Integrating Palliative Care and Heart Failure: the PalliatHeartSynthesis realist synthesis

Background

Cardiovascular disease is the most common cause of death worldwide, highlighting the need for studies to determine options for palliative care within the management of patients with heart failure. Although there are promising examples of integrated palliative care and heart failure interventions, there is heterogeneity in terms of countries, healthcare settings, multidisciplinary team delivery, modes of delivery and intervention components. Hence, this review is vital to identify what works, for whom and in what circumstances when integrating palliative care and heart failure.

Objectives

To (1) develop a programme theory of why, for whom and in what contexts desired outcomes occur; and (2) use the programme theory to co-produce with stakeholders key implications to inform best practice and future research.

Design

A realist review of the literature underpinned by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Searches of bibliographic databases were conducted in November 2021 using the following databases: EMBASE, MEDLINE, PsycInfo, AMED, HMIC and CINAHL. Further relevant documents were identified via alerts and the stakeholder group.

Review methods

Realist review is a theory-orientated and explanatory approach to the synthesis of evidence. A realist synthesis was used to synthesise the evidence as successful implementation of integrated palliative care and heart failure depends on the context and people involved. The realist synthesis followed Pawson's five iterative stages: (1) locating existing theories; (2) searching for evidence; (3) document selection; (4) extracting and organising data; and (5) synthesising the evidence and drawing conclusions. We recruited an international stakeholder group (n = 32), including National Health Service management, healthcare professionals involved in the delivery of palliative care and heart failure, policy and community groups, plus members of the public and patients, to advise and give us feedback throughout the project, along with Health Education England to disseminate findings.

Results

In total, 1768 documents were identified, of which 1076 met the inclusion criteria. This was narrowed down to 130 included documents based on the programme theory and discussions with stakeholders. Our realist analysis developed and refined 6 overarching context-mechanism-outcome configurations and 30 sub context-mechanism-outcome configurations. The realist synthesis of the literature and stakeholder feedback helped uncover key intervention strategies most likely to support integration of palliative care into heart failure management. These included protected time for evidence-based palliative care education and choice of educational setting (e.g. online, face to face or hybrid), and the importance of increased awareness of the benefits of palliative care as key intervention strategies, the emotive and intellectual need for integrating palliative care and heart failure via credible champions, seeing direct patient benefit, and prioritising palliative care and heart failure guidelines in practice. The implications of our findings are further outlined in the capability, opportunity, motivation, behaviour model.

Limitations

The realist approach to analysis means that findings are based on our interpretation of the data.

Future work

Future work should use the implications to initiate and optimise palliative care in heart failure management.

Conclusion

Ongoing refinement of the programme theory at each stakeholder meeting allowed us to co-produce implications. These implications outline the required steps to ensure the core components and determinants of behaviour are in place so that all key players have the capacity, opportunity and motivation to integrate palliative care into heart failure management.

Study registration

This study is registered as PROSPERO CRD42021240185.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131800) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 34. See the NIHR Funding and Awards website for further award information.

Integrating palliative care and heart failure: a systematic realist synthesis (PalliatHeartSynthesis)

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.

Ethnographic closeness: methodological reflections on the interplay of engagement and detachment in immersive ethnographic research

With the reflexive turn in the social sciences, emotional engagement is an inevitable and crucial part of data-gathering and analysis. However, there is a glaring gap in methodological discussions to this end. Presenting ethnographic research into end of life with people living at home in England with heart failure, we argue for a methodological blend of engagement and detachment that shifts throughout the research process, and that sensory experience is a core part of engagement. We offer ethnographic examples which present and explore some alternatives to emotional engagement and objective detachment: (1) moving with participants to facilitate engagement during fieldwork through shared sensory experience; (2) detachment as a different way of relating when exiting the field and drawing participant relationships to a close; and (3) ethnographic closeness as the interplay of engagement and detachment in participant debriefing and data analysis. Based on well-established anthropological concepts, and taking both engagement and detachment as embodied and relational, we develop a notion of ethnographic closeness in which detachment is a necessary part. Our detailed methodological discussion thus offers theoretically grounded possibilities and alternatives for approaching and managing the core tension of 'how close is too close?' in ethnographic practice. Further contributions supporting researchers in navigating ethnographic research are needed.

Comprehensive end-of-life care practices for older patients with heart failure provided by specialized nurses: a qualitative study

BACKGROUND

The context of end-of-life care for older heart failure patients with a complex clinical course provided by certified nurse specialists in gerontology (GCNSs) and Certified nurses in chronic heart failure (CNCHFs) is unclear; therefore, this study aims to describe comprehensive nursing practice for older patients with heart failure at their end of life.

METHODS

This study adopts a qualitative descriptive design using content analysis. Five GCNSs, and five CNCHFs were interviewed using a web app from January to March 2022.

RESULTS

Thirteen categories of nursing practices for older patients with heart failure were generated: (1) Provide thorough acute care by a multidisciplinary team to alleviate dyspnea, (2) Assess psychiatric symptoms and use a suitable environment to perform treatment, (3) Explain the progression of heart failure with the doctor, (4) Build a trusting relationship with the patient and family and implement advance care planning (ACP) early during the patient's recovery, (5) Involve multiple professions to help patients to achieve their desired life, (6) Perform ACP always in collaboration with multiple professionals, (7) Provide lifestyle guidance according to patients' feelings so that they can continue living at home after discharge from the hospital, (8) Provide palliative and acute care in parallel with multiple professions, (9) Achieve end-of-life care at home through multidisciplinary cooperation, (10) Provide basic nursing care to the patient and family until the moment of death, (11) Provide concurrent acute and palliative care as well as psychological support to alleviate physical and mental symptoms, (12) Share the patient's prognosis and future wishes with multiple professionals, and (13) Engage in ACP from early stages, through several conversations with patients and their families.

CONCLUSIONS

Specialized nurses provide acute care, palliative care, and psychological support to alleviate physical and mental symptoms throughout the different stages of chronic heart failure. In addition to nursing care by specialized nurses at each stage shown in this study, it is important to initiate ACP early in the end-of-life stage and to provide care for patients with multiple professionals.

Health and social care services for people with dementia at home at the end of life: A qualitative study of bereaved informal caregivers' experiences

BACKGROUND

More people are dying at home with dementia and Alzheimer's disease. While informal caregivers are the main providers of care for people with dementia dying at home, they require support from health and social care services. However, little is known about how they experience these services.

AIM

To explore informal caregivers' views and experiences of health and social care services when looking after a person with dementia at home at the end-of-life.

DESIGN

A qualitative interview study. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS

Twenty-nine bereaved informal caregivers who had looked after a person with dementia at home during the last 6 months of life.

RESULTS

Specialist palliative care for people with dementia dying at home is rare and care is mostly managed by General Practitioners and domiciliary care workers. Four overarching themes were identified: Poor continuity of care; Lack of expertise; Limited advance care planning; and Loss of autonomy.

CONCLUSIONS

End-of-life care at home for people with dementia must be proactively planned with an emphasis on advance care planning. Policy makers should recognise the critical role of domiciliary care services in end-of-life care and ensure that they are adequately qualified and trained.

Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden

BACKGROUND

The Serious Illness Care Program (SICP) is a model developed for structured communication, identifying patients, and training physicians to use a structured guide for conversations with patients and family members. However, there is a lack of knowledge regarding the sustainable implementation of this conversation model. Therefore, the aim of this study was to identify barriers and enablers during the implementation of the SICP in hospital settings.

METHODS

The SICP was implemented at 20 units in two hospitals in Sweden. During the implementation process, seven individual interviews and two group interviews were conducted with seven facilitators (five physicians, one behavioral therapist, and one administrator). Data were analyzed using qualitative content analysis, first inductively, and then deductively using the organizational readiness for change as a theoretical framework.

RESULT

The analysis resulted in three factors acting as enablers and eight factors acting as enablers and/or barriers during the implementation of the SICP. The three factors considered as enablers were preliminaries, identifying patients, and facilitator's role. The eight factors considered as enablers and/or barriers were broad implementation, leadership, time, confidence, building foundation, motivation to work change, motivation for training in serious illness conversations, and attitudes.

CONCLUSION

This study indicates limited readiness to implement the SICP in hospital settings due to considerable variation in organizational contextual factors, change efficacy, and change commitment. The identified enablers and barriers for implementation of the SICP could guide and support future implementations to be sustainable over time.

Communication about Prognosis and End-of-Life in Heart Failure Care and Experiences Using a Heart Failure Question Prompt List

BACKGROUND

To further advance the use of a heart-failure-specific question prompt list (HF-QPL) for communication about prognosis and end-of-life care, knowledge about such communication and the perceptions and experiences of professionals is needed.

OBJECTIVES

1. to describe health care professionals' perceptions of communication about prognosis and end-of-life in heart failure (HF) care, and 2. to describe their experiences of using a HF-QPL.

DESIGN

A qualitative design that analyzed material from written assignments of nurses and physicians who were using a HF-QPL while participating in a communication course.

METHODS

Fifteen health care professionals from different regions in the south of Sweden were included. The data were collected from course assignments on 1. their reflection on the suitable timepoint for talking about prognosis for the first time, 2. their reflection on the HF-QPL, and 3. their experiences of using the HF-QPL in clinical practice. Data were analyzed using thematic analysis.

RESULTS

Five overarching themes were identified. The first theme was awareness of professional role responsibilities that described the recognition of different responsibilities in these conversations within the HF team. The second theme described the importance of being optimally prepared, and the third that confidence and skills are required to use the HF-QPL. The fourth theme described the HF-QPL as a bridge in the communication between professionals, patients, and family members. The fifth theme identified challenges using the HF-QPL in HF care.

CONCLUSIONS

Using a HF-QPL in HF care has the potential to start conversation and facilitate discussion about the HF trajectory.

Attitudes and practices towards palliative care in chronic heart failure: a survey of cardiovascular nurses and physicians

BACKGROUND

Heart failure is a chronic condition with various implications for individuals and families. Although the importance of implementing palliative care is recommended in best practice guidelines, implementation strategies are less clear.

AIMS

This study sought to; (1) determine Australian and New Zealand cardiovascular nurses and physicians' end of life care attitudes and specialist palliative care referral in heart failure and; (2) determine self-reported delivery of supportive care and attitudes towards service names.

METHODS

An electronic survey was emailed to members of four peak bodies and professional networks. Participants were also recruited through social media. Paper-based versions of the survey were completed by attendees of the 66th Cardiac Society of Australia and New Zealand Annual Scientific Meeting, August 2018.

FINDINGS

There were 113 completed responses included in the analyses. Participants were nurses (n = 75), physicians (n = 32) and allied health professionals (n = 4). Most (67%) reported they were comfortable with providing end of life care; however, fewer respondents agreed they received support for their dying patients and one-third experienced a sense of failure when heart failure progressed. Most (84-100%) participants agreed they would refer a heart failure patient later in the illness trajectory. There was a more favourable attitude towards the service name 'supportive care' than to 'palliative care'.

CONCLUSION

Comfort with end of life discussions is encouraging as it may lead to a greater likelihood of planning future care and identifying palliative care needs. Peer support and supervision may be useful for addressing feelings of failure. The use of needs-based assessment tools, adopting the service name 'supportive care' and further research focusing on primary palliative team-based approach is required to improve palliative care access.

IMPACT STATEMENT

Cardiovascular nurses and physicians are comfortable providing end of life care, but referrals to palliative care in the later stages of heart failure persists.

Implantable cardioverter defibrillator devices: when, how and who should discuss deactivation with patients: a systematic literature review

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are used to treat life-threatening cardiac arrhythmias and prevent sudden cardiac arrest. As recipients age they may develop greater risk of dying as a result of progressive multimorbidity rather than sudden cardiac death. Defibrillation shocks may prolong an uncomfortable dying process. Deactivation of the defibrillator would prevent this, yet is not always discussed and planned.

AIM

To systematically review published evidence on ICD deactivation discussions and make recommendations on when, how and who should facilitate effective and patient-centred deactivation discussions.

METHODS

Using standard systematic review methods, MEDLINE, EMBASE, CINAHL and PsycInfo were searched for studies published in the English language between 2010 and March 2021. Inclusion criteria were studies of adults (≥18 years) and including discussions on ICD deactivation and/or related communication. Included studies were independently reviewed, data extracted, quality assessed and data synthesised using a deductive approach.

RESULTS

Of the 8893 articles identified, 22 papers met the inclusion criteria. Deductive approach led to identification of five main themes: (1) timing of ICD deactivation discussions, (2) initiation of deactivation discussions, (3) advance directives, (4) barriers to discussions and (5) facilitators of discussions.

CONCLUSIONS

Despite available guidelines, conversations on device deactivation are not being undertaken consistently. Evidence suggests lack of professional awareness of guidelines and limited training in communication skills. To prevent distress and promote comfortable dying, there needs to be a proactive clinical and policy initiative in the education of both professionals and patients and their relatives about device deactivation.

Realization and personalization by facing fatality: A grounded theory of developing the view of dying in people with heart failure

AIM

To explore how people with heart failure develop and change their views of dying and death.

DESIGN

A Straussian grounded theory approach.

METHODS

Purposive and theoretical sampling were used. Data collection and analysis were repeated until reaching data saturation using the constant comparative method. We conducted semi-structured interviews between January 2019 and July 2020 with 24 people with heart failure from a university and a community hospital in Japan.

RESULTS

Initially, participants' views of dying and death were unrelated to their disease. After the first turning point, namely the confirmation of the deterioration and incurability of the disease, their views became related to their own disease, adding to the suffering caused by the exacerbated symptoms. After the second turning point, namely when participants became tormented by the inevitability of death, they added their struggles with physical, psychological, and spiritual pain owing to medical interventions to their views of dying and death. Only a few participants reached the last stage of this process as it was emotionally distressing; some chose not to proceed to the next stage.

CONCLUSION

Participants develop their views of dying and death gradually and in stages while they experience two turning points. Healthcare providers need to address this process while keeping in mind that proceeding this process requires some turning points, and it can be painful.

IMPACT

This study provides a theoretical framework on the development of the views regarding dying and death of people with heart failure; it showed that these people need some turning points and to pass through stages to develop/individualize their views, and that this process is inherently distressing. This theory provides a cornerstone for healthcare professionals to understand the disease-specific transition in views of dying and psychological readiness, and it may help establish a therapeutic relationship that includes advance care planning.

Palliative Care Conversations for Heart Failure Nurses: A Pilot Education Intervention

INTRODUCTION

Heart failure is a progressive condition affecting 6.2 million Americans. The use of palliative and supportive care for symptom management and improved quality of life is recommended for persons with heart failure. However, 91% of nurses believe they need further training to have palliative care conversations. The purpose of this pilot education intervention was to determine if providing nurses with education on the timing and content of palliative care conversations would improve their perceived skill and knowledge.

METHODS

This was a pilot study of an online educational intervention. Data were electronically collected from 13 participants using validated questionnaires delivered via Qualtrics. Participants completed a demographic survey and End-of-Life Professional Caregiver Survey (EPCS) before and after completing an online, asynchronous education module.

RESULTS

Mean scores were higher on all posttest measures. Independent samples t-tests revealed statistically significant differences on the Effective Care Delivery (ECD) scale (t[32] = -2, p = .05) and total EPCS scale scores (t[32] = -2.2, p = .03) from pre- to posttest.

CONCLUSION

Scores increased on all dimensions pretest to posttest with statistically significant differences in ECD and total scores. Providing asynchronous online education on timing and content of palliative care conversations to nurses caring for people with heart failure is a feasible and effective way to improve perceived knowledge and skill of palliative care conversations.

Dying to know: prognosis communication in heart failure

Prognosis communication in heart failure is often narrowly defined as a discussion of life expectancy, but as clinical guidelines and research suggest, these discussions should provide a broader understanding of the disease, including information about disease trajectory, the experiences of living with heart failure, potential burden on patients and families, and mortality. Furthermore, despite clinical guidelines recommending early discussions, evidence suggests that these discussions occur infrequently or late in the disease trajectory. We review the literature concerning patient, caregiver, and clinician perspectives on discussions of this type, including the frequency, timing, desire for, effects of, and barriers to their occurrence. We propose an alternate view of prognosis communication, in which the patient and family/caregiver are educated about the nature of the disease at the time of diagnosis, and a process of engagement is undertaken so that the patient's full participation in their care is marshalled, and the care team engages the patient in the informed decision making that will guide care throughout the disease trajectory. We also identify and discuss evidence gaps concerning (i) patient preferences and readiness for prognosis information along the trajectory; (ii) best practices for communicating prognosis information; and (iii) effects of prognosis communication on patient's quality of life, mental health, engagement in critical self-care, and clinical outcomes. Research is needed to determine best practices for engaging patients in prognosis communication and for evaluating the effects of this communication on patient engagement and clinical outcomes.

Optimizing of a question prompt list to improve communication about the heart failure trajectory in patients, families, and health care professionals

Background

The aim of this study was to optimize a Question Prompt List which is designed to improve communication about the heart failure trajectory among patients, family members, and health care professionals.

Methods

Data were collected in a two-round Delphi survey and a cross-sectional survey, including patients with heart failure, their family members, and health care professionals working in heart failure care in Sweden and the Netherlands. Acceptability for and demand of the Question Prompt List were assessed.

Results

A total of 96 patients, 63 family members and 26 health care professionals participated in the study. Regarding acceptability, most of the original questions were found to be relevant by the participants for inclusion in the Question Prompt List but some cultural differences exist, which resulted in two versions of the list: a Swedish version including 33 questions and a Dutch version including 38 questions. Concerning demand, participants reported that they were interested in discussing the questions in the revised Question Prompt List with a physician or a nurse. Few patients and family members reported that they were worried by the questions in the Question Prompt List and hence did not want to discuss the questions.

Conclusions

This Question Prompt List has successfully been adapted into a Swedish version and a Dutch version and includes questions about the HF trajectory which patients, their families, and health care professionals perceived to be relevant for discussion in clinical practice. Overall, patients and family members were not worried about the content in the Question Prompt List and if used in accordance with patients’ and family members’ preferences, the Question Prompt List can help to improve communication about the heart failure trajectory.

Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper

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.

Implantable cardioverter defibrillators at the end of life: future perspectives on clinical practice

The implantable cardioverter defibrillator (ICD) is effective in terminating life-threatening arrhythmias. However, in the last phase of life, ICD shocks may no longer be appropriate. Guidelines recommend timely discussion with the patient regarding deactivation of the shock function of the ICD. However, research shows that such conversations are scarce, and some patients experience avoidable and distressful shocks in the final days of life. Barriers such as physicians’ lack of time, difficulties in finding the right time to discuss ICD deactivation, patients’ reluctance to discuss the topic, and the fragmentation of care, which obscures responsibilities, prevent healthcare professionals from discussing this topic with the patient. In this point-of-view article, we argue that healthcare professionals who are involved in the care for ICD patients should be better educated on how to communicate with patients about ICD deactivation and the end of life. Optimal communication is needed to reduce the number of patients experiencing inappropriate and painful shocks in the terminal stage of their lives.

Life and priorities before death: A narrative inquiry of uncertainty and end of life in people with heart failure and their family members

BACKGROUND

Most patients with advanced heart failure are ill-prepared and poorly supported during the end of life. To date, research has focused primarily on generalized patient accounts of the management or self-care phase of the syndrome. Little research has examined the end of life in depth or from the perspectives of family members.

AIMS

The purpose of this study is to describe how people diagnosed with heart failure and their family members describe uncertainty related to impending death.

METHODS AND RESULTS

A narrative inquiry was undertaken using a social constructionist perspective. Twenty participants took part in over 60 interviews: 12 participants with heart failure (eight male and four female; mean = 67.3 years) and eight family members (mean = 61.6 years) engaged in two in-depth interviews, approximately 3-4 months apart, followed by a telephone follow-up 2-3 months later. Six key themes/storylines were identified. These included: prognosis messages received from physicians; whenever I die, I die; loss isn't new to me but … ; carrying on amidst the fragility of life; ultimately living not knowing; and the need to prepare.

CONCLUSION

The six key storylines of death and dying with advanced heart failure were consistent for both patients and family members. There was a desire for better communication with physicians. Many participants were critical of how the prognosis of advanced heart failure was communicated to them, even if they anticipated the news. Participants wanted frank, open conversations with their healthcare providers that both acknowledged that they were at end of life but did not remove all hope.

Cardiologists' attitudes on communication about prognosis with heart failure patients

Aim

According to guidelines, a prognosis should be discussed with all heart failure (HF) patients. However, many patients do not have these conversations with a healthcare provider. The aim of this study was to describe attitudes of cardiologists in Sweden and the Netherlands regarding this topic.

Methods and results

A survey was sent to 250 cardiologists in Sweden and the Netherlands with questions whether should the prognosis be discussed, what time should the prognosis be discussed, whom should discuss, what barriers were experienced and how difficult it is to discuss the prognosis (scale from 1–10). A total of 88 cardiologists participated in the study. Most cardiologists (82%) reported to discussing the prognosis with all HF patients; 47% at the time of diagnoses. The patient's own cardiologist, another cardiologist, the HF nurse, or the general practitioner could discuss this with the patient. Important barriers were cognitive problems (69%) and a lack of time (64%). Cardiologists found it not very difficult to discuss the topic (mean score 4.2) with a significant difference between Swedish and Dutch cardiologist (4.7 vs. 3.7; P < 0.05).

Conclusion

Most cardiologists found it important to discuss the prognosis with HF patients although there are several barriers. Swedish cardiologists found it more difficult compared with their Dutch colleagues. A multidisciplinary approach seems important for improvement of discussing prognosis with HF patients.

Advance care planning for adults with heart failure

BACKGROUND

People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain.

OBJECTIVES

To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information.

MAIN RESULTS

We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI -0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD -0.58, 95% CI -0.82 to -0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD -0.40, 95% CI -1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment.

AUTHORS' CONCLUSIONS

ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.

Variables Related to Communication About Prognosis Between Nurses and Patients at Heart Failure Clinics in Sweden and the Netherlands

BACKGROUND

In contrast to recommendations in recent guidelines, prognosis is not optimally discussed with patients with heart failure (HF). Reasons for not doing so can be related to both patient and provider characteristics.

PURPOSE

The purpose of the study was to explore which patient- and nurse-related variables influence discussing prognosis with patients at an HF clinic.

METHOD

Data from a previous survey on attitudes and clinical practice of HF nurses on discussing prognosis that was conducted in Sweden and the Netherlands were combined with data from a registration on topics that nurses discussed with their patients during a prespecified week at the HF clinic. Multivariable logistic regression analysis was performed to assess which variables are related to discussing prognosis.

RESULTS

A total of 275 HF nurses (mean age, 49 years) and data of 1633 patients with HF (mean age, 71 years) were included in the study. Prognosis was discussed with 42% of all patients during the visit at the HF clinic. Patients with whom prognosis was discussed were more often in New York Heart Association classes III to IV (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.44-2.26). Nurses discussing prognosis reported more knowledge on the topic (OR, 1.71; 95% CI, 1.36-2.16) and discussed more topics with the patient (OR, 1.27; 95% CI, 1.21-1.32). Dutch HF nurses were more likely to discuss prognosis compared with their Swedish colleagues (OR, 1.83; 95% CI, 1.43-2.33).

CONCLUSIONS

Discussing prognosis with patients with HF by nurses at the HF clinic is related to the characteristics of patients and HF nurses. Future interventions to improve communications about prognosis therefore should have a broad approach.

Talking about end of life in general palliative care - what's going on? A qualitative study on end-of-life conversations in an acute care hospital in Denmark

BACKGROUND

End-of-life (EOL) conversations in hospital should serve to give patients the opportunity to consider future treatment options and help them clarify their values and wishes before it becomes relevant to make decisions about treatment. However, it is known that EOL conversations are not performed systematically in hospital. This may mean that patients and their relatives do not address EOL issues. There is a lack of knowledge about who is responsible for conducting these conversations, and when and under what circumstances they are conducted. The aim of this study was to explore the existing practices regarding EOL conversations in an acute care hospital setting.

METHODS

The design was Interpretive Description and the methods for the data collection included: 1. Participatory observational studies in a pulmonary medical and surgical ward (a total of 66 h); 2. Four focus group interviews with healthcare professionals (n = 14) from the wards. The analysis followed Spradley's ethnosemantic analysis.

RESULTS

The results revealed three cultural categories related to: 1. The physical and organizational setting; 2. The timing of EOL conversations and competencies and roles in addressing EOL issues and 3. Topics addressed in EOL conversations. The EOL conversations were part of daily clinical practice, but there was a lack of competencies, roles were unclear and the physical and organizational environment was not conducive to the conversations. The topics of the EOL conversations revolved around a "here-and-now" status of the patient's disease progression and decisions about the level of treatment. To a lesser extent, the conversations included the patient's and relatives' thoughts and wishes concerning EOL, which allowed long-term care planning.

CONCLUSION

This study demonstrates that there are several barriers to talking about EOL in an acute care hospital setting, and future strategies must address an overall approach. In order to provide patients and their relatives with better opportunities to express their EOL wishes, there is a need for clearer roles and guidelines in an interdisciplinary approach to EOL conversations, alongside improved staff competencies and changes to the organizational and physical environment.

Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis

BACKGROUND

Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP.

METHODS

We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators.

RESULTS

Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient.

CONCLUSIONS

Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.

Pediatric Oncology Nurses' Experiences With Prognosis-Related Communication

OBJECTIVES

To examine nurses' experiences of prognosis-related communication (PRC) with parents of children with cancer.

SAMPLE & SETTING

Cross-sectional, correlational study in the pediatric oncology setting involving 316 members of the Association of Pediatric Hematology/Oncology Nurses.

METHODS & VARIABLES

Online survey regarding individual nurse factors, PRC, interprofessional collaboration, moral distress, and perceived quality of care.

RESULTS

Nurses strongly agreed that prognostic disclosure is critical for decision making, but they are challenged in determining their role. Nurses with more years of experience and training in PRC, those working in an outpatient setting, and those with higher levels of nurse-physician collaboration reported more positive experiences with PRC. Positive experiences with PRC and collaboration were significantly associated with higher nurse-perceived quality of care and reduced nurse moral distress.

IMPLICATIONS FOR NURSING

Nurses should work to be active participants in the process of PRC by collaborating with physician colleagues. When nurses sense that prognostic discussions have been absent or unclear, they should feel confident in approaching physician colleagues to ensure parent understanding and satisfaction with communication.

Differences in primary palliative care between people with organ failure and people with cancer: An international mortality follow-back study using quality indicators

BACKGROUND

Measuring the quality of palliative care in a systematic way using quality indicators can illuminate differences between patient groups.

AIM

To investigate differences in the quality of palliative care in primary care between people who died of cancer and people who died of organ failure.

DESIGN

Mortality follow-back survey among general practitioners in Belgium, the Netherlands, and Spain (2013-2014), and Italy (2013-2015). A standardized registration form was used to construct quality indicators regarding regular pain measurement, acceptance of the approaching end of life, communication about disease-related topics with patient and next-of-kin; repeated multidisciplinary consultations; involvement of specialized palliative care; place of death; and bereavement counseling.

SETTING/PARTICIPANTS

Patients (18+) who died non-suddenly of cancer, cardiovascular disease, or respiratory disease ( n = 2360).

RESULTS

In all countries, people who died of cancer scored higher on the quality indicators than people who died of organ failure, particularly with regard to pain measurement (between 17 and 35 percentage-point difference in the different countries), the involvement of specialized palliative care (between 20 and 54 percentage points), and regular multidisciplinary meetings (between 12 and 24 percentage points). The differences between the patient groups varied by country, with Belgium showing most group differences (eight out of nine indicators) and Spain the fewest (two out of nine indicators).

CONCLUSION

People who died of organ failure are at risk of receiving lower quality palliative care than people who died of cancer, but the differences vary per country. Initiatives to improve palliative care should have different priorities depending on the healthcare and cultural context.

Communication in heart failure and palliative care

Communicating difficult information is an essential skill for clinicians of every specialty. The clinical complexity of the heart failure disease process lends itself to important opportunities to determine patient preferences about medical decisions and share information about prognosis. Nevertheless, traditionally most communication between clinicians and patients with heart failure has focused primarily on pathophysiology and treatment options. Studies indicate that patients and families wish to engage with their cardiologists in advance care planning and, when appropriate, end-of-life decision-making. Critical to whole-person care, this review describes several important communication strategies that enhance patient and family support through the inevitable rises and falls of progressive heart failure.

Using co-design to develop an intervention to improve communication about the heart failure trajectory and end-of-life care

BACKGROUND

The aim of this paper was to describe the development of an intervention that is developed to improve communication about the heart failure (HF) trajectory and end-of-life care. We also present data that provides a first insight in specific areas of feasibility of the intervention.

METHODS

Co-design was used and patients, family members and health care professionals were constructive participants in the design process of the intervention. Feasibility of the intervention was tested in two areas; acceptability and limited efficacy.

RESULTS

Two communication tools were designed and evaluated; 1) a Question Prompt List (QPL) for patients and family members and 2) a communication course for professionals which was web -based with one face-to-face training day with simulation. Data on feasibility was collected with questionnaires that were developed for this study, from the 13 participants who completed the course (all nurses). They reported improved knowledge, confidence and skills to discuss the HF trajectory and end-of-life care. The QPL was evaluated to be a useful tool in communication with patients and family members.

CONCLUSIONS

In a co-design process, future users identified the need for a QPL and a communication course. These communication tools can be used as a dual intervention to improve communication about the HF trajectory and end-of-life care. The QPL can help patients and families to ask questions about the HF trajectory and end-of-life care. The communication course can prepare the professionals to be knowledgeable, confident and skilled to discuss the questions in the QPL. Before the tools are ready for implementation in clinical practice, further studies testing the feasibility of the intervention are needed, including also patients and their families.

The incidence and impact of implantable cardioverter defibrillator shocks in the last phase of life: An integrated review

BACKGROUND

Although the implantable cardioverter defibrillator is successful in terminating life threatening arrhythmias, it might give unwanted shocks in the last phase of life if not deactivated in a timely manner.

AIMS

This integrated review aimed to provide an overview of studies reporting on implantable cardioverter defibrillator shock incidence and impact in the last phase of life.

METHODS AND RESULTS

We systematically searched five electronic databases. Studies reporting on the incidence and/or impact of implantable cardioverter defibrillator shocks in the last month of life were included. Fifteen studies were included. Two American studies published in 1996 and 1998 reported on the incidence of shocks in patients who died non-suddenly: incidences were 24% and 33%, respectively, in the last 24 hours, and 7% and 14%, respectively, in the last hour of life. Six American studies and one Danish study published between 1991-1999 reported on patients dying suddenly: incidences were 41% and 68% in the last 24 hours and 22-66% in the last hour. Four American studies and two Swedish studies published between 2004-2015 did not distinguish the cause of death: incidences were 17-32% in the last month, 3-32% in the last 24 hours, and 8% and 31% in the last hour of life. Three American studies published between 2004-2011 reported that shocks in dying patients are painful and distressing for patients, and distressing for relatives and professional caregivers.

CONCLUSION

If the implantable cardioverter defibrillator is not deactivated in a timely manner, a potentially significant proportion of implantable cardioverter defibrillator patients experience painful and distressing shocks in their last phase of life.

Planning for Deactivation of Implantable Cardioverter Defibrillators at the End of Life in Patients With Heart Failure

Implantable cardioverter defibrillators (ICDs) may be burdensome in end-stage heart failure. At the end of life, as many as one-fifth to one-third of patients experience an ICD shock. Critical care nurses should be aware of the potential burden of these shocks at the end of life as well as the ethics and organizational policies surrounding ICD deactivation. This literature review examines the issues surrounding ICD therapy at the end of life. Based on this author's findings, recommendations for discussing and implementing ICD deactivation are offered. Health care organizations should have clear policies addressing ICD deactivation to provide for seamless integration of palliative care services throughout the course of heart failure. These policies should empower nurses to activate resources in a timely manner and should clearly outline processes for ICD deactivation.

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

Nurses' Perceptions of Diagnosis and Prognosis-Related Communication: An Integrative Review

BACKGROUND

Disclosure of diagnostic and prognostic information has become the standard in the United States and increasingly around the world. Disclosure is generally identified as the responsibility of the physician. However, nurses are active participants in the process both intentionally and inadvertently. If not included in initial discussions regarding diagnosis and prognosis, the nurse may find it challenging to openly support the patient and family.

OBJECTIVE

The aim of this study is to synthesize published literature regarding nurses' perceptions and experiences with diagnosis and prognosis-related communication.

METHODS

The Whittemore and Knafl method guided the integrative review process. Electronic databases including Cumulative Index to Nursing and Allied Health Literature, Health Sciences in ProQuest, PubMed, and Web of Science were used to review the literature from 2000 to 2015. Constant comparison methods were used to analyze the data and develop themes.

RESULTS

Thirty articles met all of the inclusion criteria and were included in this review. Several themes emerged from the data, including the nurse's role in the process of diagnosis and prognosis-related communication, barriers and difficulties related to communication, and positive and negative outcomes.

CONCLUSIONS

Nurses play an integral role in the process of diagnostic and prognostic disclosure. Further exploration of both physician and patient perceptions of the nurse's role are needed. Interprofessional training regarding diagnosis and prognosis-related communication is essential to promote collaboration and better empower nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses should aim to purposefully partner with physician colleagues to plan and participate in diagnostic and prognostic discussions. Nurses should identify opportunities to improve their knowledge, understanding, and comfort with challenging conversations.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

An Intervention to Enhance Goals-of-Care Communication Between Heart Failure Patients and Heart Failure Providers

CONTEXT

Heart failure patients contend with a markedly impaired quality of life, experiencing emotional distress and severe physical discomfort that increases in frequency in the last months of life. Improving communication between patients and providers about goals of care has the potential to improve patient-provider communication and patient outcomes.

OBJECTIVES

To determine the effects of a goals-of-care (GoC) intervention compared to usual care on the number of GoC conversations, quality of communication between patients and providers, referrals to palliative care services and completion of advance care directives.

METHODS

A two-group randomized study (n = 40/group) compared a GoC intervention to usual care, conducted in an academic heart failure (HF) clinic. The GoC intervention was a previsit patient activation-education, telephone-based intervention delivered by a nurse. The primary outcome of the study was number of GoC conversations between HF patients and HF providers. Secondary outcomes were quality of communication, number of referrals to palliative care, and completion of advance directives.

RESULTS

Patients averaged 58.15 ± 11.26 years of age, with mean left ventricular ejection fraction = 30.31 ± 9.72% and Seattle Heart Failure Model scores = 95.1 ± 1.60. There was a significant increase in goals-of-care conversations (58% vs. 2.6%, P < 0.001) and quality of end-of-life communication (P = 0.03) in the GoC group compared to usual care after the intervention. There were no differences between groups on the other outcomes.

CONCLUSION

The GoC intervention resulted in more GoC conversations and higher quality communication between HF patients and providers without increased anxiety or depression. Further studies are needed to assess impact on longer term quality of care and patient outcomes.

Barriers to goals of care discussions with hospitalized patients with advanced heart failure: feasibility and performance of a novel questionnaire

Aims

Good end‐of‐life communication and decision‐making are important to patients with advanced heart failure (HF) and their families, but their needs remain unmet. In this pilot study, we describe the feasibility and performance of a novel questionnaire aimed at identifying barriers and solutions to improve communication and decision‐making about goals of care for hospitalized patients with advanced HF.

Methods

We distributed questionnaires to staff cardiologists, cardiology trainees, and cardiology nurses who provide care for HF patients at a Canadian teaching hospital. The questionnaire asked about the importance of various barriers to goals of care discussions. It also asked participants to rank their willingness to engage in goals of care discussions and their views on other clinicians could engage in such discussions.

Results

Of 76 clinicians, 44 (58%) completed the questionnaire (median completion time, 17 min). Individual survey questions had few missing responses (0% to 2%) for questions about barriers to goals of care discussions. There was appreciable discrimination of the importance of different barriers (mean scores 2.2 to 6.0 on a 7‐point scale). Preliminary data suggest that clinicians perceive patient and family factors, such as difficulty accepting a poor prognosis, as the most important barriers preventing goals of care discussions.

Conclusions

In this pilot study, we have demonstrated the feasibility of a novel questionnaire to be used in a larger multi‐centre study of end‐of‐life HF care. Essential information will be obtained to inform the design and evaluation of interventions that seek to improve communication and decision‐making about goals of care with HF patients.

Heart failure patients' future expectations and their association with disease severity, quality of life, depressive symptoms and clinical outcomes

BACKGROUND

Although treatment of heart failure (HF) patients has improved, prognosis still remains poor. Current HF Guidelines recommend communication about prognosis with all patients. Little is known about HF patients' awareness of their shortened life expectancy.

AIM

To explore HF patients' future expectations and to examine whether these expectations are associated with disease severity, quality of life, depressive symptoms and clinical outcomes.

METHOD

Patients randomised to the intervention groups of the COACH study, who were at the end of HF hospitalisation, were asked about their future expectations. Patients were divided into three groups: patients expecting improvement/stabilisation, patients expecting deterioration and those not knowing what to expect. Depressive symptoms were measured by CES-D and quality of life with the Ladder of Life and RAND-36.

RESULTS

Six hundred and seventy eight patients (age 70 ± 12; 41% female patients; LVEF 33% ± 15) participated in the study. Most patients (56%, N = 380) expected improvement or stabilisation, 8% (N = 55) expected deterioration and 21% (N = 144) did not know what to expect for the future. Patients who expected to deteriorate were significantly older, experienced a lower quality of life and more depressive symptoms compared with patients in the other two groups. They also had a higher mortality rate, both after 18 and 36 months, and had more HF admissions. No association with severity of the disease (NYHA-class, LVEF, BNP levels) was found.

CONCLUSION

Many hospitalised HF patients are not aware of their poor prognosis. Depressive symptoms, poor quality of life, increased mortality and rehospitalisation were related to expected deterioration. Improvement of communication about prognosis with HF patients is needed in the future.

Patient-Nurse Communication about Prognosis and End-of-Life Care

BACKGROUND

Although several studies advise that discussions about prognosis and end-of-life care should be held throughout the whole heart failure (HF) trajectory, data is lacking on the prevalence and practice of such discussions in HF care.

OBJECTIVE

The study objective was to explore how often and why HF nurses in outpatient clinics discuss prognosis and end-of-life care in the context of patient education.

METHODS

This was a descriptive and comparative study. Participants were HF nurses from Swedish and Dutch HF outpatient clinics. Measurements were taken via a survey for both quantitative and qualitative data. Additional data was collected via open-ended questions and analyzed with content analysis.

RESULTS

Two hundred seventy-nine nurses registered 1809 patient conversations using a checklist. Prognosis and end-of-life care were among the least frequently discussed topics, whereas symptoms of HF was discussed most often. Prognosis was discussed with 687 patients (38%), and end-of-life care was discussed with 179 patients (10%). Prognosis and end-of-life care were discussed more frequently in The Netherlands than in Sweden (41% versus 34%, p<0.001, 13% versus 4%, p<0.001). The nurses did not always recognize prognosis and end-of-life care discussions as a part of their professional role.

CONCLUSIONS

Currently, patient-nurse communication about prognosis and end-of-life care does not seem to be routine in patient education in HF clinics, and these discussions could be included more often. The reasons for nurses to discuss these topics were related to clinical routines, the patient's situation, and professional responsibilities. To improve future care, communication with patients needs to be further developed.