) or quality (59%) of the PC education provided. Barriers to PC education included an overabundance of other content to cover (36%) and perceived lack of fellow (20%) or faculty (18%) interest. Comments demonstrated the importance of PC education in fellowship, the lack of a requirement to provide PC education, difficulty in covering all topics, and suggestions of how PC skills should be taught. CONCLUSIONS In a national survey of CVD educational leadership concerning approaches to PC education in CVD training, respondents highlighted both challenges to implementation of formal PC curricula in cardiology training and opportunities for comprehensive PC education.
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Affiliation(s)
- Sarah Godfrey
- University of Texas Southwestern Medical Center, Dallas, TX.
| | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Falls Church, VA; Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | | | - Gwen Bernacki
- University of Washington Medical Center, Seattle, WA; Veterans' Administration of Puget Sound, Seattle, WA
| | - Sarah Goodlin
- Patient-Centered Education and Research, Oregon Health and Sciences University, Portland, OR
| | | | - John Mulrow
- Cardiology Clinic of San Antonio, San Antonio, TX
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Uemura T, Ito K, Yuasa M, Shiozawa Y, Ishikawa H, Nakagawa S, Onishi E, Ouchi K. Enduring Positive Impact of a Virtual Communication Skills Workshop of VitalTalk Pedagogy in a Non-U.S. Setting. Am J Hosp Palliat Care 2024; 41:424-430. [PMID: 37216960 PMCID: PMC11267240 DOI: 10.1177/10499091231177863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
CONTEXT While in-person workshops on serious illness communication skills using VitalTalk pedagogy have been shown to have a long-lasting impact, whether changing the format into virtual would maintain its enduring impact is unknown. Objectives. To examine long-term impacts of a virtual VitalTalk communication workshop. METHODS Physicians in Japan who participated in our virtual VitalTalk workshop were asked to complete a self-assessment survey at 3 time points: before, immediately after, and 2 months after the workshop. We examined self-reported preparedness in 11 communication skills on a 5-point Likert scale at 3 time points, as well as self-reported frequency of practice on 5 communication skills at the pre- and 2-month time points. RESULTS Between January 2021 and June 2022, 117 physicians from 73 institutions across Japan completed our workshop. Seventy-four participants returned the survey at all the 3 time points. Their skill preparedness significantly improved upon the completion of the workshop in all 11 skills (P < .001 for all items). The improvement remained at the same level at 2 months in 7 skills. In 4 of the 11 skills, there was further improvement at the 2-month point. The frequency of self-directed skill practice also increased significantly in the 2-month survey for all 5 skills. CONCLUSION A virtual workshop of VitalTalk pedagogy improved self-reported preparedness of communication skills, and the impact was long-lasting in a non-U.S. setting as it likely induced self-practice of skills. Our findings encourage the use of a virtual format in any geographical location considering its enduring impact and easy accessibility.
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Affiliation(s)
- Takeshi Uemura
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery, School of Medicine, Teikyo University, Itabashi-ku, Japan
| | - Misuzu Yuasa
- Hospice Division, Seirei Mikatahara General Hospital, Tsu, Japan
| | | | - Hirono Ishikawa
- Teikyo University Graduate School of Public Health, Itabashi-ku, Japan
| | - Shunichi Nakagawa
- Adult Palliative Care Services, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Eriko Onishi
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
- Serious Illness Care Program, Ariadne Labs, Boston, MA, USA
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Giffard M, VAN Bulck L, Seydou Sall F, Becoulet N, Quenot JP, Seronde MF, Ecarnot F. Profiles of patients referred to specialized palliative care from the cardiology department at a university hospital: an 11-year longitudinal retrospective study. Panminerva Med 2023; 65:467-472. [PMID: 37212751 DOI: 10.23736/s0031-0808.23.04829-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Although the majority of patients with cardiovascular diseases (CVD) have a significant symptom burden and progressive course towards the end of life, only a small proportion of patients currently receive palliative care. The current referral practices to palliative care from the cardiology department need to be scrutinized. The current study aimed to examine: 1) the clinical profile; 2) time between referral to palliative care and death; and 3) place of death for CVD patients who were referred to palliative care from a cardiology department. METHODS This retrospective descriptive study included all patients who were referred to the mobile palliative care team from the cardiology unit in the University Hospital of Besançon in France between January 2010 and December 2020. Information was extracted from the medical hospital files. RESULTS A total of 142 patients were included, of whom 135 (95%) died. The mean age at the time of death was 76±14 years. The median time between referral to palliative care and death was 9 days. Most patients had chronic heart failure (54%). A total of 17 patients (13%) died at home. CONCLUSIONS This study showed that referral of patients to palliative care from the cardiology department is suboptimal and a large proportion of patients die in the hospital setting. Further prospective studies are warranted to investigate whether these dispositions correspond to patients' wishes and end-of-life care needs, and should investigate how the integration of palliative care into the care of cardiovascular patients can be improved.
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Affiliation(s)
- Mathilde Giffard
- Mobile Palliative Care Team, University Hospital Besançon, Besançon, France
- Inserm CIC1431, University Hospital Besançon, Besançon, France
| | - Liesbet VAN Bulck
- Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium
- Research Foundation Flanders (FWO), Brussels, Belgium
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Fatimata Seydou Sall
- Inserm CIC1431, University Hospital Besançon, Besançon, France
- Department of Cardiology, University Hospital Besançon, Besançon, France
| | - Nicolas Becoulet
- Mobile Palliative Care Team, University Hospital Besançon, Besançon, France
| | - Jean-Pierre Quenot
- Intensive Care Unit, University Hospital Dijon-Bourgogne, Dijon, France
- Inserm CIC1432, module Épidémiologie Clinique (CIC-EC), University Hospital Dijon-Bourgogne, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
| | - Marie-France Seronde
- EA3920, University of Burgundy Franche-Comté, Besançon, France
- Department of Cardiology, University Hospital Besançon, Besançon, France
| | - Fiona Ecarnot
- EA3920, University of Burgundy Franche-Comté, Besançon, France -
- Department of Cardiology, University Hospital Besançon, Besançon, France
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Sulistio MS, Chen CL, Eleazu I, Godfrey S, Abraham RA, Toft LEB. Personal Actions to Create a Culture of Inclusion: Navigating Difficult Conversations With Medical Colleagues. Ann Intern Med 2023; 176:1520-1525. [PMID: 37931258 DOI: 10.7326/m23-1374] [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: 11/08/2023] Open
Abstract
Microaggressions between members of a team occur often in medicine, even despite good intentions. Such situations call for difficult conversations that restore inclusivity, diversity, and a healthy work culture. These conversations are often hard because of the unique background, experiences, and biases of each person. In medicine, skillful navigation of these interactions is paramount as it influences patient care and the workplace culture. Although much has been published about difficult interactions between providers and patients, significantly less information is available to help navigate provider-to-provider interactions, despite their critical role in improving multidisciplinary patient care teams and organizational environments. This article is intended to serve as a guide for medical professionals who are interested in taking personal responsibility for promoting a safe and inclusive culture by engaging in and modeling difficult conversations with colleagues. The article outlines important considerations to assist with intentional preparation and modulation of responses for all parties involved: conversation initiators, observers of the incident, and conversation receivers. Although these interactions are challenging, together as medical professionals we can approach each other with humility and compassion to achieve our ultimate goal of promoting humanity, not only for our patients but for ourselves and one another.
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Affiliation(s)
- Melanie S Sulistio
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas (M.S.S., I.E., S.G.)
| | - Christine L Chen
- Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota (C.L.C.)
| | - Ijeoma Eleazu
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas (M.S.S., I.E., S.G.)
| | - Sarah Godfrey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas (M.S.S., I.E., S.G.)
| | - Reeni A Abraham
- Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas (R.A.A.)
| | - Lorrel E B Toft
- Department of Medicine, Cardiology, University of Nevada Reno School of Medicine, Reno, Nevada (L.E.B.T.)
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Gautier WC, Abaye M, Dev S, Seaman JB, Butler RA, Norman MK, Arnold RM, Witteman HO, Cook TE, Mohan D, White DB. An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness. Am J Crit Care 2022; 31:189-201. [PMID: 35466353 DOI: 10.4037/ajcc2022105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support. OBJECTIVE To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness. METHODS A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively. RESULTS Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training. CONCLUSIONS Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.
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Affiliation(s)
- William C. Gautier
- William C. Gautier is a medical student, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Menna Abaye
- Menna Abaye is a research project manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Shelly Dev
- Shelly Dev is an assistant professor, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Jennifer B. Seaman
- Jennifer B. Seaman is an assistant professor, School of Nursing, Department of Acute and Tertiary Care, University of Pittsburgh, Pennsylvania
| | - Rachel A. Butler
- Rachel A. Butler is a research program manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Marie K. Norman
- Marie K. Norman is an associate professor, School of Medicine, General Internal Medicine, Medicine and Clinical and Translational Science, Innovation Design for Education and Assessment (IDEA) Lab, University of Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Robert M. Arnold is a professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, and University of Pittsburgh Medical Center Palliative and Supportive Institute, Pennsylvania
| | - Holly O. Witteman
- Holly O. Witteman is a professor, Department of Family and Emergency Medicine & Office of Education and Professional Development, Faculty of Medicine, Laval University, Québec, Canada
| | - Tara E. Cook
- Tara E. Cook was an assistant professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pennsylvania
| | - Deepika Mohan
- Deepika Mohan is an associate professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Douglas B. White
- Douglas B. White is a professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
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Thammana RV, Goodlin SJ. Telecommunication for Advance Care Planning in Heart Failure. Card Fail Rev 2022; 8:e11. [PMID: 35433031 PMCID: PMC9006123 DOI: 10.15420/cfr.2021.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/10/2022] [Indexed: 12/23/2022] Open
Abstract
Heart failure is a chronic illness that carries a significant burden for patients, caregivers and health systems alike. The integration of palliative care and telehealth is a growing area of interest in heart failure management to help alleviate these burdens. This review focuses on the incorporation of advance care planning for complex decision-making in heart failure in the setting of increasing virtual care and telehealth. The review will also consider the role of virtual education for advance care planning and serious illness communication. Telecommunication for clinical care and clinical education are both described as non-inferior to in-person methods. Nevertheless, more research is needed to discern best practices and the optimal integration of methods.
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Affiliation(s)
- Rekha V Thammana
- Geriatrics and Palliative Care, Rehabilitation and Long Term Care, Veterans Affairs Portland Health Care System, Portland, OR, US; School of Medicine, Hematology and Medical Oncology, Oregon Health and Sciences University, Portland, OR, US
| | - Sarah J Goodlin
- Geriatrics and Palliative Care, Rehabilitation and Long Term Care, Veterans Affairs Portland Health Care System, Portland, OR, US
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Neo SHS, Zhou JX, Wong GC, Mok NK, Yee AC, Phua GL. Teaching Communication Micro-Skills to Cardiologists Managing Seriously Ill Patients in Asia: Challenges Encountered Amidst the COVID-19 Pandemic and Future Perspectives. Cureus 2021; 13:e19957. [PMID: 34976539 PMCID: PMC8713428 DOI: 10.7759/cureus.19957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/18/2022] Open
Abstract
Background Patients with advanced cardiac conditions value effective symptom control and empathic communication with their doctors. However, studies have shown that empathic communication with seriously ill patients does not occur adequately in cardiology. Therefore, we piloted a program for teaching communication skills in a bite-sized manner. The primary aim of the research was to understand the feasibility and acceptability of the training program and to perform a preliminary evaluation of its efficacy. Methodology Clinicians were recruited from the cardiology unit of a tertiary hospital in Singapore. Patients were also recruited for the audio recording of clinic consults. Recruited patients had to have a chronic cardiac condition and be deemed at risk of dying within one year. We utilized a pre-post intervention design. Prior to the educational intervention, clinicians were asked to audio record a single clinic consult at baseline. They were then asked to participate in a training program that consisted of video-annotated presentations and role-play scenarios. Subsequently, the audio recordings of their clinic consults with seriously ill patients were recorded. The audio recordings were evaluated by trainers and used for feedback with clinicians. Data on the completion rate of the training program were collected. In addition, changes in the clinicians’ self-rated communication skills and views on the acceptability and relevance of the training program were collected. Results Overall, five of the six clinicians (83.3%) completed all sessions in the program. One clinician only completed four out of the five sessions in the program. Clinicians deemed the program acceptable and relevant and found audio recordings to be useful for reflective learning. There was an improvement in the clinicians’ self-assessed competency. However, the planned number of audio recordings could not be completed due to the coronavirus disease 2019 pandemic. Conclusions The pilot training program was acceptable and relevant for the participants. However, it will require adaptation to allow it to be transferrable and scalable to all settings, especially in situations that limit prolonged face-to-face contact.
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Figura A, Kuhlmann SL, Rose M, Slagman A, Schenk L, Möckel M. Mental health conditions in older multimorbid patients presenting to the emergency department for acute cardiac symptoms: Cross-sectional findings from the EMASPOT study. Acad Emerg Med 2021; 28:1262-1276. [PMID: 34309134 DOI: 10.1111/acem.14349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study aimed to (1) examine the proportion of patients presenting to an emergency department (ED) for acute cardiac symptoms with comorbid mental health conditions (MHCs) comprising current depression, generalized anxiety disorder, and panic disorder; (2) compare cardiac patients with and without MHCs regarding sociodemographic, medical, and psychological characteristics; and (3) examine recognition and treatment rates of MHCs. METHODS Multimorbid patients, aged ≥50 years, presenting to an inner-city ED with acute cardiac symptoms including chest pain, dyspnea, and palpitations, completed validated self-report instruments assessing MHCs and a questionnaire collecting psychosocial and medical information. In addition, routine medical data were extracted from the electronic health record. RESULTS A total of 641 patients were included in the study. Mean (±SD) age was 68.8 (±10.8) years and 41.7% were female. Based on screening instruments, 28.4% of patients were affected with comorbid MHCs. Patients reported clinically significant symptoms of depression (23.3% PHQ-9 ≥10), generalized anxiety disorder (12.2% GAD-7 ≥10), and panic disorder (4.7% PHQ-PD). Patients with MHCs were more likely to be younger, female, lower educated, and unemployed. The presence of MHCs was associated with higher cardiac symptom burden and subjective treatment urgency as well as more psychosocial distress (PHQ-stress) and impaired quality of life (SF-12v2). Of all patients, 15.6% were identified with new or unrecognized MHCs. CONCLUSIONS MHCs are prevalent in nearly one-third of patients presenting with cardinal cardiac symptoms. Thus, the ED visit offers an opportunity to identify and refer patients with MHCs to appropriate and timely care after exclusion of life-threatening conditions.
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Affiliation(s)
- Andrea Figura
- Department of Psychosomatic Medicine Charité–Universitätsmedizin Berlin Berlin Germany
| | - Stella L. Kuhlmann
- Division of Emergency and Acute Medicine (Campus Virchow‐Klinikum, Campus Charité Mitte) Charité–Universitätsmedizin Berlin Berlin Germany
| | - Matthias Rose
- Department of Psychosomatic Medicine Charité–Universitätsmedizin Berlin Berlin Germany
| | - Anna Slagman
- Division of Emergency and Acute Medicine (Campus Virchow‐Klinikum, Campus Charité Mitte) Charité–Universitätsmedizin Berlin Berlin Germany
| | - Liane Schenk
- Institute of Medical Sociology and Rehabilitation Science Charité–Universitätsmedizin Berlin Berlin Germany
| | - Martin Möckel
- Division of Emergency and Acute Medicine (Campus Virchow‐Klinikum, Campus Charité Mitte) Charité–Universitätsmedizin Berlin Berlin Germany
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Tan XH, Foo MA, Lim SLH, Lim MBXY, Chin AMC, Zhou J, Chiam M, Krishna LKR. Teaching and assessing communication skills in the postgraduate medical setting: a systematic scoping review. BMC MEDICAL EDUCATION 2021; 21:483. [PMID: 34503497 PMCID: PMC8431930 DOI: 10.1186/s12909-021-02892-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 08/17/2021] [Indexed: 05/17/2023]
Abstract
BACKGROUND Poor communication skills can potentially compromise patient care. However, as communication skills training (CST) programs are not seen as a priority to many clinical departments, there is a discernible absence of a standardised, recommended framework for these programs to be built upon. This systematic scoping review (SSR) aims to gather prevailing data on existing CSTs to identify key factors in teaching and assessing communication skills in the postgraduate medical setting. METHODS Independent searches across seven bibliographic databases (PubMed, PsycINFO, EMBASE, ERIC, CINAHL, Scopus and Google Scholar) were carried out. Krishna's Systematic Evidence-Based Approach (SEBA) was used to guide concurrent thematic and content analysis of the data. The themes and categories identified were compared and combined where possible in keeping with this approach and then compared with the tabulated summaries of the included articles. RESULTS Twenty-five thousand eight hundred ninety-four abstracts were identified, and 151 articles were included and analysed. The Split Approach revealed similar categories and themes: curriculum design, teaching methods, curriculum content, assessment methods, integration into curriculum, and facilitators and barriers to CST. Amidst a wide variety of curricula designs, efforts to develop the requisite knowledge, skills and attitudes set out by the ACGME current teaching and assessment methods in CST maybe categorised into didactic and interactive methods and assessed along Kirkpatrick's Four Levels of Learning Evaluation. CONCLUSIONS A major flaw in existing CSTs is a lack of curriculum structure, focus and standardisation. Based upon the findings and current design principles identified in this SSR in SEBA, we forward a stepwise approach to designing CST programs. These involve 1) defining goals and learning objectives, 2) identifying target population and ideal characteristics, 3) determining curriculum structure, 4) ensuring adequate resources and mitigating barriers, 5) determining curriculum content, and 6) assessing learners and adopting quality improvement processes.
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Affiliation(s)
- Xiu Hui Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 11 Hospital Dr, Singapore, 169610, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Malia Alexandra Foo
- Yong Loo Lin School of Medicine, National University of Singapore, 11 Hospital Dr, Singapore, 169610, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Shaun Li He Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 11 Hospital Dr, Singapore, 169610, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Marie Bernadette Xin Yi Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 11 Hospital Dr, Singapore, 169610, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, Block MD 6, 14 Medical Drive, #05-01, Singapore, 117599, Singapore
| | - Jamie Zhou
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Lien Centre of Palliative Care, Duke-NUS Graduate Medical School, 8College Road, Singapore, 169857, Singapore
- Duke-NUS Medical School, National University of Singapore, 8 College Rd, Singapore, 169857, Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, 11 Hospital Dr, Singapore, 169610, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore.
- Duke-NUS Medical School, National University of Singapore, 8 College Rd, Singapore, 169857, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK.
- Centre of Biomedical Ethics, National University of Singapore, Block MD 11, 10 Medical Drive, #02-03, Singapore, 117597, Singapore.
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436, Singapore.
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Ma JE, Haverfield M, Lorenz KA, Bekelman DB, Brown-Johnson C, Lo N, Foglia MB, Lowery JS, Walling AM, Giannitrapani KF. Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach. Palliat Med 2021; 35:1542-1552. [PMID: 34080488 DOI: 10.1177/02692163211020473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. AIM Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. DESIGN A qualitative thematic analysis of semi-structured interviews. SETTING/PARTICIPANTS Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. RESULTS Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers. CONCLUSIONS Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
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Affiliation(s)
- Jessica E Ma
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC, USA
| | - Marie Haverfield
- Department of Communication Studies, San José State University, San José, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA.,Center of Innovation for Veteran-Centered and Value Driven Care and Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie Lo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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11
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Chuzi S, Khan SS, Pak ES. Primary Palliative Care Education in Advanced Heart Failure and Transplantation Cardiology Fellowships. J Am Coll Cardiol 2021; 77:501-505. [PMID: 33509401 DOI: 10.1016/j.jacc.2020.11.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Esther S Pak
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Division of Cardiology, Department of Medicine, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
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12
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Sanders JJ, Dubey M, Hall JA, Catzen HZ, Blanch-Hartigan D, Schwartz R. What is empathy? Oncology patient perspectives on empathic clinician behaviors. Cancer 2021; 127:4258-4265. [PMID: 34351620 DOI: 10.1002/cncr.33834] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/04/2021] [Accepted: 02/11/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oncology patients and physicians value empathy because of its association with improved health outcomes. Common measures of empathy lack consistency and were developed without direct input from patients. Because of their intense engagement with health care systems, oncology patients may have unique perspectives on what behaviors signal empathy in a clinical setting. METHODS As part of a cross-sectional study of patient perspectives on clinician empathy at an academic cancer center in the northeastern United States, the authors solicited up to 10 free-text responses to an open-ended question about what clinician behaviors define empathy. RESULTS The authors categorized open-ended responses from 89 oncology patients into 5 categories representing 14 themes. These categories were relationship sensitivity, focus on the whole person, communication, clinician attributes, and institutional resources and care processes. Frequently represented themes, including listening, understanding, and attention to emotions and what matters most, aligned with existing measures of empathy; behaviors that were not well represented among existing measures included qualities of information sharing and other communication elements. Patients also associated clinician demeanor, accessibility, and competence with empathy. CONCLUSIONS Oncology patients' perspectives on empathy highlight clinician behaviors and attributes that may help to refine patient experience measures and may be adopted by clinicians and cancer centers to enhance patient care and outcomes. High-quality communication skills training can promote active listening and paying attention to the whole person. A system-level focus on delivering empathic care may improve patients' experiences and outcomes. LAY SUMMARY Oncology patients' responses to an open-ended question about empathic clinician behavior have revealed insights into a variety of behaviors that are perceived as demonstrative of empathy. These include behaviors that imply sensitivity to the clinician-patient relationship, such as listening and understanding and attention to the whole person. Participants valued caring communication and demeanor and clinician accessibility. Perspective taking was not common among answers. Many existing measures of clinical care quality do not include the behaviors cited by patients as empathic. These results can inform efforts to refine quality measures of empathy-associated behaviors in clinical practice. Cancer centers can use skills training to improve elements of communication.
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Affiliation(s)
- Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Manisha Dubey
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Judith A Hall
- Department of Psychology, Northeastern University, Boston, Massachusetts
| | - Hannah Z Catzen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Rachel Schwartz
- WellMD and WellPhD Center, Stanford University School of Medicine, Palo Alto, California
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13
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Chuzi S, Ogunseitan A, Cameron KA, Grady K, Schulze L, Wilcox JE. Perceptions of Bereaved Caregivers and Clinicians About End-of-Life Care for Patients With Destination Therapy Left Ventricular Assist Devices. J Am Heart Assoc 2021; 10:e020949. [PMID: 34308687 PMCID: PMC8475670 DOI: 10.1161/jaha.121.020949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022]
Abstract
Background Patients with left ventricular assist devices (LVADs) implanted as destination therapy may receive suboptimal preparation for and care at the end of life, but there is limited understanding of the reasons for these shortcomings. Exploring perceptions of individuals (caregivers and clinicians) who are closely involved in the end-of-life experience with patients with destination therapy LVADs can help identify key opportunities for improving care. Methods and Results We conducted semistructured qualitative interviews with 7 bereaved caregivers of patients with destination therapy LVADs and 10 interdisciplinary LVAD clinicians. Interviews explored perceptions of preparing for end of life, communicating about end of life, and providing and receiving end-of-life care, and were analyzed using a 2-step team-based inductive approach to coding and analysis. Six themes pertaining to end-of-life experiences were derived: (1) timing end-of-life discussions in the setting of unpredictable illness trajectories, (2) prioritizing end-of-life preparation and decision-making, (3) communicating uncertainty while providing support and hope, (4) lack of consensus on responsibility for end-of-life discussions, (5) perception of the LVAD team as invincible, and (6) divergent perceptions of LVAD withdrawal. Conclusions This study revealed 6 unique aspects of end-of-life care for patients with destination therapy LVADs as reported by clinicians and caregivers. Themes coalesced around communication, team-based care, and challenges unique to patients with LVADs at end of life. Programmatic changes may address some aspects, including training clinicians in LVAD-specific communication skills. Other aspects, such as standardizing the role of the palliative care team and developing practical interventions that enable timely advance care planning during LVAD care, will require multifaceted interventions.
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Affiliation(s)
- Sarah Chuzi
- Division of CardiologyDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Adeboye Ogunseitan
- Division of Hospital Medicine (Palliative Care)Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Kenzie A. Cameron
- Division of General Internal Medicine and GeriatricsDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Kathleen Grady
- Division of CardiologyDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
- Division of Cardiac SurgeryDepartment of SurgeryFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Lauren Schulze
- Division of Cardiac SurgeryDepartment of SurgeryFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Jane E. Wilcox
- Division of CardiologyDepartment of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
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14
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Onishi E, Nakagawa S, Uemura T, Shiozawa Y, Yuasa M, Ito K, Kobayashi Y, Ishikawa H, Ouchi K. Physicians' Perceptions and Suggestions for the Adaptation of a US-Based Serious Illness Communication Training in a Non-US Culture: A Qualitative Study. J Pain Symptom Manage 2021; 62:400-409.e3. [PMID: 33290856 PMCID: PMC8244824 DOI: 10.1016/j.jpainsymman.2020.11.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT US-based serious illness communication training pedagogy has not been well studied outside of the United States. OBJECTIVES To explore the perception of a US-based, serious illness communication training pedagogy in a non-US culture and to identify aspects requiring cultural adaptations. METHODS In September 2019, we conducted a qualitative study using convenient sampling at two urban, academic medical centers in Tokyo, Japan. Semistructured interviews were conducted to Japanese physicians who participated in the four-hour VitalTalk training in Japanese. We explored six majored themes: 1) global impression of the training; 2) main goals from participation; 3) appropriateness of didactics; 4) role play experiences; 5) take away points from the training; and 6) changes in their own communication practice after the training. Interviews were transcribed, coded, and analyzed using phenomenological approach. RESULTS All 24 participants found the VitalTalk pedagogy novel and beneficial, stressing the importance of demonstrating empathy, reflecting on own skills, and recognizing the importance of feedback that emphasizes the use of specific words. Participants also pointed out that Japanese patients generally do not express their strong emotions explicitly. CONCLUSION Our study found empirical evidence that the VitalTalk pedagogy is perceived to be novel and beneficial in a non-US cultural setting. Cultural adaptations in expression and response to emotion may be required to maximize its efficacy in Japan. To meet the needs of clinical practice in Japan, further studies are needed to empirically test the suggested refinements for the VitalTalk pedagogy.
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Affiliation(s)
- Eriko Onishi
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA.
| | - Shunichi Nakagawa
- Adult Palliative Care Services, Columbia University, New York, New York, USA
| | - Takeshi Uemura
- University Health Partners of Hawaii, Honolulu, Hawaii, USA
| | | | | | - Kaori Ito
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuki Kobayashi
- Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Hirono Ishikawa
- Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA; Serious illness care program, Ariadne Labs, Boston, Massachusetts, USA
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15
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Carroll T, Mooney C, Horowitz R. Re-ACT: Remote Advanced Communication Training in a Time of Crisis. J Pain Symptom Manage 2021; 61:364-368. [PMID: 32898590 PMCID: PMC7474842 DOI: 10.1016/j.jpainsymman.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND We used a quality improvement framework to transform two-day and in-person advanced communication training (ACT) course into a remote ACT (Re-ACT) format to help clinicians improve serious illness conversation (SIC) skills. MEASURES We assessed the reach, impact, and costs of Re-ACT and compared these measures to in-person ACT courses. INTERVENTIONS About 45-60 minutes of synchronous, remote sessions consisting of a didactic introduction to SIC skills, tailored to the SARS-Cov-2 (COVID-19) crisis, and a live demonstration of SICs with patient-actors. OUTCOMES The transition to Re-ACT sessions resulted in reaching a greater number of clinicians in less time, although depth of content and opportunities for skill practice decreased. Although both formats were well received, Re-ACT respondents felt less prepared than ACT respondents to use SIC skills. The costs of Re-ACT were significantly less than in-person ACT courses. CONCLUSIONS/LESSONS LEARNED We provided effective and well-received SIC training during a time of crisis. Future work should further define the optimal mix of in-person and remote experiences to teach SIC skills.
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Affiliation(s)
- Thomas Carroll
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA.
| | - Christopher Mooney
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert Horowitz
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
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16
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Lestuzzi C, Annunziata MA, Nohria A, Muzzatti B, Bisceglia I, Ewer MS. Cancer patients in cardiology: how to communicate with patients with special psychological needs and manage their cardiac problems in daily clinical practice. J Cardiovasc Med (Hagerstown) 2020; 21:286-291. [PMID: 31977538 DOI: 10.2459/jcm.0000000000000936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: Cancer patients are increasingly referred for cardiology evaluations. These patients differ from those routinely seen in cardiology clinics because of their psychological burden and because the therapies and cancer itself can cause cardiac symptoms. A humane approach is critical to managing these patients. Cardiologists may see patients who are newly diagnosed with cancer or are in various phases of treatment; these patients may or may not have preexisting cardiac disease, and may develop cardiotoxicity from chemoimmunotherapy or radiotherapy. Each of these situations presents unique communication challenges for cardiologists. Although some oncology centers provide training in communication skills for their personnel, including cardiologists, this training is not widely available to physicians in general hospitals or private practice. This article examines the psychological aspects of cardio-oncology. It offers practical suggestions on how to best communicate with cancer patients in different phases of oncology care, and discusses when professional psychological help is needed.
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Affiliation(s)
- Chiara Lestuzzi
- Cardiology and Cardio-Oncology Rehabilitation Unit, Cardiology Department, AAS5
| | | | - Anju Nohria
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital.,Cardio-Oncology Program, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Barbara Muzzatti
- Psychology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Irma Bisceglia
- Cardiovascular Department, San Camillo Forlanini Hospital, Rome, Italy
| | - Michael S Ewer
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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17
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Hill L, Prager Geller T, Baruah R, Beattie JM, Boyne J, de Stoutz N, Di Stolfo G, Lambrinou E, Skibelund AK, Uchmanowicz I, Rutten FH, Čelutkienė J, Piepoli MF, Jankowska EA, Chioncel O, Ben Gal T, Seferovic PM, Ruschitzka F, Coats AJS, Strömberg A, Jaarsma T. Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper. Eur J Heart Fail 2020; 22:2327-2339. [PMID: 32892431 DOI: 10.1002/ejhf.1994] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 12/18/2022] Open
Abstract
The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for those affected by this burdensome condition. Integrating palliative care into evidence-based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a 'good death'. This new position paper aims to provide day-to-day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline-directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure.
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Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Tal Prager Geller
- Palliative Care Ward at Dorot Health Centre, Heart Failure Unit at Rabin Medical Center, Netanya, Israel
| | - Resham Baruah
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - James M Beattie
- Cicely Saunders Institute, King's College London, London, UK
| | - Josiane Boyne
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Giuseppe Di Stolfo
- Cardiovascular Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | | | - Izabella Uchmanowicz
- Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Massimo Francesco Piepoli
- Heart Failure Unit, Cardiology, Guglielmo da Saliceto Hospital, Piacenza, Italy.,University of Parma, Parma, Italy
| | - Ewa A Jankowska
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland.,Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania.,University of Medicine Carol Davila, Bucharest, Romania
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Petar M Seferovic
- Cardiology Department, Clinical Centre Serbia, Medical School Belgrade, Belgrade, Serbia
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
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18
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Love KR, Karin E, Morogo D, Toroitich F, Boit JM, Tarus A, Barasa FA, Goldstein NE, Koech M, Vedanthan R. "To Speak of Death Is to Invite It": Provider Perceptions of Palliative Care for Cardiovascular Patients in Western Kenya. J Pain Symptom Manage 2020; 60:717-724. [PMID: 32437947 DOI: 10.1016/j.jpainsymman.2020.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 01/02/2023]
Abstract
CONTEXT Cardiovascular disease (CVD) is the leading cause of death globally and a significant health burden in Kenya. Despite improved outcomes in CVD, palliative care has limited implementation for CVD in low-income and middle-income countries. This may be partly because of providers' perceptions of palliative care and end-of-life decision making for patients with CVD. OBJECTIVES Our goal was to explore providers' perceptions of palliative care for CVD in Western Kenya to inform its implementation. METHODS We conducted eight focus group discussions and five key informant interviews. These were conducted by moderators using structured question guides. Qualitative analysis was performed using the constant comparative method. A coding scheme was developed and agreed on by consensus by two investigators, each of whom then independently coded each transcript. Relationships between codes were formulated, and codes were grouped into distinct themes. New codes were iteratively added with successive focus group or interview until thematic saturation was reached. RESULTS Four major themes emerged to explain the complexities of integrating of palliative care for patients with CVD in Kenya: 1) stigma of discussing death and dying, 2) mismatch between patient and clinician perceptions of disease severity, 3) the effects of poverty on care, and 4) challenges in training and practice environments. All clinicians expressed a need for integrating palliative care for patients with CVD. CONCLUSION These results suggest that attainable interventions supported by local providers can help improve CVD care and quality of life for patients living with advanced heart disease in low-resource settings worldwide.
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Affiliation(s)
- Keith R Love
- Yale New Haven Hospital, New Haven, Connecticut, USA.
| | - Elizabeth Karin
- Tacoma Family Medicine, University of Washington, Tacoma, Washington, USA
| | - Daniel Morogo
- Living Room Ministries International, Eldoret, Kenya
| | | | - Juli M Boit
- Living Room Ministries International, Eldoret, Kenya
| | - Allison Tarus
- Living Room Ministries International, Eldoret, Kenya
| | | | - Nathan E Goldstein
- The Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Myra Koech
- Department of Pediatrics, MUSOM, MUCHS, Eldoret, Kenya
| | - Rajesh Vedanthan
- Department of Population Health, New York University School of Medicine, New York, New York, USA
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19
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Paulsen K, Wu DS, Mehta AK. Primary Palliative Care Education for Trainees in U.S. Medical Residencies and Fellowships: A Scoping Review. J Palliat Med 2020; 24:354-375. [PMID: 32640863 DOI: 10.1089/jpm.2020.0293] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: The medical profession increasingly recognizes the growing need to educate nonpalliative physicians in palliative care. Objective: This study aims to provide a scoping review of the primary palliative care (PPC) education currently available to graduate medical trainees in primary and specialty tracks. Design: Studies of PPC interventions in U.S. residency or fellowship programs of all subspecialties published in English and listed on MEDLINE, CINAHL, and EMBASE through January 2020 were included. To meet admission criteria, studies had to describe the content, delivery methods, and evaluation instruments of a PPC educational intervention. Results: Of 233 eligible full texts, 85 studies were included for assessment, of which 66 were novel PPC educational interventions and 19 were standard education. Total number of publications evaluating PPC education increased from 8 (2000-2004) to 36 (2015-2019), across 11 residency and 10 fellowship specialties. Residency specialties representing the majority of publications were emergency medicine, general surgery, internal medicine, and pediatric/medicine-pediatrics. PPC content domains most taught in residencies were communication and symptom management; the primary delivery method was didactics, and the outcome assessed was attitudes. Fellowship specialties representing the majority of publications were pediatric subspecialties, nephrology, and oncology. The PPC content domain most taught in fellowships was communication; the primary delivery method was didactics and the outcome evaluated was attitudes. Conclusions: While PPC education has increased, it remains varied in content, delivery method, and intervention evaluations. Future studies should include more widespread evaluation of behavioral outcomes, longitudinal persistence of use, and clinical impact.
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Affiliation(s)
- Kate Paulsen
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - David S Wu
- Palliative Care Program, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of Medicine, University of California, Los Angeles Medical Center, Santa Monica, California, USA
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20
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Nakagawa S, Fischkoff K, Berlin A, Arnell TD, Blinderman CD. Communication Skills Training for General Surgery Residents. JOURNAL OF SURGICAL EDUCATION 2019; 76:1223-1230. [PMID: 31005480 DOI: 10.1016/j.jsurg.2019.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/19/2019] [Accepted: 04/02/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Although good communication skills are essential for surgeons, there is no formal communication training during general surgery residency. OBJECTIVES To implement a communication skills training program based on evidence-based teaching methods in general surgery residency. DESIGN We developed a 2-hour communication skills training program for general surgery residents, consisting of a small group skill practice session using role play with simulated patients along with real-time feedback from facilitators and observing peer residents. A board-certified palliative care physician and a board-certified surgeon facilitated each session. Outcome measures were self-assessment of preparedness with the session immediately before and after the session and 2 months after the session, resident satisfaction, and self-report frequency of skill practice. Results were compared between junior residents (postgraduate year 1-3) and senior residents (postgraduate year 4-5). SETTING Columbia University Medical Center in New York City, a tertiary care, urban academic center with a 5-year General Surgery Residency program. PARTICIPANTS Thirty-one out of 39 (79.4%) general surgery residents (20 junior and 11 senior) were trained over a 9-month period. All participants completed the immediate pre- and post-session surveys, and twenty residents (64.5%) completed the 2-month postsession follow-up survey. RESULTS Overall, self-assessment of preparedness for specific communication challenges improved significantly for 7 of 11 tasks. At baseline, senior residents felt significantly more prepared than junior residents in all 11 tasks. Junior residents' self-assessment of preparedness improved significantly in 10 of 11 tasks. Overall satisfaction with the session was very high (mean 4.74 on a 5-point scale). Residents reported high frequency of self-directed skill practice in the 2-month follow-up survey. CONCLUSIONS This 2-hour communication skills practice session for general surgery residents was feasible, and it improved resident self-assessment of preparedness in communication and augmented self-directed skill practice.
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Affiliation(s)
- Shunichi Nakagawa
- Department of Medicine, Adult Palliative Care Services, Columbia University Medical Center, New York, New York.
| | - Katherine Fischkoff
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Ana Berlin
- Department of Medicine, Adult Palliative Care Services, Columbia University Medical Center, New York, New York; Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Tracey D Arnell
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Craig D Blinderman
- Department of Medicine, Adult Palliative Care Services, Columbia University Medical Center, New York, New York
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21
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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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22
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Gřiva M, Šťastný J, Švancara J, Loučka M, Belanová V. End-of-life preferences of cardiac patients. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2018. [DOI: 10.15452/cejnm.2018.09.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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23
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New Dimensions in Palliative Care Cardiology. Can J Cardiol 2018; 34:914-924. [PMID: 29960618 DOI: 10.1016/j.cjca.2018.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 12/19/2022] Open
Abstract
The landscape of patient care at the beginning of the 19th century was dramatically different than it is today. With few good treatment options, illness courses were generally brief. Near the end of life, patients were attended to by spiritual advisors, not health care professionals. Death typically occurred at home, surrounded by friends and family. Moving to the present time, decades of medical advances have significantly improved life expectancy. Cardiology has particularly benefited from many of these advances. Cardiac patients are initiated on optimal medication regimens. As disease burdens progress, interventions such as implantable defibrillators and cardiac resynchronization pacing systems become options for many patients. With further clinical deterioration, select patients might be candidates for ventricular assist devices and heart transplants. These advances have unquestionably improved the prognosis with advanced cardiovascular illnesses. However, they have also changed patient and family attitudes about death and dying, to the point where we have effectively "medicalized our mortality." The importance of introducing palliative care to the cardiac patient population is now well recognized, with the major cardiovascular societies incorporating palliative care principles into their guideline and consensus statement documents. However, despite this recognition, few cardiac patients get access to palliative care and other resources such as hospice. In this article the existing literature on this topic is reviewed and opportunities for developing and fostering a more collaborative relationship between the disciplines of cardiology and palliative care are discussed.
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24
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Challenges in clarifying goals of care in patients with advanced heart failure. Curr Opin Support Palliat Care 2017; 12:32-37. [PMID: 29206702 DOI: 10.1097/spc.0000000000000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with advanced heart failure require communication about goals of care, yet many challenges exist, leaving it suboptimal. High mortality rates and advances in the use of life-sustaining technology further complicate communication and underscore the urgency to understand and address these challenges. This review highlights current research with a view to informing future research and practice to improve goals of care communication. RECENT FINDINGS Clinicians view patient and family barriers as more impactful than clinician and system factors in impeding goals of care discussions. Knowledge gaps about life-sustaining technology challenge timely goals of care discussions. Complex, nurse-led interventions that activate patient, clinician and care systems and video-decision aids about life-sustaining technology may reduce barriers and facilitate goals of care communication. SUMMARY Clinicians require relational skills in facilitating goals of care communication with diverse patients and families with heart failure knowledge gaps, who may be experiencing stress and discord. Future research should explore the dynamics of goals of care communication in real-time from patient, family and clinician perspectives, to inform development of upstream and complex interventions that optimize communication. Further testing of interventions is needed in and across community and hospital settings.
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25
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Kavalieratos D, Gelfman LP, Tycon LE, Riegel B, Bekelman DB, Ikejiani DZ, Goldstein N, Kimmel SE, Bakitas MA, Arnold RM. Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities. J Am Coll Cardiol 2017; 70:1919-1930. [PMID: 28982506 PMCID: PMC5731659 DOI: 10.1016/j.jacc.2017.08.036] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 12/25/2022]
Abstract
Patients with heart failure (HF) and their families experience stress and suffering from a variety of sources over the course of the HF experience. Palliative care is an interdisciplinary service and an overall approach to care that improves quality of life and alleviates suffering for those living with serious illness, regardless of prognosis. In this review, we synthesize the evidence from randomized clinical trials of palliative care interventions in HF. While the evidence base for palliative care in HF is promising, it is still in its infancy and requires additional high-quality, methodologically sound studies to clearly elucidate the role of palliative care for patients and families living with the burdens of HF. Yet, an increase in attention to primary palliative care (e.g., basic physical and emotional symptom management, advance care planning), provided by primary care and cardiology clinicians, may be a vehicle to address unmet palliative needs earlier and throughout the illness course.
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Affiliation(s)
- Dio Kavalieratos
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Geriatric Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Laura E Tycon
- University of Pittsburgh Medical Center Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David B Bekelman
- Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
| | - Dara Z Ikejiani
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen E Kimmel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert M Arnold
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
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