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Kaur P, George PP, Xian SNH, Yip WF, Seng ECS, Tay RY, Tan J, Chu J, Low ZJ, Tey LH, Hoon V, Tan CK, Tan L, Aw CH, Tan WS, Hum A. Risk Factors for All-Cause Mortality in Patients Diagnosed with Advanced Heart Failure: A Scoping Review. J Palliat Med 2024. [PMID: 39083426 DOI: 10.1089/jpm.2024.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
Introduction: Identifying the evolving needs of patients with advanced heart failure (AdHF) and triaging those at high risk of death can facilitate timely referrals to palliative care and advance patient-centered individualized care. There are limited models specific for patients with end-stage HF. We aim to identify risk factors associated with up to three-year all-cause mortality (ACM) and describe prognostic models developed or validated in AdHF populations. Methods: Frameworks proposed by Arksey, O'Malley, and Levac were adopted for this scoping review. We searched the Medline, EMBASE, PubMed, CINAHL, Cochrane library, Web of Science and gray literature databases for articles published between January 2010 and September 2020. Primary studies that included adults aged ≥ 18 years, diagnosed with AdHF defined as New York Heart Association class III/IV, American Heart Association/American College of Cardiology Stage D, end-stage HF, and assessed for risk factors associated with up to three-year ACM using multivariate analysis were included. Studies were appraised using the Quality of Prognostic Studies tool. Data were analyzed using a narrative synthesis approach. Results: We reviewed 167 risk factors that were associated with up to three-year ACM and prognostic models specific to AdHF patients across 65 articles with low-to-moderate bias. Studies were mostly based in Western and/or European cohorts (n = 60), in the acute care setting (n = 56), and derived from clinical trials (n = 40). Risk factors were grouped into six domains. Variables related to cardiovascular and overall health were frequently assessed. Ten prognostic models developed/validated on AdHF patients displayed acceptable model performance [area under the curve (AUC) range: 0.71-0.81]. Among the ten models, the model for end-stage-liver disease (MELD-XI) and acute decompensated HF with N-terminal pro b-type natriuretic peptide (ADHF/proBNP) model attained the highest discriminatory performance against short-term ACM (AUC: 0.81). Conclusions: To enable timely referrals to palliative care interventions, further research is required to develop or validate prognostic models that consider the evolving landscape of AdHF management.
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Affiliation(s)
- Palvinder Kaur
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Pradeep Paul George
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Sheryl Ng Hui Xian
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Wan Fen Yip
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Eric Chua Siang Seng
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Ri Yin Tay
- Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Joyce Tan
- Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Jermain Chu
- Department of Palliative Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Zhi Jun Low
- Department of Palliative Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Lee Hung Tey
- Department of Palliative Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Violet Hoon
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Chong Keat Tan
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Laurence Tan
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chia Hui Aw
- Palliative and Supportive Care, Woodlands Health Campus, 2 Yishun Central 2 Tower E, Singapore, Singapore
| | - Woan Shin Tan
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Allyn Hum
- Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Department of Palliative Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
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Sivanathan V, Smallwood N, Ong J, Wee E, Zentner D. Heart failure and the cost of dying: must the ferryman always be paid? Intern Med J 2024; 54:1077-1086. [PMID: 38351669 DOI: 10.1111/imj.16338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/02/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Provision of palliative care in chronic heart failure (CHF) can support complex decision-making, significantly improve quality of life and may lower healthcare costs. AIMS To examine whether healthcare costs differed in terminal admissions according to the adoption of a palliative approach. DESIGN Retrospective review of medical records and costing data for all admissions resulting in death from CHF (July 2011 to December 2019), analysed as two groups (2011-2016 and 2016-2019) because of background changes in costings. SETTING Admissions with CHF resulting in death in an Australian tertiary referral centre. RESULTS The cohort (n = 439) were elderly (median age 83.7 years, interquartile range (IQR) = 77.6-88.7 years) and mostly men (54.9%). Half (230, 52.4%) were referred to a specialist palliative care team, whereas over a third (172, 39.2%) received a palliative approach. Receiving a palliative approach was associated with a nonstatistically significant lower admission cost (AU$12 710 vs AU$15 978; P = 0.19) between 2011 and 2016 (n = 101, 38.8%) and a significantly lower cost (AU$11 319 vs AU$15 978; P < 0.01) between 2016 and 2019 (n = 71, 39.7%). Intensive care admission resulted in the single greatest additional cost at AU$14 624 (IQR = AU$4130-AU$44 197) (n = 48, 2011-2016). Median terminal admission cost was lower for patients with comfort goals of care (P < 0.01), without life-sustaining interventions (P < 0.01) or who received a palliative approach (P < 0.01). Referral to inpatient specialist palliative care or receiving a palliative approach resulted in comparable admission costings (AU$11 621 [IQR = AU$4705-AU$32 457] and AU$11 466 [IQR = AU$4973-AU$25 614]). CONCLUSION A palliative approach in terminal CHF admission may improve quality at the end of life and decrease costs associated with care.
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Affiliation(s)
| | - Natasha Smallwood
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical School, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Ong
- Clinical Costing, Health Intelligence, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Elin Wee
- Clinical Costing, Health Intelligence, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dominica Zentner
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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3
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Quattrone F, Aimo A, Zuccarino S, Morelli MS, Morfino P, Gioia A, Passino C, Ferrè F, Nuti S, Emdin M. Unmet needs in end-of-life care for heart failure patients. Int J Cardiol 2024; 399:131750. [PMID: 38216064 DOI: 10.1016/j.ijcard.2024.131750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVE To investigate end-of-life (EoL) care for heart failure (HF) in Tuscany (Italy) from healthcare professionals' perspective and identify areas for intervention. METHODS All the directors of Cardiology units (n = 29) and palliative care (PC) units (n = 14) in Tuscany were surveyed on the practices of EoL care. RESULTS Forty-five percent of cardiologists reported that their hospital had some EoL care services for HF patients. However, 75% did not have a multidisciplinary team providing EoL care for HF patients. Sixty-four percent stated that <25% of patients who might benefit from PC did receive it, and 18% stated that no patient received PC. For most of PC specialists, HF patients accounted for <25% of their patients. PC specialists believed that patients with cancer diseases were much more likely to receive PC than HF patients at EoL, and 36% judged that almost no HF patients were timely referred to hospice care. The majority of PC specialists reported that almost no HF patient prepared advance healthcare directives, as opposite to 57% for cancer patients, suggesting poor understanding or acceptance of their terminal condition. CONCLUSIONS The management of HF patients in the EoL stage in Tuscany is often suboptimal. EoL care should be implemented to ensure an adequate quality of life to these patients.
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Affiliation(s)
- Filippo Quattrone
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Sara Zuccarino
- Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria Sole Morelli
- Bioinformatica Traslazionale e e-Health, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Angela Gioia
- Hospice, UF Cure Palliative, Azienda USL Toscana Nord Ovest, Pisa, Italy
| | - Claudio Passino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Francesca Ferrè
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sabina Nuti
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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McClung JA, Frishman WH, Aronow WS. The Role of Palliative Care in Cardiovascular Disease. Cardiol Rev 2024:00045415-990000000-00182. [PMID: 38169299 DOI: 10.1097/crd.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.
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Affiliation(s)
- John Arthur McClung
- From the Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
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5
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McConnell T, Blair C, Burden J, Duddy C, Hill L, Howie C, Jones B, Ruane B, Wong G, Reid J. Integrating palliative care and heart failure: a systematic realist synthesis (PalliatHeartSynthesis). Open Heart 2023; 10:e002438. [PMID: 38097362 PMCID: PMC10729146 DOI: 10.1136/openhrt-2023-002438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/10/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES (1) Develop a programme theory of why, for whom and in what contexts integrated palliative care (PC) and heart failure (HF) services work/do not work; (2) use the programme theory to co-produce with stakeholders, intervention strategies to inform best practice and future research. METHODS A systematic review of all published articles and grey literature using a realist logic of analysis. The search strategy combined terms significant to the review questions: HF, PC and end of life. Documents were included if they were in English and provided data relevant to integration of PC and HF services. Searches were conducted in November 2021 in EMBASE, MEDLINE, PsycINFO, AMED, HMIC and CINAHL. Further relevant documents were identified via monthly alerts (up until April 2023) and the project stakeholder group (patient/carers, content experts and multidisciplinary practitioners). RESULTS 130 documents were included (86 research, 22 literature reviews, 22 grey literature). The programme theory identified intervention strategies most likely to support integration of PC and HF services. These included protected time for evidence-based PC and HF education from undergraduate/postgraduate level and continuing professional practice; choice of educational setting (eg, online, face-to-face or hybrid); increased awareness and seeing benefits of PC for HF management; conveying the emotive and intellectual need for integrating PC and HF via credible champions; and prioritising PC and HF guidelines in practice. CONCLUSIONS The review findings outline the required steps to take to increase the likelihood that all key players have the capacity, opportunity and motivation to integrate PC into HF management. PROSPERO REGISTRATION NUMBER CRD42021240185.
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Affiliation(s)
- Tracey McConnell
- School of Nursing and Midwifery, Queen's University Belfast Faculty of Medicine, Health and Life Sciences, Belfast, UK
| | - Carolyn Blair
- School of Nursing and Midwifery, Queen's University Belfast Faculty of Medicine, Health and Life Sciences, Belfast, UK
| | - John Burden
- Patient and Public Involvement Network members, British Heart Foundation, London, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast Faculty of Medicine, Health and Life Sciences, Belfast, UK
| | - Clare Howie
- School of Nursing and Midwifery, Queen's University Belfast Faculty of Medicine, Health and Life Sciences, Belfast, UK
| | - Bob Jones
- Patient and Public Involvement Network members, British Heart Foundation, London, UK
| | - Bob Ruane
- Patient and Public Involvement Network members, British Heart Foundation, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast Faculty of Medicine, Health and Life Sciences, Belfast, UK
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6
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Akbarian-Rokni M, Mardani-Hamooleh M, Abbasi M, Seyedfatemi N, Pezaro S. Nurses' perceptions of the challenges involved in providing of end-of-life care to people with heart failure: a context-based study. BMC Palliat Care 2023; 22:180. [PMID: 37968669 PMCID: PMC10648333 DOI: 10.1186/s12904-023-01305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND High quality end-of-life care is essential. Yet for those experiencing heart failure, the provision of high-quality end- of -life care can be challenging. The aim of this study was to explore Iranian nurses' perceptions of the challenges involved in providing of end-of-life care to people with heart failure. METHODS Conventional content analysis was used to analyze qualitative data collected from nurses (n = 33) using semi-structured and individual interviews. Participants were aged between 29 and 51 years. The majority of participants were women (n = 20). Most had a bachelor's degree (n = 24), and work experience of between 7 and 18 years. RESULTS Nurses challenges in providing end-of-life care to those with heart failure included (1) adverse consequences relating to compassion fatigue and continued futility in care and (2) lack of palliative care services with regards to a lack of specialists, lack of support from health systems, and poor teamwork. CONCLUSIONS This is the first qualitative study to explore Iranian nurses' challenges in providing end-of-life care to those with heart failure. Investment is required in education and research in this area. Particular attention must be paid to prevention of compassion fatigue. Law changes would enable the delivery of higher-quality palliative care in this context overall.
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Affiliation(s)
- Mostafa Akbarian-Rokni
- Department of Nursing, Nursing and Midwifery Care Research Centre, Iran University of Medical Sciences, Zafar St, Tehran, 1996713883, Iran
| | - Marjan Mardani-Hamooleh
- Department of Nursing, Nursing and Midwifery Care Research Centre, Iran University of Medical Sciences, Zafar St, Tehran, 1996713883, Iran.
| | - Mohammad Abbasi
- Department of Nursing, Nursing and Midwifery Care Research Centre, Iran University of Medical Sciences, Zafar St, Tehran, 1996713883, Iran
| | - Naima Seyedfatemi
- Department of Nursing, Nursing and Midwifery Care Research Centre, Iran University of Medical Sciences, Zafar St, Tehran, 1996713883, Iran
| | - Sally Pezaro
- Research Centre for Healthcare and Communities' at Coventry University, Coventry University, Coventry, UK
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7
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Thandra A, Balakrishna AM, Walters RW, Alugubelli N, Koripalli VS, Alla VM. Trends in and predictors of multiple readmissions following heart failure hospitalization: A National wide analysis from the United States. Am J Med Sci 2023; 365:145-151. [PMID: 36152813 DOI: 10.1016/j.amjms.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 05/23/2022] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Readmission following Heart failure (HF) hospitalization is common: 25% are readmitted within a month of discharge and ≈50% within 6 months. A small proportion of these patients can have multiple readmissions within this period, adding disproportionately to the health care costs. In this study, we assessed the trends, predictors and costs associated with multiple readmissions using National readmissions database (NRD). METHODS We queried NRD for HF hospitalizations from 2010 to 2018 using ICD-9/10-CM codes. Multinomial logistic regression was used to compare readmission cohorts, with the multivariable model adjusting for other factors. All analyses accounted for the NRD sampling design were conducted using SAS v. 9.4 with p < 0.05 used to indicate statistical significance. RESULTS Within the study period, an estimated 6,763,201 HF hospitalizations were identified. Of these, 58% had no readmission; 26% had 1 readmission; and 16% had ≥2 readmissions within 90 days of index hospitalization. There was no statistically significant change in readmission rates during the observation period. Multiple readmissions which accounted for 37% of all readmissions contributed to 57% of readmission costs. Younger age was identified as a predictor of multiple readmissions while sex, comorbidities and the type of insurance were not significantly different from those with single readmission. CONCLUSIONS Multiple readmissions in HF are common (16%), have remained unchanged between 2010 and 2018 and impose a significant health care cost burden. Future research should focus on identifying these patients for targeted intervention that may minimize excessive readmissions particularly in those patients who are in the palliation phase of HF.
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Affiliation(s)
- Abhishek Thandra
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States.
| | | | - Ryan W Walters
- Department of Medicine, Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, United States
| | - Navya Alugubelli
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States
| | | | - Venkata M Alla
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States
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8
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Yang J, Kim HJ, Heo S, An M, Park S, Ounpraseuth S, Kim J. Factors associated with attitudes toward advance directives in nurses and comparisons of the levels between emergency nurses and palliative care nurses. Jpn J Nurs Sci 2023; 20:e12508. [PMID: 36054594 DOI: 10.1111/jjns.12508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 01/05/2023]
Abstract
AIM Little is known about attitudes toward advance directives and factors associated with them among emergency and palliative care nurses who often or daily face end-of-life circumstances. Thus, we aimed to compare the levels of attitudes toward advance directives, communication skills, knowledge about end-of-life care (knowledge), and awareness of the concept of a good death (good death awareness) between emergency and palliative care nurses, and to examine factors associated with attitudes toward advance directives in the total sample. METHODS In this cross-sectional, correlational study, data were collected from 153 nurses (59 emergency and 94 palliative care nurses) at three tertiary hospitals using online or offline surveys and were analyzed using t-tests and multiple linear regression analysis. RESULTS The levels of attitudes, communication skills, knowledge, and good death awareness were moderate in both groups. Attitudes in emergency compared to palliative care nurses were less positive (46.78 vs. 48.38; p = .044), and knowledge was significantly lower (13.64 vs. 15.00; p = .004). Communication skills and good death awareness between the two groups were similar. In the total sample, emergency practice (B = -1.59, p = .024), and lower levels of good death awareness (B = 0.30, p < .001), communication skills (B = 0.18, p = .001), and education (B = -2.84, p = .015) were associated with less positive attitudes (F = 9.52, p < .001; R2 = 0.35). CONCLUSIONS The findings demonstrate the need for improvements in attitudes, knowledge, communication skills, and good death awareness in both groups, especially emergency nurses. Two modifiable targets of interventions to improve nurses' attitudes were also noted.
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Affiliation(s)
- Jisun Yang
- Gachon University, College of Nursing, Incheon, South Korea
| | - Hee Jung Kim
- Gachon University, College of Nursing, Incheon, South Korea
| | - Seongkum Heo
- Mercer University, Georgia Baptist College of Nursing 3001 Mercer University Drive, Atlanta, Georgia, USA
| | - Minjeong An
- College of Nursing, Chonnam National University, Gwangju, South Korea
| | - SeongHu Park
- College of Nursing Sciences, Sungshin Women's University, Seoul, South Korea
| | - Songthip Ounpraseuth
- University of Arkansas for Medical Sciences, College of Public Health, Little Rock, Arkansas, USA
| | - JinShil Kim
- Gachon University, College of Nursing, Incheon, South Korea
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9
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Graham C, Schonnop R, Killackey T, Kavalieratos D, Bush SH, Steinberg L, Mak S, Quinn K, Isenberg SR. Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study. J Am Heart Assoc 2022; 11:e024628. [PMID: 35730640 PMCID: PMC9333360 DOI: 10.1161/jaha.121.024628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home-based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home. Methods and Results We conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi-structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on-going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours). Conclusions Our results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.
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Affiliation(s)
- Cassandra Graham
- Division of Palliative Medicine, Department of Medicine University of Toronto Toronto Canada.,Division of Palliative Care University Health Network Toronto Canada
| | - Rebecca Schonnop
- Department of Emergency Medicine University of Alberta Edmonton Canada.,Department of Emergency Medicine Royal Alexandra Hospital Edmonton Canada
| | - Tieghan Killackey
- Child Health Evaluative Sciences The Hospital for Sick Children Toronto Canada
| | - Dio Kavalieratos
- Division of Palliative Medicine Emory University Atlanta Georgia
| | - Shirley H Bush
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Canada.,Bruyere Continuing Care Ottawa Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada.,Division of Palliative Care SinaiHealth Toronto Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine University of Toronto Toronto Canada.,Division of Cardiology Department of Medicine SinaiHealth Toronto Canada
| | - Kieran Quinn
- Department of Medicine University of Toronto Toronto Canada.,ICES Toronto and Ottawa Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada.,Department of Medicine SinaiHealth Toronto Canada
| | - Sarina R Isenberg
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada
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10
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Wolfe A, Watt CL, Downar J, Bush SH. Use and Discontinuation of Milrinone for Advanced Heart Failure in an Academic Palliative Care Unit: A Case Report and Discussion of Recommendations. J Pain Palliat Care Pharmacother 2022; 36:24-33. [PMID: 35234559 DOI: 10.1080/15360288.2022.2027058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The use of intravenous inotropic medications in advanced heart failure (HF) has been shown to improve symptoms and decrease hospitalizations, prompting support for their use as a palliative measure for symptom management. Recommendations regarding inotrope management and method of discontinuation at the end of life are not specifically detailed in the literature and current guidelines. This case report describes the use of milrinone in a patient with advanced HF during the terminal phase of illness in a non-monitored palliative care unit setting, including dose reduction and discontinuation of milrinone. Increased patient anxiety during the weaning process was managed with midazolam. The provision of individualized milrinone therapy in non-monitored palliative care settings is feasible and well-tolerated using the presented detailed recommendations for its use and administration, monitoring, dose reduction and discontinuation and proactive symptom management at the end of life. Further research is needed for the optimal management of terminally ill patients with advanced HF.Supplemental data for this article is available online at here. show.
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End-of-Life Case Study: The Use of Narrative Therapy on a Holocaust Survivor with Lifelong Depression. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2022. [DOI: 10.1007/s10879-022-09532-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Hutchinson RN, Han PKJ, Lucas FL, Black A, Sawyer D, Fairfield K. Rural disparities in end-of-life care for patients with heart failure: Are they due to geography or socioeconomic disparity? J Rural Health 2021; 38:457-463. [PMID: 34043838 DOI: 10.1111/jrh.12597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The impact of rurality and socioeconomic deprivation on end-of-life (EOL) care for patients with heart failure (HF) is unknown. We analyzed claims to describe the prevalence and predictors of EOL health care utilization for patients dying with HF in a predominantly rural state. METHODS We used the MaineHealth Data Organization's All-Payer Claims Data to identify 15,168 patients ≥35 who died with HF between 2012 and 2017. The primary outcome was health care utilization during the last 180 days of life (EOL definition for this analysis), including emergency department (ED) visits, hospitalizations, intensive care unit (ICU) admissions, and hospice utilization. Patient characteristics analyzed included age, gender, comorbidities, area deprivation index (ADI), and rurality. FINDINGS Among 15,168 patients ≥35 who died with HF, 48% had ≥2 hospitalizations, 72% had ≥2 ED visit, 29% had an ICU stay, 2% initiated dialysis during EOL, and 64% received hospice. Rural patients were more likely to have an ICU admission and have ≥2 hospitalizations. Patients residing in areas with higher ADI were more likely to be hospitalized, admitted to the ICU, and started on dialysis. Both rural patients and those living in higher ADI areas were less likely to receive hospice. After multivariable adjustment, rurality and ADI were independently associated with a decreased likelihood of receiving hospice (OR 0.62 [95% CI: 0.53-0.72] for the most rural patients and OR 0.64 [95% CI: 0.57-0.72] for the highest ADI). CONCLUSION Both rurality and local area deprivation drive disparities in EOL care for patients dying with heart failure.
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Affiliation(s)
- Rebecca N Hutchinson
- Division of Palliative Medicine, Maine Medical Center, Portland, Maine, USA.,Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine, USA
| | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine, USA
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine, USA
| | - Adam Black
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine, USA
| | - Douglas Sawyer
- Division of Academic Affairs, Maine Medical Center, Portland, Maine, USA
| | - Kathleen Fairfield
- Department of Internal Medicine, Maine Medical Center, Portland, Maine, USA
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Hutchinson RN, Gutheil C, Wessler BS, Prevatt H, Sawyer DB, Han PKJ. What is Quality End-of-Life Care for Patients With Heart Failure? A Qualitative Study With Physicians. J Am Heart Assoc 2020; 9:e016505. [PMID: 32862771 PMCID: PMC7727006 DOI: 10.1161/jaha.120.016505] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Advanced heart failure (AHF) carries a morbidity and mortality that are similar or worse than many advanced cancers. Despite this, there are no accepted quality metrics for end‐of‐life (EOL) care for patients with AHF. Methods and Results As a first step toward identifying quality measures, we performed a qualitative study with 23 physicians who care for patients with AHF. Individual, in‐depth, semistructured interviews explored physicians' perceptions of characteristics of high‐quality EOL care and the barriers encountered. Interviews were analyzed using software‐assisted line‐by‐line coding in order to identify emergent themes. Although some elements and barriers of high‐quality EOL care for AHF were similar to those described for other diseases, we identified several unique features. We found a competing desire to avoid overly aggressive care at EOL alongside a need to ensure that life‐prolonging interventions were exhausted. We also identified several barriers related to identifying EOL including greater prognostic uncertainty, inadequate recognition of AHF as a terminal disease and dependence of symptom control on disease‐modifying therapies. Conclusions Our findings support quality metrics that prioritize receipt of goal‐concordant care over utilization measures as well as a need for more inclusive payment models that appropriately reflect the dual nature of many AHF therapies.
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Affiliation(s)
- Rebecca N. Hutchinson
- Division of Palliative MedicineMaine Medical CenterPortlandME
- Center for Outcomes Research and EvaluationMaine Medical CenterPortlandME
| | - Caitlin Gutheil
- Center for Outcomes Research and EvaluationMaine Medical CenterPortlandME
| | | | - Hayley Prevatt
- Center for Outcomes Research and EvaluationMaine Medical CenterPortlandME
| | | | - Paul K. J. Han
- Center for Outcomes Research and EvaluationMaine Medical CenterPortlandME
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