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McConnell T, Blair C, Wong G, Duddy C, Howie C, Hill L, Reid J. Integrating Palliative Care and Heart Failure: the PalliatHeartSynthesis realist synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-128. [PMID: 39324696 DOI: 10.3310/ftrg5628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Background Cardiovascular disease is the most common cause of death worldwide, highlighting the need for studies to determine options for palliative care within the management of patients with heart failure. Although there are promising examples of integrated palliative care and heart failure interventions, there is heterogeneity in terms of countries, healthcare settings, multidisciplinary team delivery, modes of delivery and intervention components. Hence, this review is vital to identify what works, for whom and in what circumstances when integrating palliative care and heart failure. Objectives To (1) develop a programme theory of why, for whom and in what contexts desired outcomes occur; and (2) use the programme theory to co-produce with stakeholders key implications to inform best practice and future research. Design A realist review of the literature underpinned by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards. Data sources Searches of bibliographic databases were conducted in November 2021 using the following databases: EMBASE, MEDLINE, PsycInfo, AMED, HMIC and CINAHL. Further relevant documents were identified via alerts and the stakeholder group. Review methods Realist review is a theory-orientated and explanatory approach to the synthesis of evidence. A realist synthesis was used to synthesise the evidence as successful implementation of integrated palliative care and heart failure depends on the context and people involved. The realist synthesis followed Pawson's five iterative stages: (1) locating existing theories; (2) searching for evidence; (3) document selection; (4) extracting and organising data; and (5) synthesising the evidence and drawing conclusions. We recruited an international stakeholder group (n = 32), including National Health Service management, healthcare professionals involved in the delivery of palliative care and heart failure, policy and community groups, plus members of the public and patients, to advise and give us feedback throughout the project, along with Health Education England to disseminate findings. Results In total, 1768 documents were identified, of which 1076 met the inclusion criteria. This was narrowed down to 130 included documents based on the programme theory and discussions with stakeholders. Our realist analysis developed and refined 6 overarching context-mechanism-outcome configurations and 30 sub context-mechanism-outcome configurations. The realist synthesis of the literature and stakeholder feedback helped uncover key intervention strategies most likely to support integration of palliative care into heart failure management. These included protected time for evidence-based palliative care education and choice of educational setting (e.g. online, face to face or hybrid), and the importance of increased awareness of the benefits of palliative care as key intervention strategies, the emotive and intellectual need for integrating palliative care and heart failure via credible champions, seeing direct patient benefit, and prioritising palliative care and heart failure guidelines in practice. The implications of our findings are further outlined in the capability, opportunity, motivation, behaviour model. Limitations The realist approach to analysis means that findings are based on our interpretation of the data. Future work Future work should use the implications to initiate and optimise palliative care in heart failure management. Conclusion Ongoing refinement of the programme theory at each stakeholder meeting allowed us to co-produce implications. These implications outline the required steps to ensure the core components and determinants of behaviour are in place so that all key players have the capacity, opportunity and motivation to integrate palliative care into heart failure management. Study registration This study is registered as PROSPERO CRD42021240185. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131800) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 34. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Tracey McConnell
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
- Marie Curie Hospice, Belfast, UK
| | - Carolyn Blair
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Howie
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
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Bharani A, Mehta A, Hiensch K, Zeng L, Lala A, Pinney S, Goldstein N, Chai E, Gelfman LP. Referral Versus Embedded Palliative Care Consultation Among People Hospitalized With Heart Failure: A Report From a Single Center Pilot Program. J Pain Symptom Manage 2024; 67:241-249. [PMID: 38040389 DOI: 10.1016/j.jpainsymman.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023]
Abstract
CONTEXT Despite calls for integration into routine heart failure (HF) care, optimal palliative care delivery for people living with HF remains unclear. OBJECTIVES Describe an innovative model of an embedded palliative care nurse practitioner (NP) within a HF team. Compare demographics and utilization among people hospitalized with HF receiving referral or embedded consultation. METHODS Using an electronic health record-based palliative care registry, we conducted descriptive analyses and t-tests and χ2 tests, as appropriate, to examine bivariate associations between sociodemographic, clinical and utilization data of hospitalized people with HF receiving a traditional, referral-based palliative care consultation generated exclusively by the primary team vs. a novel, embedded-based consultation generated by collaboration between a palliative care NP and the advanced HF team at an urban, quaternary care academic medical center in New York City. RESULTS During the study period from January 1, 2019-December 31, 2021, consultation volume nearly doubled with 363 consults from traditional referrals and an additional 317 consults from the newly embedded NP. People in the embedded group, as compared to referral, were younger (mean age: 60.1 vs. 71.9 years (2019); 59.2 vs. 70.4 (2020); 61.3 vs. 69.6 (2021), p-value < 0.001), more functional (median Karnofsky Performance Status: 40% vs. 30%, p-value = 0.01 (2019); 40% vs 20%, p-value < 0.0001 (2020); 40% vs. 20%, p-value = 0.02 (2021)), more likely had capacity to designate a medical decision maker (56.4% vs. 20.6%, p-value < 0.001 (2020); 76.3% vs. 49.5%, p-value < 0.001 (2021)), received earlier consultation (median days before discharge: 9.5 vs. 4 (2019); 11 vs. 5 (2020); 7 vs. 3 (2021), p-value ≤ 0.001), and more likely to discharge home (60% vs. 26%, p-value ≤ 0.001 (2019); 62.7% vs 20.6%, p-value ≤ 0.001 (2020); 42.3% vs. 28%, p-value = 0.03 (2021)). CONCLUSION Hospitalized people living with advanced HF who received an embedded palliative care consult were younger, had higher functional status and less illness severity compared to those served by a traditional, referral-based consult.
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Affiliation(s)
- Anup Bharani
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Ankita Mehta
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karen Hiensch
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anuradha Lala
- The Zena and Michael A. Wiener Cardiovascular Institute (A.L., S.P.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.L.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Pinney
- The Zena and Michael A. Wiener Cardiovascular Institute (A.L., S.P.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine (A.B., A.M., K.H., L.Z., N.G., E.C., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Geriatric Research Education and Clinical Center (L.P.G.), James J. Peters VA Medical Center, Bronx, New York, USA
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Singh GK, Ivynian SE, Davidson PM, Ferguson C, Hickman LD. Elements of Integrated Palliative Care in Chronic Heart Failure Across the Care Continuum: A Scoping Review. Heart Lung Circ 2021; 31:32-41. [PMID: 34593316 DOI: 10.1016/j.hlc.2021.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/09/2021] [Accepted: 08/01/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Individuals with chronic heart failure experience high symptom burden, reduced quality of life and high health care utilisation. Although there is growing evidence that a palliative approach, provided concurrently with usual treatment improves outcomes, the method of integrating palliative care for individuals living with chronic heart failure across the care continuum remains elusive. AIM To examine the key elements of integrated palliative care recommended for individuals living with chronic heart failure across the care continuum. DESIGN Scoping review. DATA SOURCES Databases searched were CINAHL, Ovid MEDLINE, Scopus and OpenGrey. Studies written in English and containing key strategic elements specific to chronic heart failure were included. Search terms relating to palliative care and chronic heart failure and the Joanna Briggs Institute methodology for scoping reviews was used. RESULTS Seventy-nine (79) articles were selected that described key elements to integrate palliative care for individuals with chronic heart failure. This review identifies four levels of key strategic elements: 1) clinical; 2) professional; 3) organisational and 4) system-level integration. Implementing strategies across these elements facilitates integrated palliative care for individuals with chronic heart failure. CONCLUSIONS Inter-sectorial collaborations across systems and the intersection of health and social services are essential to delivering integrated, person-centred palliative care. Further research focussing on patient and family needs at a system-level is needed. Research with strong theoretical underpinnings utilising implementation science methods are required to achieve and sustain complex behaviour change to translate key elements.
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Affiliation(s)
- Gursharan K Singh
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Qld, Australia; Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology (QUT), Brisbane, Qld, Australia.
| | - Serra E Ivynian
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Patricia M Davidson
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA & Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Caleb Ferguson
- School of Nursing & Midwifery, Western Sydney University, Penrith, NSW, Australia; Western Sydney Local Health District, Blacktown Hospital, Sydney, NSW, Australia
| | - Louise D Hickman
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
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Development of a Home Health-Based Palliative Care Program for Patients With Heart Failure. Home Healthc Now 2018; 36:84-92. [PMID: 29498988 DOI: 10.1097/nhh.0000000000000634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Heart failure is a significant burden to the healthcare system. Approximately 5.7 million adults in the United States were diagnosed with heart failure between 2009 and 2012 (). The American Heart Association projects that direct costs for heart failure may be as high as $77.7 billion by 2030 (). Technological and pharmaceutical advancements have delayed the progression of the disease; however, it is predicted that close to half of individuals with heart failure will die within 5 years of the initial diagnosis (; ). Current research suggests that the utilization of palliative care and an interdisciplinary team approach to the care of patients with heart failure improves the quality of life and decreases utilization of healthcare resources at the end of life (). This performance improvement project examined the knowledge of a home healthcare interdisciplinary team's knowledge about palliative care in patients with heart failure, the 30-day readmission rate for patients enrolled in a home-based palliative care program, and documentation of advanced directives in a home healthcare organization.
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Fruhwald S, Pollesello P, Fruhwald F. Advanced heart failure: an appraisal of the potential of levosimendan in this end-stage scenario and some related ethical considerations. Expert Rev Cardiovasc Ther 2016; 14:1335-1347. [PMID: 27778514 DOI: 10.1080/14779072.2016.1247694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The later stages of heart failure are characterized by a steady decline in quality of life. Clinical priorities should be to maintain functional capacity and quality of life. In the absence of sufficient organs for transplantation, options include left ventricular assist devices and inotropic support. Areas covered: We examined data published in the last two decades on the use of inotropes and inodilators in advanced heart failure. Expert commentary: In the literature, use of conventional inotropes, including adrenergic agonists and phosphodiesterase inhibitors, appears to be suboptimal for achieving the clinical priorities of late-stage heart failure. Evidence suggests instead that the calcium-sensitizing inodilator levosimendan, administered intermittently, delivers improvements in functional capacity and quality of life and does so with no adverse impact on life expectancy. At a terminal or near-terminal stage of heart failure, the therapeutic philosophy should shift towards meeting patients' existential priorities rather than traditional heart failure-centric targets.
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Affiliation(s)
- Sonja Fruhwald
- a Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine , Medical University of Graz , Graz , Austria
| | - Piero Pollesello
- b Critical Care Proprietary Products , Orion Pharma , Espoo , Finland
| | - Friedrich Fruhwald
- c Department of Internal Medicine, Division of Cardiology , Medical University of Graz , Graz , Austria
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