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Beattie JM, Castiello T, Jaarsma T. The Importance of Cultural Awareness in the Management of Heart Failure: A Narrative Review. Vasc Health Risk Manag 2024; 20:109-123. [PMID: 38495057 PMCID: PMC10944309 DOI: 10.2147/vhrm.s392636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/27/2024] [Indexed: 03/19/2024] Open
Abstract
Heart failure is a commonly encountered clinical syndrome arising from a range of etiologic cardiovascular diseases and manifests in a phenotypic spectrum of varying degrees of systolic and diastolic ventricular dysfunction. Those affected by this life-limiting illness are subject to an array of burdensome symptoms, poor quality of life, prognostic uncertainty, and a relatively onerous and increasingly complex treatment regimen. This condition occurs in epidemic proportions worldwide, and given the demographic trend in societal ageing, the prevalence of heart failure is only likely to increase. The marked upturn in international migration has generated other demographic changes in recent years, and it is evident that we are living and working in ever more ethnically and culturally diverse communities. Professionals treating those with heart failure are now dealing with a much more culturally disparate clinical cohort. Given that the heart failure disease trajectory is unique to each individual, these clinicians need to ensure that their proposed treatment options and responses to the inevitable crises intrinsic to this condition are in keeping with the culturally determined values, preferences, and worldviews of these patients and their families. In this narrative review, we describe the importance of cultural awareness across a range of themes relevant to heart failure management and emphasize the centrality of cultural competence as the basis of appropriate care provision.
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Affiliation(s)
- James M Beattie
- School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
- Department of Palliative Care and Rehabilitation, Cicely Saunders Institute, King’s College London, London, UK
| | - Teresa Castiello
- Department of Cardiology, Croydon University Hospital, London, UK
- Department of Cardiovascular Imaging, King’s College London, London, UK
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Nursing Science, Julius Center, University Medical Center Utrecht, Utrecht, the Netherlands
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Mathew T, Patel A, DiGrande K, Michelis ND, Mody B, Lombardo D. Improving Advance Care Planning for Hospitalized Patients With Heart Failure. Palliat Med Rep 2023; 4:339-343. [PMID: 38155912 PMCID: PMC10754343 DOI: 10.1089/pmr.2023.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 12/30/2023] Open
Abstract
Advance care planning (ACP) is a valuable and proven approach for enhancing end-of-life communication and quality of life for individuals with heart failure (HF) and their family members. However, the adoption of ACP in practice is still lower than desired. According to University of California, Irvine Medical Center HF metrics, only 15.3% of hospitalized HF patients had completed ACP documentation before discharge, as recorded in the electronic medical record (EMR). This quality improvement project aimed to investigate whether the rate of ACP completion could be increased by utilizing EMR reminders to health care teams regarding individual patients. Personalized reminders were sent to providers for each hospitalized patient diagnosed with HF, who did not have existing ACP documentation in the EMR, to encourage completion of ACP documentation. Our findings have shown that, during the three-month intervention period, the average ACP completion rate was 21.0%. This represents a 5.7% absolute increase in ACP completion compared to the six months before our intervention (15.3%); a relative increase of 37.3%. Direct message reminders to providers prove to be an effective method for enhancing ACP completion among this specific patient group.
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Affiliation(s)
- Tobin Mathew
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Akash Patel
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Kyle DiGrande
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Nathalie De Michelis
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Behram Mody
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
| | - Dawn Lombardo
- Division of Cardiology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
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Dennison Himmelfarb CR, Beckie TM, Allen LA, Commodore-Mensah Y, Davidson PM, Lin G, Lutz B, Spatz ES. Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation 2023; 148:912-931. [PMID: 37577791 DOI: 10.1161/cir.0000000000001162] [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] [Indexed: 08/15/2023]
Abstract
Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.
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Walenczyk KM, Cavanagh CE, Skanderson M, Feder SL, Soliman AA, Justice A, Burg MM, Akgün KM. Advance directive screening among veterans with incident heart failure: Comparisons among people aging with and without HIV. Heart Lung 2023; 61:1-7. [PMID: 37023581 PMCID: PMC10524135 DOI: 10.1016/j.hrtlng.2023.03.018] [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] [Received: 12/27/2022] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Heart failure (HF) is common among people aging with HIV (PWH) and without HIV (PWoH). Despite the poor prognosis for HF, advance directives (AD) completion is low but has not been compared among PWH and PWoH. OBJECTIVES Determine the prevalence and predictors of AD screening among PWH and PWoH with incident HF. METHODS We included Veterans with an incident HF diagnosis code from 2013-2018 in the Veterans Aging Cohort Study (VACS) without prior AD screening. Health records were reviewed for AD screening note titles within -30 days to 1-year post-HF diagnosis. Analyses were stratified by HIV status. Trends in annual AD screening were evaluated with the Cochran-Mantel-Haenszel test. The associations of AD screening with demographics, disease severity (Charlson Comorbidity Index, VACS 2.0 Index), and healthcare encounters (cardiology, palliative care, hospitalization) were evaluated with Cox proportional hazards regression. RESULTS HF was diagnosed in 4516 Veterans (28.2% PWH, 71.8% PWoH). Annual AD screening rates increased in both groups (Ptrend<0.0001) and aggregate rates were higher among PWH than PWoH (53.5% vs. 48.2%, p=.001). In both groups, the likelihood of AD screening increased with greater disease severity, palliative care contact, and hospitalization (HR range=1.04-3.32, all p≤.02) but not with cardiology contact (p≥.53). CONCLUSIONS AD screening rates after incident HF remain suboptimal but increased over time and were higher in PWH. Future quality improvement and implementation efforts should aim for universal AD screening with incident HF diagnosis, initiated by providers skilled in discussing AD, including in the cardiology subspecialty setting.
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Affiliation(s)
- Kristie M Walenczyk
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Cardiology, VA Connecticut Healthcare System, West Haven, CT, USA.
| | - Casey E Cavanagh
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Shelli L Feder
- Medicine Service, VA Connecticut Healthcare System, West Haven, CT, USA; Yale School of Nursing, New Haven, CT, USA
| | - Ann A Soliman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Medicine Service, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Amy Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Medicine Service, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Matthew M Burg
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Cardiology, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kathleen M Akgün
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Medicine Service, VA Connecticut Healthcare System, West Haven, CT, USA
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Prevalence and predictors of advance directive among terminally ill patients in Taiwan before enactment of Patient Right to Autonomy Act: a nationwide population-based study. BMC Palliat Care 2022; 21:178. [PMID: 36224654 PMCID: PMC9554959 DOI: 10.1186/s12904-022-01069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Signing advance directives (ADs) ensures that terminally ill patients receive end-of-life care, according to their wishes, thereby promoting human dignity and sparing them from unnecessary suffering. Despite the enactment of the Hospice Palliative Care Act in Taiwan in 2000, the completion rates of ADs have been found to be low among patients with chronic illness conditions. To date, limited existing research is available regarding the factors associated with AD completion in terminally ill patients in Taiwan. To explore signed AD characteristics, compare differences in signing ADs between patients with and without cancer, and examine the factors associated with signing ADs in terminally ill patients. METHODS A nationwide study was conducted using data collected via a retrospective review of medical death records from 18 randomly selected hospitals in the northern, central, and southern parts of Taiwan. We collected 200 records, including both cancer and non-cancer-related deaths, from each hospital. Univariate and multivariate logistics regressions were conducted to examine factors associated with signing advance directives among all patients- with and without cancer. RESULTS Among the 3004 reviewed medical records, 79% had signed ADs, with most (95%) being signed by patients' caregivers. A higher education level (OR = 1.52, 95% CI = 1.10, 2.08, p = 0.010); cancer diagnosis (OR = 2.37, 95% CI = 1.79, 3.16, p < 0.001); having family members (OR = 5.62, 95% CI = 2.95, 10.69, p < 0.001), care homes (OR = 4.52, 95% CI = 1.97, 10.38, p < 0.001), friends, or maids (OR = 3.82, 95% CI = 1.76, 8.29, p = 0.001) as primary caregivers; and patients knowing about their poor prognosis (OR = 15.39, 95% CI = 5.66, 41.83, p < 0.001) were associated with a higher likelihood of signing ADs. CONCLUSIONS Patients with non-malignant chronic illnesses were less likely to have ADs signed by either patients or family caregivers than those with cancer, with the lowest likelihood observed in patients with cardiovascular diseases. Whenever possible, primary caregivers should be involved in discussing ADs with patients, and the importance of truth telling should be reinforced. Following these principles, each patient's end-of-life care preferences can be respected, thereby promoting quality of care before the patient's death.
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Kowalczys A, Bohdan M, Wilkowska A, Pawłowska I, Pawłowski L, Janowiak P, Jassem E, Lelonek M, Gruchała M, Sobański P. Comprehensive care for people living with heart failure and chronic obstructive pulmonary disease—Integration of palliative care with disease-specific care: From guidelines to practice. Front Cardiovasc Med 2022; 9:895495. [PMID: 36237915 PMCID: PMC9551106 DOI: 10.3389/fcvm.2022.895495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the leading global epidemiological, clinical, social, and economic burden. Due to similar risk factors and overlapping pathophysiological pathways, the coexistence of these two diseases is common. People with severe COPD and advanced chronic HF (CHF) develop similar symptoms that aggravate if evoking mechanisms overlap. The coexistence of COPD and CHF limits the quality of life (QoL) and worsens symptom burden and mortality, more than if only one of them is present. Both conditions progress despite optimal, guidelines directed treatment, frequently exacerbate, and have a similar or worse prognosis in comparison with many malignant diseases. Palliative care (PC) is effective in QoL improvement of people with CHF and COPD and may be a valuable addition to standard treatment. The current guidelines for the management of HF and COPD emphasize the importance of early integration of PC parallel to disease-modifying therapies in people with advanced forms of both conditions. The number of patients with HF and COPD requiring PC is high and will grow in future decades necessitating further attention to research and knowledge translation in this field of practice. Care pathways for people living with concomitant HF and COPD have not been published so far. It can be hypothesized that overlapping of symptoms and similarity in disease trajectories allow to draw a model of care which will address symptoms and problems caused by either condition.
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Affiliation(s)
- Anna Kowalczys
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
- *Correspondence: Anna Kowalczys,
| | - Michał Bohdan
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Iga Pawłowska
- Department of Pharmacology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Leszek Pawłowski
- Department of Palliative Medicine, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Piotr Janowiak
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Ewa Jassem
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Łódź, Poland
| | - Marcin Gruchała
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr Sobański
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Schwyz Hospital, Schwyz, Switzerland
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The Impact of Advance Directive Perspectives on the Completion of Life-Sustaining Treatment Decisions in Patients with Heart Failure: A Prospective Study. J Clin Med 2021; 10:jcm10245962. [PMID: 34945258 PMCID: PMC8703517 DOI: 10.3390/jcm10245962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/21/2022] Open
Abstract
Evidence for non-modifiable and modifiable factors associated with the utilization of advance directives (ADs) in heart failure (HF) is lacking. The purpose of this study was to examine baseline-to-3-month changes in knowledge, attitudes, and benefits/barriers regarding ADs and their impact on the completion of life-sustaining treatment (LST) decisions at 3-month follow-up among patients with HF. Prospective, descriptive data on AD knowledge, attitudes, and benefits/barriers and LSTs were obtained at baseline and 3-month follow-up after outpatient visits. Of 64 patients (age, 68.6 years; male, 60.9%; New York Heart Association (NYHA) classes I/II, 70.3%), 53.1% at baseline and 43.8% at 3-month follow-up completed LST decisions. Advanced age (odds ratio (OR) = 0.91, p = 0.012) was associated with less likelihood of the completion of LST decisions at 3-month follow-up, while higher education (OR = 1.19, p = 0.025) and NYHA class III/IV (OR = 4.81, p = 0.049) were associated with more likelihood. In conclusion, advanced age predicted less likelihood of LST decisions at 3 months, while higher education and more functional impairment predicted more likelihood. These results imply that early AD discussion seems feasible in mild symptomatic HF patients with poor knowledge about ADs, considering the non-modifiable and modifiable factors.
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Xu C, Yan S, Chee J, Lee EPY, Lim HW, Lim SWC, Low LL. Increasing the completion rate of the advance directives in primary care setting - a randomized controlled trial. BMC FAMILY PRACTICE 2021; 22:115. [PMID: 34144695 PMCID: PMC8214280 DOI: 10.1186/s12875-021-01473-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/17/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The completion rate of Advance Directives (ADs) has been low. This study aims to examine the effectiveness of two interventions 1) active counseling sessions coupled with passive patient education pamphlets, and 2) patient education pamphlets alone, compared with 3) control group (usual care), in increasing the completion rates of ADs in the primary care setting. METHODS Multicenter randomised controlled trial in four public primary care clinics in Singapore under Singapore Health Services. Randomization was performed via block randomization with Sequential Numbered Opaque Sealed Envelopes. Participants were randomized into 1) active intervention group (both counseling by primary care physicians and patient education pamphlets) or 2) passive intervention group (only patient education pamphlets), and 3) control group (usual care) with follow-up at 6 weeks. The main outcome measure is the proportion of participants who completed / planned to complete) ADs six weeks post-intervention. RESULTS Four hundred five participants were eligible to participate in the study. One hundred eighty-eight participants were recruited into the study (response rate = 46.4%), of which 158 completed the study. There was no significant difference between the control group, passive intervention group, and active intervention group, in terms of completion rates of ADs (29.4, 36.4, and 30.8% respectively). CONCLUSIONS This randomized controlled trial did not support the use of patient education pamphlets with or without active counseling sessions in increasing the completion of ADs in a primary care setting in Singapore. The optimal intervention strategy depends on each health system's context and resources, taking into consideration patients' profiles, which deserves further studies. TRIAL REGISTRATION Registered on April 17, 2018 clinicaltrials.gov ( NCT03499847 ).
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Affiliation(s)
- Cunzhi Xu
- Singapore Health, Services, 31 Third Hospital Ave, #03-03 Bowyer Block C, Singapore, 168753, Singapore
| | - Shi Yan
- Singapore Health, Services, 31 Third Hospital Ave, #03-03 Bowyer Block C, Singapore, 168753, Singapore
| | - Jade Chee
- Singapore Health, Services, 31 Third Hospital Ave, #03-03 Bowyer Block C, Singapore, 168753, Singapore
| | - Emily Pui-Yan Lee
- Singapore Health, Services, 31 Third Hospital Ave, #03-03 Bowyer Block C, Singapore, 168753, Singapore
| | - Han Wei Lim
- My Family Clinic (Punggol Central), 301 Punggol Central #01-02, Singapore, 820301, Singapore
| | - Sarah Woon Ching Lim
- Singapore Health, Services, 31 Third Hospital Ave, #03-03 Bowyer Block C, Singapore, 168753, Singapore
| | - Lian Leng Low
- Singapore Health, Services, 31 Third Hospital Ave, #03-03 Bowyer Block C, Singapore, 168753, Singapore. .,Department of Family Med & Continuing Care, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore.
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Kim J, Shin MS, Jang AY, Kim S, Heo S, Cha E, An M. Advance Directives and Factors Associated with the Completion in Patients with Heart Failure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041780. [PMID: 33673089 PMCID: PMC7918223 DOI: 10.3390/ijerph18041780] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 12/16/2022]
Abstract
Advance directive (AD) has been underutilized among patients with heart failure (HF). This study was performed to explore the ADs and examine factors associated with the completion of an AD survey in patients with HF. In a descriptive, correlational study, data on end-of-life values, treatment directives, and proxy (Korean-Advance Directive (K-AD) questionnaire) and factors associated with K-AD completion were collected among HF patients during outpatient visits. Of 67 patients (age, 67 years; male, 61.2%), 52.2% completed all or part of the K-AD. Among values, comfortable death was the most preferred (n = 15) followed by avoiding family burden (n = 6). In those completers, preferences for hospice care, cardiopulmonary resuscitation, ventilation support, and hemodialysis were 68.6%, 42.9%, 28.6%, and 28.6%, respectively. Female sex (odds ratio (OR) = 0.167), poorer HF prognosis (OR = 0.156), and better functional status (OR = 0.905) were associated with less likelihood of completing the AD survey. The findings suggest that in-depth AD discussion needs to be started earlier in patients with HF to facilitate completion of AD, especially in female patients. Future research should investigate if early discussion of ADs as part of advance care planning with integration into standard care of HF facilitates the documentation of ADs.
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Affiliation(s)
- JinShil Kim
- College of Nursing, Gachon University, 191 Hambakmeoro, Yeonsu-gu, Incheon 21936, Korea;
| | - Mi-Seung Shin
- Division of Cardiology, Gil Medical Center, Department of Internal Medicine, Gachon University College of Medicine, 21 Namdong-daero 774 beon-gil, Namdong-gu, Incheon 21565, Korea;
- Correspondence: (M.-S.S.); (M.A.); Tel.: +82-32-460-3663 (M.-S.S.); +82-62-530-4944 (M.A.)
| | - Albert Youngwoo Jang
- Division of Cardiology, Gil Medical Center, Department of Internal Medicine, Gachon University College of Medicine, 21 Namdong-daero 774 beon-gil, Namdong-gu, Incheon 21565, Korea;
| | - Shinmi Kim
- Department of Nursing, Changwon National University, 20 Changwondaehakro, Euichanggu, Kyungsangnamdo, Changwon 51140, Korea;
| | - Seongkum Heo
- Georgia Baptist College of Nursing, Mercer University, 3001 Mercer University Drive, Atlanta, GA 30341, USA;
| | - EunSeok Cha
- College of Nursing, Chungnam National University, 266 MunWharo, Junggu, Daejeon 35015, Korea;
| | - Minjeong An
- College of Nursing, Interdisciplinary Program of Arts & Design Technology, Chonnam National University, 160 Baekseoro, Donggu, Gwangju 61469, Korea
- Correspondence: (M.-S.S.); (M.A.); Tel.: +82-32-460-3663 (M.-S.S.); +82-62-530-4944 (M.A.)
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Mosoiu D, Rogozea L, Landon A, Bisoc A, Tint D. Palliative Care in Heart Failure: A Public Health Emergency. Am J Ther 2020; 27:e204-e223. [PMID: 31688067 DOI: 10.1097/mjt.0000000000001067] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Palliative care (PC) is the holistic care of patients with life-limiting illnesses focused on relief of suffering and maximizing quality of life for patients and their families. Patients with heart failure (HF) are the largest group eligible for PC services, but only a small percentage of them receive PC. AREAS OF UNCERTAINTY The optimal content and method of delivery of PC interventions to HF patients in resource-limited countries remain unknown. The integration of PC into existing HF disease management continues to be a challenge. DATA SOURCES PUBMED was searched to identify articles on the topic published in the last 5 years (2014-April 2019). One hundred thirty-six articles were identified-14 articles out of were included in the revision. THERAPEUTIC ADVANCES Research concerning PC in HF is still scarce and comes predominantly from developed countries. PC in HF improves patients' and caregivers' outcomes in terms of dyspnea, sleep, depression, communication, coping, and care-giving burden. Specialized home-based PC services have a positive impact on patients' physical and emotional wellbeing while decreasing utilization of medical services. Fatigue, dyspnea, and pain are frequent symptoms. Evidence concerning use of opioids for dyspnea is increasing. Family caregivers offer a considerable amount of care during the disease trajectory. There is often incongruence between the carer's and the patient's wishes in terms of treatment decisions and preferences. Carers should be assessed for risk and supported in their roles in care management and care coordination. CONCLUSIONS Because of the unpredictability of the disease and difficulty in prognostication, PC should be introduced at the point of diagnosis of HF. Basic education in PC needs to be introduced early in the training of cardiology staff, focused on concept definition, differencing PC and terminal care, symptom management, communication, and decision-making.
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Affiliation(s)
- Daniela Mosoiu
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania.,Education and National Development Department, Hospice Casa Sperantei, Brasov, Romania
| | - Liliana Rogozea
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania
| | | | - Alina Bisoc
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania.,Emergency County Clinical Hospital, Brasov, Romania; and
| | - Diana Tint
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania.,ICCO Clinics, Brasov, Romania
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Greene SJ, Adusumalli S, Albert NM, Hauptman PJ, Rich MW, Heidenreich PA, Butler J. Building a Heart Failure Clinic: A Practical Guide from the Heart Failure Society of America. J Card Fail 2020; 27:2-19. [PMID: 33289664 DOI: 10.1016/j.cardfail.2020.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/13/2020] [Indexed: 01/09/2023]
Abstract
Heart failure (HF) remains a leading cause of mortality and morbidity and a primary driver of health care resource use in the United States. As such, there continues to be much interest in the development and refinement of HF clinics that manage patients with HF in a guideline-directed, technology-enabled, and coordinated approach. Optimization of resource use and maintenance of collaboration with other providers are also important themes when considering implementation of HF clinics. Through this document, the Heart Failure Society of America aims to provide a contemporary, practical guide to creating and sustaining a HF clinic. The guide discusses (1) patient care considerations for delivering guideline-directed and patient-centered care, and (2) operational considerations including development of a HF clinic business plan, setting goals, leadership support, triggers for patient referral and patient follow-up, patient population served, optimal clinic staffing models, relationships with subspecialists, and continuous quality improvement. This document was developed to empower providers and clinicians who wish to build and sustain community-based, successful HF clinics.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nancy M Albert
- Nursing Institute and Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio USA
| | - Paul J Hauptman
- University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Michael W Rich
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, Mississippi, USA.
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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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13
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Kim J, Choi J, Shin MS, Kim M, Seo E, An M, Shim JL, Heo S. Do advance directive attitudes and perceived susceptibility and end-of-life life-sustaining treatment preferences between patients with heart failure and cancer differ? PLoS One 2020; 15:e0238567. [PMID: 32898165 PMCID: PMC7478644 DOI: 10.1371/journal.pone.0238567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/19/2020] [Indexed: 11/28/2022] Open
Abstract
There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.
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Affiliation(s)
- JinShil Kim
- College of Nursing, Gachon University, Incheon, South Korea
| | - Jiin Choi
- Office of Hospital Information, Seoul National University Hospital, Seoul, South Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, College of Medicine, Gachon University, Incheon, South Korea
| | - Miyeong Kim
- Gil Medical Center, Gachon University, Incheon, South Korea
| | - EunJu Seo
- Department of Nursing, National Cancer Center, Seoul, South Korea
| | - Minjeong An
- College of Nursing, Chonnam National University, Gwangju, South Korea
| | - Jae Lan Shim
- Department of Nursing, College of Medicine, Dongguk University, Gyeongju, South Korea
| | - Seongkum Heo
- Georgia Baptist College of Nursing, Mercer University, Atlanta, Georgia, United States of America
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14
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Gelfman LP, Sudore RL, Mather H, McKendrick K, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Prognostic Awareness and Goals of Care Discussions Among Patients With Advanced Heart Failure. CIRCULATION. HEART FAILURE 2020; 13:e006502. [PMID: 32873058 DOI: 10.1161/circheartfailure.119.006502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prognostic awareness (PA)-the understanding of limited life expectancy-is critical for effective goals of care discussions (GOCD) in which patients discuss their goals and values in the context of their illness. Yet little is known about PA and GOCD in patients with advanced heart failure (HF). This study aims to determine the prevalence of PA among patients with advanced HF and patient characteristics associated with PA and GOCD. METHODS We assessed the prevalence of self-reported PA and GOCD using data from a multisite communication intervention trial among patients with advanced HF with an implantable cardiac defibrillator at high risk of death. RESULTS Of 377 patients (mean age 62 years, 30% female, 42% nonwhite), 78% had PA. Increasing age was a negative predictor of PA (odds ratio, 0.95 [95% CI, 0.92-0.97]; P<0.01). No other patient characteristics were associated with PA. Of those with PA, 26% had a GOCD. Higher comorbidities and prior advance directives were associated with GOCD but were of only borderline statistical significance in a fully adjusted model. Symptom severity (odds ratio, 1.77 [95% CI, 1.19-2.64]; P=0.005) remained a robust and statistically significant positive predictor of having a GOCD in the fully adjusted model. CONCLUSIONS In a sample of patients with advanced HF, the frequency of PA was high, but fewer patients with PA discussed their end-of-life care preferences with their physician. Improved efforts are needed to ensure all patients with advanced HF have an opportunity to have GOCD with their doctors. Clinicians may need to target older patients with HF and continue to focus on those with signs of worsening illness (higher symptoms). Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01459744.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
| | - Rebecca L Sudore
- Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco.,San Francisco Veterans Affairs Health Care System, CA (R.L.S.)
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ (M.D.H.)
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT (R.J.L.)
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, NJ (H.I.L.).,Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (H.I.L.)
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (D.D.M.).,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO (D.D.M.)
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama, Birmingham, AL (K.M.S.)
| | - Sean P Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine (S.P.P.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
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15
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Exploring Advance Directive Perspectives and Associations with Preferences for End-of-Life Life-Sustaining Treatments among Patients with Implantable Cardioverter-Defibrillators. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124257. [PMID: 32549238 PMCID: PMC7345790 DOI: 10.3390/ijerph17124257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 12/02/2022]
Abstract
Deactivation of an implantable cardioverter-defibrillator (ICD) is a critical issue in the advance care planning (ACP) of ICD recipients; however, related perspectives have rarely been explored. Thus, this study aimed to provide an initial investigation of ICD recipients’ perceived susceptibility and barriers/benefits regarding ACP and/or advance directives (ADs), and associations of these modifiable factors with preferences for end-of-life life-sustaining treatments (LSTs) (cardiopulmonary resuscitation (CPR), ventilator support, hemodialysis, and hospice care). Using a descriptive correlational design, 48 ICD recipients (age, 50.1 years; male, 85.4%) completed survey questionnaires. “No burden on family” was the most highly valued (59.1%), followed by “comfortable death” (20.4%), and both (11.4%). LST preference was 43.8% for ventilator support, 45.8% for both hemodialysis and hospice care, and 54.2% for CPR. Perceived susceptibility to having unexpected end-of-life experiences increased the likelihood of preference for aggressive LSTs, with preferences increasing by 15% for CPR, 17% for ventilator support, and 23% for hemodialysis. A non-modifiable factor, older age, was the only predictor of increased preference for hospice care (odds ratio = 1.09, p = 0.016). Among the modifiable factors, a higher perceived susceptibility increased the likelihood of aggressive LST preferences. The findings imply that to facilitate informed decisions for LSTs, early ACP discussion could be helpful and enhance these modifiable factors.
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16
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Pak ES, Jones CA, Mather PJ. Ethical Challenges in Care of Patients on Mechanical Circulatory Support at End-of-Life. Curr Heart Fail Rep 2020; 17:153-160. [DOI: 10.1007/s11897-020-00460-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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17
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Psychometric Testing of the Korean Version of the Attitudes toward the Advance Directives in Low-Income Chronically Ill Older Adults. Healthcare (Basel) 2020; 8:healthcare8010062. [PMID: 32197488 PMCID: PMC7151054 DOI: 10.3390/healthcare8010062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022] Open
Abstract
The purpose of this study was to examine the psychometric properties of the Advance Directive Attitude Survey in Korean (K-ADAS), a measure of attitudes toward advance directives (ADs). A total of 118 low-income, community-dwelling older adults (mean age, 75.09 years) participated. An exploratory factor analysis (EFA) was conducted to determine the factor structure of the K-ADAS. Validity was further assessed by known associations of the K-ADAS with perceived susceptibility and severity using part of the Advance Care Planning surveys. Its reliability was examined by calculating alpha coefficients. EFA determined a three-factor structure model with good model fit. Validity was further supported with significant correlations between the K-ADAS and susceptibility and severity. Reliability was supported by adequate level of Cronbach’s alpha. The K-ADAS was a valid and reliable measure for assessment of AD attitudes with a sound model fit. Thus, the K-ADAS can be used to assess AD attitudes among community-dwelling elders.
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18
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Avula S, LaFata M, Nabhan M, Allana A, Toprani B, Scheidel C, Suneja A. Heart failure mortality prediction using PRISM score and development of a classification and regression tree model to refer patients for palliative care consultation. IJC HEART & VASCULATURE 2020; 26:100440. [PMID: 31886404 PMCID: PMC6921143 DOI: 10.1016/j.ijcha.2019.100440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION We sought to assess one-year mortality in heart failure (HF) patients by using (Placement Resource Indicator for Systems Management) PRISM, a disease nonspecific risk stratification score, and use it along with modified Seattle Heart Failure Model (SHFM) to guide patient selection for palliative care consultation. METHODS A retrospective study design was used to examine 1-year mortality in 689 HF patients admitted from 2012 to 2014. One-year mortality was calculated using Pmort30/PRISM and modified SHFM scores, and the predicted scores were validated using the area under the ROC curve. CART was used to develop an algorithm to classify patients based on their mortality risk. RESULTS The discriminatory ability of PRISM categorical score (AUC = 0.701) was not significantly different than the discriminatory ability of modified SHFM (AUC = 0.686) (DeLong's test p = 0.56) but improved significantly with the combination of PRISM (categorical) score + modified SHFM (AUC = 0.740) (p = 0.002). The predictive capability of the CART tree model after cross-validation was 72.2% (AUC 0.631). CONCLUSION Our study suggests PRISM score performed as well as modified SHFM for one-year mortality prediction. Moreover, the addition of modified SHFM to PRISM score increases discriminatory ability in predicting 1-year mortality in heart failure patients compared to either of the two models alone. Together, when combined in a CART model, they can be used to identify the population subset with the highest mortality risk and hence guide goals of care discussion.
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Affiliation(s)
- Sindhu Avula
- Mercy St. Vincent Medical Center, Toledo, OH, United States
| | - Michael LaFata
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| | - Mohammed Nabhan
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| | | | - Bhavana Toprani
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| | | | - Anupam Suneja
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
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19
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Kim J, An M, Heo S, Shin MS. Attitudes toward advance directives and prognosis in patients with heart failure: a pilot study. Korean J Intern Med 2020; 35:109-118. [PMID: 30759965 PMCID: PMC6960039 DOI: 10.3904/kjim.2018.158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Advance directives (ADs) in Korean patients with heart failure (HF) and the associations of attitude towards ADs and HF prognosis with ADs were initially assessed using the model of the Korean-Advance Directive (K-AD). METHODS Twenty-four patients with HF (age, 67.1 years; men, 58.3%; ejection fraction, 35.9%) participated. A pilot test to evaluate the feasibility of ADs and the possible associations of attitudes towards ADs and prognosis with end-of-life treatment preferences among patients with HF was conducted. RESULTS Fifteen patients (62.5%) completed the K-ADs. The major reason for incomplete K-AD was knowledge deficit. Patients valued "comfortable death" the most (45.4%), followed by "giving no burden to the family" (13.6%). Among treatment preferences, hospice care was preferred by the majority (66.7%), while cardiopulmonary resuscitation (CPR) was preferred by the minority (31.8%). Children (50.0%) were mostly appointed as a proxy, followed by the spouse (33.3%). More patients with moderately positive attitudes completed the K-ADs than their counterparts (70.0% vs. 57.1%). The 5-year survival rate was 69.2%; the patients who preferred CPR had a higher survival rate (70.6% vs. 68.5%) whereas those who preferred hospice care had a lower survival rate than their counterparts (70.7% vs. 75.2%). CONCLUSION The findings support the feasibility of the K-AD model, with a high acceptance rate in two-thirds of the sample. Further studies are warranted to investigate whether treatment preferences are associated with attitude towards ADs and/or HF prognosis using larger sample size.
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Affiliation(s)
- JinShil Kim
- Gachon University College of Nursing, Incheon, Korea
| | - Minjeong An
- Chonnam National University College of Nursing, Gwangju, Korea
| | - Seongkum Heo
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mi-Seung Shin
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Correspondence to Mi-Seung Shin, M.D. Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82-32-460-3663 Fax: +82-32-469-1906 E-mail:
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20
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A Context-oriented Communication Algorithm for Advance Care Planning: A Model to Assist Palliative Care in Heart Failure. J Cardiovasc Nurs 2019; 33:446-452. [PMID: 28248746 DOI: 10.1097/jcn.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Access to consultation or referral for decisions about advance care planning (ACP) is limited, particularly for nonmalignant models pertinent to palliative care in heart failure (HF). OBJECTIVES The aim of this study was to solicit professional opinions about the feasibility of using an exemplary context-oriented communication algorithm for ACP discussions. METHODS Using a panel of expert physicians and nurses in cardiovascular care, a 3-round Delphi study was conducted to evaluate the proposed model. RESULTS A consensus was determined based on a content validity ratio (CVR) of 0.318 or greater, a critical value for selection of an item scored as important (≥4 on a 5-point Likert scale). A total of 50, 44, and 38 experts in Korea completed each round, respectively. Item evaluation did not differ across rounds (Friedman χ > P = .05), except for timing of the ACP discussion. A lack of consensus was observed on the issue of after HF diagnosis for right timing of the ACP discussion across rounds (CVRs from -0.80 to -0.83); consensus was reached on the expectation of a terminal state (CVRs from 0.60 to 0.78). Content validity ratios were moderately high for Korean advance directive, ranging from 0.59 to 0.91. Experts also reached consensus about each of 5 steps of a communication model-patients' determination of decisional capacity (CVR, 0.72-1.0), awareness (CVR, 0.95-1.0), willingness for advance care planning (CVR, 0.76-0.84), family dynamics (CVR, 0.92-1.0) and patient readiness for advance care planning (CVR, 0.76-0.95). CONCLUSIONS A context-oriented communication model could be used to facilitate the decision-making process for palliative care and continuity of care in HF.
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21
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Ludmir J, Steiner JM, Wong HN, Kloosterboer A, Leong J, Aslakson RA. Palliative Care Opportunities Among Adults With Congenital Heart Disease-A Systematic Review. J Pain Symptom Manage 2019; 58:891-898. [PMID: 31404639 DOI: 10.1016/j.jpainsymman.2019.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 01/08/2023]
Abstract
CONTEXT Little is known about advance care planning (ACP) and palliative care needs among adults with congenital heart disease (ACHD). OBJECTIVES The objective of this study was to identify and synthesize studies concerning palliative care among ACHD patients. METHODS We searched five electronic databases (PubMed, Embase, SCOPUS, Web of Science, and CINAHL) using the keywords palliative care and congenital heart disease. Inclusion criteria were adults (age > 18 years) with congenital heart disease and publications in English through March 3, 2019. RESULTS Our search yielded 2872 studies, and after removal of duplicates, we screened 2319 abstracts and identified seven for inclusion. Study findings were grouped into three domains: ACP, symptomatology, and end-of-life care. Among the five cross-sectional studies, only 1%-28% of ACHD patients recalled participating in ACP discussions with their doctors but 69%-78% reported a strong interest and desire to participate in ACP. In one study, 46% (n = 67) of patients had elevated anxiety symptoms (Hospital Anxiety and Depression Scale [HADS-A] ≥ 8) and 11% (n = 15) had elevated depressive symptoms (HADS-A ≥ 8). ACHD patients who had a documented goals of care conversation before cardiac decompensation had a lower incidence of resuscitation and aggressive treatments at end of life (12% [n = 3] vs. 100% [n = 12], P < 0.001). CONCLUSION While few ACHD patients complete advance directives, our findings support that many ACHD patients recognize the value of initiating end-of-life and goals of care conversations early on in the course of illness. Future studies investigating communication and implementation strategies of ACP as well as the symptom experience of patients with ACHD are needed.
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Affiliation(s)
- Jonathan Ludmir
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, California, USA.
| | - Jill M Steiner
- Division of Cardiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Amy Kloosterboer
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Jason Leong
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Rebecca A Aslakson
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University Medical Center, Stanford, California, USA; Palliative Care Section, Division of Primary Care and Population Health, Department of Medicine, Stanford University Medical Center, Stanford, California, USA
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22
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Tyacke MH, Guttormson JL, Garnier-Villarreal M, Schroeter K, Peltier W. Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life. Heart Lung 2019; 49:123-131. [PMID: 31492522 DOI: 10.1016/j.hrtlng.2019.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/30/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Older adults prefer comfort over life-sustaining care. Decreased intensity of care is associated with improved quality of life at the end-of-life (EOL). OBJECTIVES This study explored the association between advance directives (ADs) and intensity of care in the acute care setting at the EOL for older adults. METHODS A retrospective, correlational study of older adult decedents (N = 496) was conducted at an academic medical center. Regression analyses explored the association between ADs and intensity of care. RESULTS Advance directives were not independently predictive of aggressive care but were independently associated with referrals to palliative care and hospice; however, effect sizes were small, and the timing of referrals was late. CONCLUSION The ineffectiveness of ADs to reduce aggressive care or promote timely referrals to palliative and hospice services, emphasizes persistent inadequacies related to EOL care. Research is needed to understand if this failure is provider-driven or a flaw in the documents themselves.
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Affiliation(s)
- Marsha H Tyacke
- Marquette University, College of Nursing, PO Box 1881, Milwaukee, WI 53201, United States.
| | - Jill L Guttormson
- Marquette University, College of Nursing, PO Box 1881, Milwaukee, WI 53201, United States.
| | | | - Kathryn Schroeter
- Marquette University, College of Nursing, PO Box 1881, Milwaukee, WI 53201, United States.
| | - Wendy Peltier
- Medical College of Wisconsin, CLCC, Clinical Cancer Center, 9200 W Wisconsin Ave, Milwaukee, WI 53226, United States.
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23
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Kim J, Shin MS, Park YM, Lee HN, Heo S, Ounpraseuth S. Associations of Advance Directive Knowledge, Attitudes, and Barriers/Benefits With Preferences for Advance Treatment Directives Among Patients With Heart Failure and Their Caregivers. J Card Fail 2019; 26:61-69. [PMID: 31344402 DOI: 10.1016/j.cardfail.2019.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 07/11/2019] [Accepted: 07/17/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with heart failure (HF) have not been considered as major beneficiaries of advance directives (ADs). We analyzed factors affecting the preferences for the adoption of ADs by patients with HF and their caregivers. METHODS AND RESULTS Seventy-one patient (mean age: 68 years)-caregiver (mean age: 55 years) dyads were enrolled during clinic visits for routine care at a single institution and completed questionnaires during in-person visits. Cohen's kappa coefficients and generalized estimating equation models were used to analyze the data. The agreement on dyadic perspectives for aggressive treatments was poor or fair, whereas agreement relative to hospice care was moderate (k = 0.42, 95% confidence interval = 0.087-0.754). Both patients and caregivers demonstrated poor knowledge of ADs and similar levels of perceived benefits and barriers to advance care planning. However, the caregivers had more positive attitudes toward ADs than patients. Patients and caregivers who were older and/or males had greater odds of preferring aggressive treatments and/or hospice care. Further, those with depressive symptoms had lower odds of preferring hospice care. CONCLUSION The dyadic agreement was moderately high only for hospice care preferences. Both patients and caregivers demonstrated knowledge of shortfalls regarding ADs. Timely AD discussions could increase dyadic agreement and enhance informed and shared decision-making regarding medical care.
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Affiliation(s)
- Jinshil Kim
- Gachon University, College of Nursing, Incheon, Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University, College of Medicine, Incheon, Korea.
| | - Yae Min Park
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University, College of Medicine, Incheon, Korea
| | | | - Seongkum Heo
- University of Arkansas for Medical Sciences, College of Nursing, Little Rock, Arkansas
| | - Songthip Ounpraseuth
- University of Arkansas for Medical Sciences, College of Public Health, Little Rock, Arkansas
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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Chan CWH, Wong MMH, Choi KC, Chan HYL, Chow AYM, Lo RSK, Sham MMK. What Patients, Families, Health Professionals and Hospital Volunteers Told Us about Advance Directives. Asia Pac J Oncol Nurs 2019; 6:72-77. [PMID: 30599019 PMCID: PMC6287378 DOI: 10.4103/apjon.apjon_38_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: An advance directive (AD) is a document that allows mentally competent individuals to make healthcare decisions about their condition that they might no longer be able to make in the future. This study aimed to explore the perceptions of AD decision-making of various stakeholders in the Chinese palliative care setting. Methods: Patients with life-limiting diseases, family members, health professionals, and hospital volunteers were recruited in the palliative care unit of two hospitals in Hong Kong by purposive sampling on age and sex. Qualitative semi-structured individual interviews were conducted. Results: A total of 96 participants, including 24 participants from each group, completed the study. Most participants were willing to discuss AD but had not heard about it before the interview. Patients regarded the decisions made in the AD as a way to reduce their future sufferings, while they also considered the welfare of their family. Family members were concerned about the psychological burden when discussing about the AD. Health professionals emphasized the logistic and process of the AD. Hospital volunteers pointed out the impact of Chinese culture on AD acceptance and the lack of AD promotion in the community. Conclusions: The findings of the study indicated the need for more promotion of AD in the society. It is important to consider the opinion of a patient's family during AD discussions in a Chinese culture. Health professionals may need to identify the best timing for the discussion of AD with patients and their families.
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Affiliation(s)
- Carmen W H Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Martin M H Wong
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Helen Y L Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Amy Y M Chow
- Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, China
| | - Raymond S K Lo
- Palliative Care Department, Shatin Hospital and Bradbury Hospice, Hong Kong, China
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Chow J, Senderovich H. It's Time to Talk: Challenges in Providing Integrated Palliative Care in Advanced Congestive Heart Failure. A Narrative Review. Curr Cardiol Rev 2018; 14:128-137. [PMID: 29366424 PMCID: PMC6088451 DOI: 10.2174/1573403x14666180123165203] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/13/2018] [Accepted: 01/22/2018] [Indexed: 02/05/2023] Open
Abstract
Background: Congestive heart failure is an increasingly prevalent terminal illness in a globally aging population. Prognosis for this disease remains poor despite optimal therapy. Evidence suggests that a palliative care approach may be beneficial – and is currently recommended – in advanced congestive heart failure but these services remain underutilized. Objectives: To identify the main challenges to the access and delivery of palliative care in patients with advanced congestive heart failure, and to summarize recommendations for clinical practice based on the available literature. Methods: MEDLINE and EMBASE were searched for articles published from 1995-2017 pertaining to end of life care in individuals suffering from CHF. Only four randomized controlled trials were found. Results: We identified ten key challenges to access and delivery of palliative care services in this patient population: (1) Prognostic uncertainty, (2) Provider education/training, (3) Ambiguity surrounding coordination of care, (4) Timing of palliative care referral, (5) Inadequate community supports, (6) Difficulty communicating uncertainty, (7) Fear of taking away hope, (8) Insufficient advance care planning, (9) Inadequate understanding of illness, and (10) Discrepant patient/family care goals. Provider and patient education, early discussion about prognosis, and a multidisciplinary team-based approach are recommended as we move towards a model where symptom palliation exists concurrently with active disease-modifying therapies. Conclusion: Despite evidence that palliative care may improve symptom control and quality of life in patients with advanced congestive heart failure, a multitude of current challenges hinder access to these services. Education, early discussion of prognosis and advance care planning, and multidisciplinary team-based care may be a helpful initial approach as further targeted work addresses these challenges.
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Affiliation(s)
- Justin Chow
- Department of Medicine, University of Calgary, Calgary, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Helen Senderovich
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Physician, Geriatrics & Palliative Care & Pain Medicine, Baycrest Health Sciences System, Toronto, Canada.,Department of Family and Community Medicine, Division of Palliative Care, University of Toronto, Toronto, Canada
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Jesus JE, Marshall KD, Kraus CK, Derse AR, Baker EF, McGreevy J. Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU? J Emerg Med 2018; 55:435-440. [PMID: 30054156 DOI: 10.1016/j.jemermed.2018.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 05/17/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. OBJECTIVES In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU. DISCUSSION Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition. CONCLUSIONS End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.
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Affiliation(s)
| | | | | | | | - Eileen F Baker
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
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Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Gorenek B, Marin F, Dagres N, Ozcan EE, Lenarczyk R, Crijns HJ, Guo Y, Proietti M, Sticherling C, Huang D, Daubert JP, Pokorney SD, Cabrera Ortega M, Chin A. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2018; 21:7-8. [DOI: 10.1093/europace/euy110] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - James M Beattie
- Cicely Saunders Institute, King’s College London, London, UK
| | | | | | - Gheorghe-Andrei Dan
- Cardiology Department, University of Medicine and Pharmacy “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice; Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Vincenzo L Malavasi
- Cardiology Division, Department of Nephrologic, Cardiac, Vascular Diseases, Azienda ospedaliero-Universitaria di Modena, Modena, Italy
| | - Jacques Mansourati
- University Hospital of Brest and University of Western Brittany, Brest, France
| | - Lluis Mont
- Arrhythmia Section, Cardiovascular Clínical Institute, Hospital Clinic, Universitat Barcelona, Barcelona, Spain
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Harry J Crijns
- Cardiology Maastricht UMC+ and Cardiovascular Research Institute Maastricht, Netherlands
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | | | - Dejia Huang
- Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University, Durham, NC, USA
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Boyeros, La Havana Cuba
| | - Ashley Chin
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
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Banner D, Freeman S, Kandola DK, Meikle M, Russell BKM, Sommerfeld EA, Flood D, Schiller CJ. Community perspectives of end-of-life preparedness. DEATH STUDIES 2018; 43:211-223. [PMID: 29498611 DOI: 10.1080/07481187.2018.1446060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
While death is a universal human experience, the process of planning for death can be difficult and may be avoided altogether. To understand community perspectives of end-of-life preparedness, we undertook a multimethod study exploring the experiences of 25 community members and 10 stakeholders engaged in end-of-life planning. In addition, card sorting activities and focused discussions with 97 older adults were undertaken to highlight perspectives and needs. Data were analyzed using descriptive statistics and qualitative description. Overall, the participants perceived many benefits to being end-of-life prepared, however, few community members had engaged in formal planning. Key barriers include concerns about the accessibility and accuracy of information, discomfort when engaging in end-of-life conversations, and perceptions about the cost associated with engaging in formal legal or financial preparations. Areas for further research include the need for studies that capture the cultural dimensions of end-of-life planning and explores the implementation and evaluation of community-based interventions to improve preparedness.
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Affiliation(s)
- Davina Banner
- a School of Nursing , University of Northern British Columbia , Prince George , BC , Canada
| | - Shannon Freeman
- a School of Nursing , University of Northern British Columbia , Prince George , BC , Canada
| | - Damanpreet K Kandola
- a School of Nursing , University of Northern British Columbia , Prince George , BC , Canada
- b School of Health Sciences , University of Northern British Columbia , Prince George , BC , Canada
| | - Madeline Meikle
- c School of Social Work , University of Northern British Columbia , Prince George , BC , Canada
| | - Bridget K M Russell
- b School of Health Sciences , University of Northern British Columbia , Prince George , BC , Canada
| | - E Anne Sommerfeld
- b School of Health Sciences , University of Northern British Columbia , Prince George , BC , Canada
- d Prince George Rotary Hospice House , Prince George , BC , Canada
| | - Donna Flood
- e Prince George Hospice Society , Prince George , BC , Canada
| | - Catharine J Schiller
- a School of Nursing , University of Northern British Columbia , Prince George , BC , Canada
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Eiser AR, Kirkpatrick JN, Patton KK, McLain E, Dougherty CM, Beattie JM. Putting the “Informed” in the informed consent process for implantable cardioverter-defibrillators: Addressing the needs of the elderly patient. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:312-320. [DOI: 10.1111/pace.13288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 11/14/2017] [Accepted: 01/15/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Arnold R. Eiser
- Department of Medicine; Drexel University College of Medicine; Philadelphia PA USA
- Leonard Davis Institute; University of Pennsylvania; Philadelphia PA USA
| | - James N. Kirkpatrick
- Division of Cardiology; University of Washington School of Medicine; Seattle WA USA
| | - Kristen K. Patton
- Division of Cardiology; University of Washington School of Medicine; Seattle WA USA
| | - Emily McLain
- Summit Cardiology; Northwest Hospital; Seattle WA USA
| | - Cynthia M. Dougherty
- Research Biobehavioral and Health Systems; University of Washington School of Nursing; Seattle WA USA
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Gelfman LP, Kavalieratos D, Teuteberg WG, Lala A, Goldstein NE. Primary palliative care for heart failure: what is it? How do we implement it? Heart Fail Rev 2017; 22:611-620. [PMID: 28281018 PMCID: PMC5591756 DOI: 10.1007/s10741-017-9604-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Heart failure (HF) is a chronic and progressive illness, which affects a growing number of adults, and is associated with a high morbidity and mortality, as well as significant physical and psychological symptom burden on both patients with HF and their families. Palliative care is the multidisciplinary specialty focused on optimizing quality of life and reducing suffering for patients and families facing serious illness, regardless of prognosis. Palliative care can be delivered as (1) specialist palliative care in which a palliative care specialist with subspecialty palliative care training consults or co-manages patients to address palliative needs alongside clinicians who manage the underlying illness or (2) as primary palliative care in which the primary clinician (such as the internist, cardiologist, cardiology nurse, or HF specialist) caring for the patient with HF provides the essential palliative domains. In this paper, we describe the key domains of primary palliative care for patients with HF and offer some specific ways in which primary palliative care and specialist palliative care can be offered in this population. Although there is little research on HF primary palliative care, primary palliative care in HF offers a key opportunity to ensure that this population receives high-quality palliative care in spite of the growing numbers of patients with HF as well as the limited number of specialist palliative care providers.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA.
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.
| | - Dio Kavalieratos
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Winifred G Teuteberg
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anuradha Lala
- Divisions of Cardiology and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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Young KA, Redfield MM, Strand JJ, Dunlay SM. End-of-Life Discussions in Patients With Heart Failure. J Card Fail 2017; 23:821-825. [PMID: 28842378 DOI: 10.1016/j.cardfail.2017.08.451] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/09/2017] [Accepted: 08/16/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although guidelines call on clinicians to conduct regular conversations about advance care planning and end-of-life (EOL) preferences with patients with heart failure (HF), research suggests that physicians often avoid these discussions. METHODS AND RESULTS From January 20, 2014, to January 18, 2016, Southeastern Minnesota residents hospitalized with acute decompensated HF (ADHF) at Mayo Clinic hospitals were enrolled into an observational cohort study that included the administration of face-to-face questionnaires. Risk of death (prognosis) was estimated using the Meta-analysis Global Group in Chronic Heart Failure score. Among 400 patients (mean age 77.7 years, 46% female, 48% preserved ejection fraction), only 69 (17%) reported previously discussing EOL wishes with their physician. Patients reporting EOL discussions more often had an advance directive (81% vs 66%; P = .009), recognized the term "hospice" (96% vs 87%; P = .027), and had more favorable attitudes of dying and hospice (P = .030). Resuscitation preferences and rates of completion of advance directives varied with prognosis, although patient-clinician EOL discussions did not. CONCLUSIONS The majority of patients hospitalized with ADHF did not recall discussing their preferences for EOL care with their physician. This represents an important modifiable gap in the optimal longitudinal care of HF patients.
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Affiliation(s)
| | | | - Jacob J Strand
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shannon M Dunlay
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
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Cook I, Kirkup AL, Langham LJ, Malik MA, Marlow G, Sammy I. End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis. Gerontol Geriatr Med 2017. [PMID: 28638855 PMCID: PMC5470655 DOI: 10.1177/2333721417713422] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
With population aging, “do not resuscitate” (DNAR) decisions, pertaining to the appropriateness of attempting resuscitation following a cardiac arrest, are becoming commoner. It is unclear from the literature whether using age to make these decisions represents “ageism.” We undertook a systematic review of the literature using CINAHL, Medline, and the Cochrane database to investigate the relationship between age and DNAR. All 10 studies fulfilling our inclusion criteria found that “do not attempt resuscitation” orders were more prevalent in older patients; eight demonstrated that this was independent of other mediating factors such as illness severity and likely outcome. In studies comparing age groups, the adjusted odds of having a DNAR order were greater in patients aged 75 to 84 and ≥85 years (adjusted odds ratio [AOR] 1.70, 95% confidence interval [CI] = [1.25, 2.33] and 2.96, 95% CI = [2.34, 3.74], respectively), compared with those <65 years. In studies treating age as a continuous variable, there was no significant increase in the use of DNAR with age (AOR 0.98, 95% CI = [0.84, 1.15]). In conclusion, age increases the use of “do not resuscitate” orders, but more research is needed to determine whether this represents “ageism.”
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Gelfman LP, Bakitas M, Warner Stevenson L, Kirkpatrick JN, Goldstein NE. The State of the Science on Integrating Palliative Care in Heart Failure. J Palliat Med 2017; 20:592-603. [PMID: 29493362 DOI: 10.1089/jpm.2017.0178] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Heart failure (HF) is a chronic progressive illness associated with physical and psychological burdens, high morbidity, mortality, and healthcare utilization. Palliative care is interdisciplinary care that aims to relieve suffering and improve quality of life for persons with serious illness and their families. It is offered simultaneously with disease-oriented care, unlike hospice or end-of-life care. Despite the demonstrated benefits of palliative care in other populations, evidence for palliative care in the HF population is limited. OBJECTIVE The objective of this article is to describe the current evidence and the gaps in the evidence that will need to be improved to demonstrate the benefits of integrating palliative care into the care of patients with advanced HF and their family caregivers. METHODS We reviewed the literature to examine the state of the science and to identify gaps in palliative care integration for persons with HF and their families. We then convened an interdisciplinary working group at an NIH/NPCRC sponsored workshop to review the evidence base and develop a research agenda to address these gaps. RESULTS We identified four key research priorities to improve palliative care for patients with HF and their families: (1) to better understand patients' uncontrolled symptoms, (2) to better characterize and address the needs of the caregivers of advanced HF patients, (3) to improve patient and family understanding of HF disease trajectory and the importance of advance care planning, and (4) to determine the best models of palliative care, including models for those who want to continue life-prolonging therapies. CONCLUSIONS The goal of this research agenda is to motivate patient, provider, policy, and payor stakeholders, including funders, to identify the key research topics that have the potential to improve the quality of care for patients with HF and their families.
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Affiliation(s)
- Laura P Gelfman
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center , Bronx, New York
| | - Marie Bakitas
- 3 School of Nursing, University of Alabama at Birmingham , Birmingham, Alabama
| | - Lynne Warner Stevenson
- 4 Division of Cardiovascular Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - James N Kirkpatrick
- 5 Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center , Seattle, Washington
| | - Nathan E Goldstein
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center , Bronx, New York
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Psotka MA, McKee KY, Liu AY, Elia G, De Marco T. Palliative Care in Heart Failure: What Triggers Specialist Consultation? Prog Cardiovasc Dis 2017; 60:215-225. [PMID: 28483606 DOI: 10.1016/j.pcad.2017.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/03/2017] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) continues to cause substantial death and suffering despite the availability of numerous medical, surgical, and technological therapeutic advancements. As a patient-centered holistic discipline focused on improving quality of life and decreasing anguish, palliative care (PC) has a crucial role in the care of HF patients that has been acknowledged by multiple international guidelines. PC can be provided by all members of the HF care team, including but not limited to practitioners with specialty PC training. Unfortunately, despite recommendations to routinely include PC techniques and providers in the care of HF patients, use of general PC strategies as well as expert PC consultation is limited by a dearth of evidence-based interventions in the HF population and knowledge as to when to initiate these interventions, uncertainty regarding patient desires, prognosis, and the respective roles of each member of the care team, and a general shortage of specialist PC providers. This review seeks to provide guidance as to when to employ the limited resource of specialist PC practitioners, in combination with services from other members of the care team, to best tend to HF patients as their disease progresses and eventually overcomes.
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Affiliation(s)
- Mitchell A Psotka
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Kanako Y McKee
- Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Albert Y Liu
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Giovanni Elia
- Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco, San Francisco, CA.
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Sun A, Bui Q, Tsoh JY, Gildengorin G, Chan J, Cheng J, Lai K, McPhee S, Nguyen T. Efficacy of a Church-Based, Culturally Tailored Program to Promote Completion of Advance Directives Among Asian Americans. J Immigr Minor Health 2017; 19:381-391. [PMID: 27103618 PMCID: PMC5074907 DOI: 10.1007/s10903-016-0365-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Having an Advance Directive (AD) can help to guide medical decision-making. Asian Americans (AA) are less likely than White Americans to complete an AD. This pilot study investigated the feasibility and efficacy of a church-based intervention to increase knowledge and behavior change related to AD among Chinese and Vietnamese Americans. This study utilized a single group pre- and post-intervention design with 174 participants from 4 churches. Domain assessed: demographics; AD-related knowledge, beliefs, attitudes, and intentions; AD completion; and conversations with a healthcare proxy. Data were analyzed using Chi square and multiple logistic regression techniques. We observed significant increases in participants' AD-related knowledge, intentions, and a gain in supportive beliefs and attitudes about AD, resulting in 71.8 % AD completion, and 25.0 % having had a proxy conversation. Providing culturally-tailored intervention and step-by-step guidance can help to achieve significant changes in AD related knowledge and behavior in AA church goers.
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Affiliation(s)
- Angela Sun
- Chinese Community Health Resource Center, 728 Pacific Avenue Suite 115, San Francisco, CA, 94133, USA.
| | - Quynh Bui
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Janice Y Tsoh
- Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Ginny Gildengorin
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Joanne Chan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joyce Cheng
- Chinese Community Health Resource Center, 728 Pacific Avenue Suite 115, San Francisco, CA, 94133, USA
| | - Ky Lai
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Stephen McPhee
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Tung Nguyen
- Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
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Portanova J, Ailshire J, Perez C, Rahman A, Enguidanos S. Ethnic Differences in Advance Directive Completion and Care Preferences: What Has Changed in a Decade? J Am Geriatr Soc 2017; 65:1352-1357. [PMID: 28276051 DOI: 10.1111/jgs.14800] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Studies have documented ethnic differences in advance directive (AD) completion, with lower rates in minority groups. Of those with ADs, blacks are more likely than whites to prefer aggressive care, but little is known about how these differences in preferences have changed over time in ethnic groups. This nationally representative study aimed to investigate whether these differences in AD development persisted after adjusting for important confounding variables. Year of death was analyzed to see how AD completion changed over time within ethnic groups, and for those with an AD, the association between these factors and opting for aggressive care was investigated. Data from the 2000 to 2012 Health and Retirement Study (HRS) exit interviews from 7,177 decedents were used. Analyses included logistic regression to determine the relationship between ethnicity and AD completion and preferences for aggressive care and how it changed over time in ethnic groups. Forty-six percent of decedents had completed an AD (whites 51.7%, Hispanics 18.0%, blacks 15.0%). Of blacks completing an AD, 23.8% elected prolonged care, compared with 13.3% of Hispanics and 3.3% of whites. Logistic regression revealed that blacks 75% lower odds of completing an AD and Hispanics had 70% lower odds. Model covariates had a small influence on ethnic differences, although in examining the change in AD completion over time, the odds of having an AD increased with each subsequent death year for blacks and whites but not Hispanics. Additional research is needed to investigate the effect of cultural differences in AD completion rates of ethnic minority groups to ensure that preferences are honored in the clinical setting.
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Affiliation(s)
- Jaclyn Portanova
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Jennifer Ailshire
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Catherine Perez
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Anna Rahman
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
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Feely MA, Hildebrandt D, Edakkanambeth Varayil J, Mueller PS. Prevalence and Contents of Advance Directives of Patients with ESRD Receiving Dialysis. Clin J Am Soc Nephrol 2016; 11:2204-2209. [PMID: 27856490 PMCID: PMC5142080 DOI: 10.2215/cjn.12131115] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 07/26/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES ESRD requiring dialysis is associated with increased morbidity and mortality rates, including increased rates of cognitive impairment, compared with the general population. About one quarter of patients receiving dialysis choose to discontinue dialysis at the end of life. Advance directives are intended to give providers and surrogates instruction on managing medical decision making, including end of life situations. The prevalence of advance directives is low among patients receiving dialysis. Little is known about the contents of advance directives among these patients with advance directives. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We retrospectively reviewed the medical records of all patients receiving maintenance in-center hemodialysis at a tertiary academic medical center between January 1, 2007 and January 1, 2012. We collected demographic data, the prevalence of advance directives, and a content analysis of these advance directives. We specifically examined the advance directives for instructions on management of interventions at end of life, including dialysis. RESULTS Among 808 patients (mean age of 68.6 years old; men =61.2%), 49% had advance directives, of which only 10.6% mentioned dialysis and only 3% specifically addressed dialysis management at end of life. Patients who had advance directives were more likely to be older (74.5 versus 65.4 years old; P<0.001) and have died during the study period (64.4% versus 46.6%; P<0.001) than patients who did not have advance directives. Notably, for patients receiving dialysis who had advance directives, more of the advance directives addressed cardiopulmonary resuscitation (44.2%), mechanical ventilation (37.1%), artificial nutrition and hydration (34.3%), and pain management (43.4%) than dialysis (10.6%). CONCLUSIONS Although one-half of the patients receiving dialysis in our study had advance directives, end of life management of dialysis was rarely addressed. Future research should focus on improving discernment and documentation of end of life values, goals, and preferences, such as dialysis-specific advance directives, among these patients.
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Affiliation(s)
- Molly A. Feely
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | | | | | - Paul S. Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
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Spranzi M, Fournier V. The near-failure of advance directives: why they should not be abandoned altogether, but their role radically reconsidered. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:563-568. [PMID: 27151078 DOI: 10.1007/s11019-016-9704-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Advance directives (ADs) have been hailed for two decades as the best way to safeguard patients' autonomy when they are totally or partially incompetent. In many national contexts they are written into law and they are mostly associated with end-of-life decisions. Although advocates and critics of ADs exchange relevant empirical and theoretical arguments, the debate is inconclusive. We argue that this is so for good reasons: the ADs' project is fraught with tensions, and this is the reason why they are both important and deeply problematic. We outline six such tensions, and conclude with some positive suggestions about how to better promote patients' autonomy in end-of-life decision. We argue that ADs should continue to be an option but they cannot be the panacea that they are expected to be.
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Affiliation(s)
- Marta Spranzi
- University of Versailles-St-Quentin-en-Yvelines (UVSQ), Versailles, France
- Centre d'éthique clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Fournier
- Centre d'éthique clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Dharmarajan K, Hsieh A, Dreyer RP, Welsh J, Qin L, Krumholz HM. Relationship Between Age and Trajectories of Rehospitalization Risk in Older Adults. J Am Geriatr Soc 2016; 65:421-426. [PMID: 27874977 DOI: 10.1111/jgs.14583] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To characterize the magnitude and duration of risk of rehospitalization according to age after hospitalization for heart failure (HF), acute myocardial infarction (AMI), or pneumonia. DESIGN Retrospective cohort study. SETTING U.S. hospitals (n = 4,767). PARTICIPANTS All Medicare fee-for-service beneficiaries aged 65 and older surviving hospitalization for HF, AMI, or pneumonia between October 2012 and December 2013. MEASUREMENTS Daily risk of first rehospitalization for 1 year after hospital discharge was calculated according to age category (65-74, 75-84, ≥85) after adjustment for sex, race, comorbidities, and median ZIP code income. Time required for adjusted rehospitalization risk to decline 50% from maximum value after discharge, time required for adjusted risk to approach a plateau period of minimal day-to-day change, and degree to which adjusted risk was higher in recently hospitalized individuals than in the general elderly population were identified. RESULTS There were 414,720 hospitalizations for HF, 177,752 for AMI, and 568,304 for pneumonia. The adjusted risk of rehospitalization declined with increasing age after HF hospitalization (P < .001), rose with increasing age after AMI hospitalization (P < .001), and was slightly lower with increasing age after pneumonia hospitalization (P = .002). Adjusted risks of rehospitalization were high beyond 30 days after hospitalization for all ages. CONCLUSION Although older age has heterogeneous relationships with rehospitalization risk, risk of readmission remains high for an extended time after discharge regardless of age or admitting condition. Condition-specific data on risk can be used to guide discussions on advanced care planning and strategies for longitudinal follow-up after hospitalization.
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Affiliation(s)
- Kumar Dharmarajan
- Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Angela Hsieh
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Rachel P Dreyer
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Jack Welsh
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Health Policy and Administration, School of Public Health, Yale University, New Haven, Connecticut.,Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Patel MI, Bhattacharya J, Asch SM, Kahn J. Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer. Am J Hosp Palliat Care 2016; 33:742-7. [DOI: 10.1177/1049909115595216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer. Methods: We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral. Results: Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC. Discussion: We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jay Bhattacharya
- Health Policy & Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M. Asch
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
| | - James Kahn
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
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Nazir A, Smucker WD. Heart Failure in Post-Acute and Long-Term Care: Evidence and Strategies to Improve Transitions, Clinical Care, and Quality of Life. J Am Med Dir Assoc 2015; 16:825-31. [DOI: 10.1016/j.jamda.2015.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 12/12/2022]
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Medical decision making for older adults: an international perspective comparing the United States and India. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:329-34. [PMID: 26346983 PMCID: PMC4554781 DOI: 10.11909/j.issn.1671-5411.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 12/02/2022]
Abstract
There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutaneous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advantages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac disease with comparisons of West to East, focusing particularly on the United States versus India.
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How to discuss goals of care with patients. Trends Cardiovasc Med 2015; 26:36-43. [PMID: 25933831 DOI: 10.1016/j.tcm.2015.03.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/30/2015] [Accepted: 03/30/2015] [Indexed: 11/15/2022]
Abstract
Effective communication with patients and their caregivers continues to form the basis of a constructive clinician-patient relationship and is critical to provide patient-centered care. Engaging patients in meaningful, empathic communication not only fulfills an ethical imperative for our work as clinicians but also leads to increased patient satisfaction with their own care and improved clinical outcomes. While these same imperatives and benefits exist for discussing goals of care and end-of-life, communicating with patients about these topics can be particularly daunting. While clinicians receive extensive training on how to identify and treat illness, communication techniques, especially those centering around emotion-laden topics such as end-of-life care, receive short shrift medical education. Fortunately, communication techniques can be taught and learned through deliberate practice, and in this article, we seek to discuss a framework, drawn from published literature and our own experience, for approaching goals-of-care discussions in patients with cardiovascular disease.
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Dunlay SM, Foxen JL, Cole T, Feely MA, Loth AR, Strand JJ, Wagner JA, Swetz KM, Redfield MM. A survey of clinician attitudes and self-reported practices regarding end-of-life care in heart failure. Palliat Med 2015; 29:260-7. [PMID: 25488909 DOI: 10.1177/0269216314556565] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND As heart failure often follows an unpredictable clinical trajectory, there has been an impetus to promote iterative patient-provider discussions regarding prognosis and preferences for end-of-life care. AIM To examine clinicians' practices, expectations, and personal level of confidence in discussing goals of care and providing end-of-life care to their patients with heart failure. DESIGN Multi-site clinician survey. SETTING AND PARTICIPANTS Physicians, nurse practitioners, and physician assistants at Mayo Clinic (Rochester, Minnesota, USA) and its surrounding health system were asked to participate in an electronic survey in October 2013. Tertiary Care Cardiology, Community Cardiology, and Primary Care clinicians were surveyed. RESULTS A total of 95 clinicians participated (52.5% response rate). Only 12% of clinicians reported having annual end-of-life discussions as advocated by the American Heart Association. In total, 52% of clinicians hesitated to discuss end-of-life care citing provider discomfort (11%), perception of patient (21%) or family (12%) unreadiness, fear of destroying hope (9%), or lack of time (8%). Tertiary and Community Cardiology clinicians (66%) attributed responsibility for end-of-life discussions to the heart failure cardiologist, while 66% of Primary Care clinicians felt it was their responsibility. Overall, 30% of clinicians reported a low or very low level of confidence in one or more of the following: initiating prognosis or end-of-life discussions, enrolling patients in hospice, or providing end-of-life care. Most clinicians expressed interest in further skills acquisition. CONCLUSION Clinicians vary in their views and approaches to end-of-life discussions and care. Some lack confidence and most are interested in further skills acquisition.
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Affiliation(s)
- Shannon M Dunlay
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jilian L Foxen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terese Cole
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly A Feely
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ann R Loth
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob J Strand
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jean A Wagner
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Margaret M Redfield
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Butler J, Binney Z, Kalogeropoulos A, Owen M, Clevenger C, Gunter D, Georgiopoulou V, Quest T. Advance directives among hospitalized patients with heart failure. JACC-HEART FAILURE 2014; 3:112-21. [PMID: 25543976 DOI: 10.1016/j.jchf.2014.07.016] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/28/2014] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the frequency and correlates of documented advance directives (ADs) among patients hospitalized for heart failure (HF). BACKGROUND Discussing ADs with patients with HF is critical for identifying treatment goals consistent with patients' values and preferences and for facilitating health care team communication. METHODS We retrospectively identified electronic medical records of adult patients admitted to 2 large tertiary care hospitals with either the primary or secondary discharge diagnosis of HF from September 2008 to August 2013 to assess the presence of ADs in electronic medical records. We performed analyses including HF as either the primary or secondary admission diagnosis and HF as the primary admission diagnosis only. Multivariable models were constructed to investigate independent predictors of documented ADs. RESULTS Data included 44,768 admissions from 24,291 individual patients over 5 years. Mean age of patients at admission was 64.8 ± 15.9 years; 47.9% of these patients were female, 51.8% were black. The median length of stay for all admissions was 5 (3 to 10) days; 12.7% of patients had documented ADs. Older age, female sex, white race, higher socioeconomic status, higher risk for adverse in-hospital outcomes, length of stay ≥5 days, hospice discharge, palliative care consultation, and a do-not-resuscitate order were all associated with a significantly higher chance of having documented ADs. A significant increase in ADs over time was noted, but more than 80% of patients did not have ADs in medical records at the end of the study period. CONCLUSIONS In a diverse population of hospitalized patients with HF, most did not have a documented AD in the medical records. Although several factors were associated with a higher probability, major opportunities exist for all subgroups of patients with HF to improve documentation of ADs.
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Affiliation(s)
- Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York.
| | - Zachary Binney
- Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia
| | | | - Melissa Owen
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Carolyn Clevenger
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Debbie Gunter
- Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia
| | | | - Tammie Quest
- Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia; Atlanta Veterans Administration Medical Center, Department of Veterans Affairs, Atlanta, Georgia
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Barocas JA, Erlandson KM, Belzer BK, Hess T, Sosman J. Advance directives among people living with HIV: room for improvement. AIDS Care 2014; 27:370-7. [PMID: 25307722 DOI: 10.1080/09540121.2014.963019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
While HIV has become a largely chronic disease, age-associated comorbidities are prevalent in people living with HIV (PLWH). Therefore, PLWH are appropriate for advance care planning (ACP) and advance directives (ADs) completion. We sought to characterize AD completion among outpatient PLWH. We conducted a retrospective chart review of PLWH who receive their routine care at the University of Wisconsin HIV clinic. Data were extracted from the electronic health record. Variables were entered into a stepwise multivariate logistic regression model to assess which factors were independently associated with AD completion. Five hundred and eighty eight charts were reviewed. Eighty-one percent of subjects were male and 72% were white; mean age was 46.8 years. ADs were completed by 134 subjects and 6.7% of those were completed at the HIV clinic. In the final multivariate model, those who had completed an AD were more likely to be older than age 45; ever been diagnosed with AIDS; have cardiovascular disease, neurologic disorder, chronic kidney disease, or malignancy. In this study, a small percentage of patients had documented ADs, with only a small proportion completed in the HIV clinic. The HIV clinic is an underutilized resource to offer ACP. Interventions are needed to provide the necessary ACP resources for PLWH.
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Affiliation(s)
- Joshua A Barocas
- a Department of Medicine , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
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Ni P, Zhou J, Wang ZX, Nie R, Phillips J, Mao J. Advance directive and end-of-life care preferences among nursing home residents in Wuhan, China: a cross-sectional study. J Am Med Dir Assoc 2014; 15:751-6. [PMID: 25066002 DOI: 10.1016/j.jamda.2014.06.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/23/2014] [Accepted: 06/03/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe Chinese nursing home residents' knowledge of advance directive (AD) and end-of-life care preferences and to explore the predictors of their preference for AD. DESIGN Population-based cross-sectional survey. SETTINGS Nursing homes (n = 31) in Wuhan, Mainland Southern China. PARTICIPANTS Cognitively intact nursing home residents (n = 467) older than 60 years. MEASURES Face-to-face questionnaire interviews were used to collect information on demographics, chronic diseases, life-sustaining treatment, AD, and other end-of-life care preferences. RESULTS Most (95.3%) had never heard of AD, and fewer than one-third (31.5%) preferred to make an AD. More than half (52.5%) would receive life-sustaining treatment if they sustained a life-threatening condition. Fewer than one-half (43.3%) chose doctors as the surrogate decision maker about life-sustaining treatment, whereas most (78.8%) nominated their eldest son or daughter as their proxy. More than half (58.2%) wanted to live and die in their present nursing homes. The significant independent predictors of AD preference included having heard of AD before (odds ratio [OR] 9.323), having definite answers of receiving (OR 3.433) or rejecting (OR 2.530) life-sustaining treatment, and higher Cumulative Illness Rating Scale score (OR 1.098). CONCLUSIONS Most nursing home residents did not know about AD, and nearly one-third showed positive attitudes toward it. AD should be promoted in mainland China. Education of residents, the proxy decision maker, and nursing home staff on AD is very important. Necessary policy support, legislation, or practice guidelines about AD should be made with flexibility to respect nursing home residents' rights in mainland China.
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Affiliation(s)
- Ping Ni
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jing Zhou
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhao Xi Wang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rong Nie
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jane Phillips
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Park IK, Jun HJ, Park SJ, Lim GJ, Cho SJ, Song A, Oh SY. Differences in End-of-life Care Decision Making Between Patients With and Without Cancer. Am J Hosp Palliat Care 2014; 32:797-801. [DOI: 10.1177/1049909114542646] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Most patients and families do not want invasive life-sustaining procedures when recovery is unlikely. We compared the clinical features of advance directives (ADs) of patients with and without cancer. Methods: The ADs were obtained from retrospectively reviewing electronic medical records of 699 consecutive patients who died from April 2011 to July 2012. Results: Patients with cancer were more likely to have written ADs: 265 (85.8%) patients with cancer and 277 (71.0%) noncancer patients ( P < .001). Significantly more noncancer patients were in the intensive care unit, indicating that they had received or were receiving invasive treatments. Noncancer patients requested life-sustaining treatment more frequently but symptom control less frequently than patients with cancer. Conclusion: Advance care planning in patients with incurable, noncancer disease is important to guarantee patient autonomy at the end of life.
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Affiliation(s)
- In Ki Park
- Department of internal medicine, Seoul Medical Center, Seoul, Republic of Korea
| | - Hyun Jung Jun
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul Medical Center, Seoul, Republic of Korea
- Hospice & palliative care center, Seoul Medical Center, Seoul, Republic of Korea
| | - Sung Jae Park
- Department of internal medicine, Seoul Medical Center, Seoul, Republic of Korea
| | - Ga Jin Lim
- Department of internal medicine, Seoul Medical Center, Seoul, Republic of Korea
| | - Sung-Ja Cho
- Hospice & palliative care center, Seoul Medical Center, Seoul, Republic of Korea
| | - Aeran Song
- Hospice & palliative care center, Seoul Medical Center, Seoul, Republic of Korea
| | - So Yeon Oh
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul Medical Center, Seoul, Republic of Korea
- Hospice & palliative care center, Seoul Medical Center, Seoul, Republic of Korea
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