Engaging patients and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial

A scoping review of global patterns in reporting race, ethnicity, nationality, or religion in palliative care randomized controlled trials: Recommendations for transparency

BACKGROUND

Though randomized controlled trials of non-pharmacological palliative care interventions have shown positive outcomes, findings are often generalized with limited consideration for the impact of the influence of race, ethnicity, nationality, or religion on said outcomes.

AIM

To identify trends and gaps in global reporting of racial, ethnic, nationality, and religious demographics in non-pharmacological palliative care randomized controlled trials.

DESIGN

We conducted a scoping review guided by the Joanna Briggs methodology.

DATA SOURCES

Global randomized controlled trials published in English, between 1999 and 2021 extracted from databases: Cochrane, PubMed, and Scopus. Inclusion criteria were non-pharmacological palliative care interventions for people with serious conditions reporting on one or more of the demographics of race, ethnicity, nationality, or religion.

RESULTS

Our review included 131 (44%) articles published from 19 countries, predominantly the USA (n = 84, 64%). Most studies focused on cancer (n = 71, 54%) in inpatient settings (n = 85, 64%). Race was the most commonly reported demographic (n = 93, 70%), followed by ethnicity (n = 54, 41%), religion (n = 46, 35%), nationality (n = 20, 15%). Within racial reporting, 86 (92%) indicating a majority White/Caucasian sample. Only 14 (10%) articles provided context connecting participant demographics to intervention outcomes. Demographic data was discussed only as a limitation to generalizability in 18 cases (41%).

CONCLUSIONS

Improving greater transparency in study reporting of social and historical context about population demographics, including specific demographic data collected, may better identify unmet palliative needs, facilitate cross-cultural interpretation, and improve adaptation and implementation of non-pharmacological palliative care interventions.

Cultural adaptation of ENABLE (Educate, Nurture, Advise, Before Life Ends) an early palliative care model for Iranian patients with heart failure and their caregivers: a qualitative study protocol

BACKGROUND

ENABLE (Educate, Nurture, Advise, Before Life Ends) is a model of nurse-led, early palliative care that was originally developed for U.S. patients with advanced cancer and their family caregivers and then adapted for patients with heart failure. ENABLE coaching topics include problem-solving, communication, advance care planning, symptom management, and self-care. The purpose of this paper is to detail a qualitative study protocol to assess the cultural acceptability of ENABLE among heart failure patients and their family caregivers in Iran.

METHODS

This qualitative study employs reflexive thematic analysis (RTA) to guide the cultural adaptation of the ENABLE model. The study is conducted in two phases. In Phase 1, the ENABLE content will be translated and validated into Persian using a forward-backward translation process and expert panel review to ensure linguistic and cultural appropriateness. In Phase 2, semi-structured interviews will be conducted with individuals living with HF, their caregivers, and healthcare providers at Tehran University of Medical Sciences. The one-on-one semi-structured interviews will explore three main areas: (1) the primary needs and challenges faced by individuals with heart failure and their family caregivers, (2) the extent of patients' involvement in healthcare decision-making, and (3) participants' preferences for content and delivery method of ENABLE. Maximum variation sampling will be employed to ensure diverse representation, and data collection will continue until saturation is achieved. Interview audio recordings will be transcribed verbatim and analyzed using Braun and Clarke's reflexive thematic analysis approach. The analysis will involve iterative coding to identify patterns and the development of themes that align with the core components of the ENABLE model while ensuring cultural relevance. Trustworthiness and rigor will be ensured through reflexivity, peer debriefing, and data triangulation, ensuring credible and robust findings to guide the cultural adaptation of the ENABLE model for Iran.

DISCUSSION

This study will develop a framework for adapting the ENABLE model to Iran, offering insights into cultural and contextual factors influencing palliative care. The adapted model aims to enhance the quality of life for individuals with HF and their caregivers while addressing gaps in palliative care delivery in Iran.

Transitional Palliative Care for Family Caregivers: Outcomes From a Randomized Controlled Trial

CONTEXT

Patients receiving inpatient palliative care often face physical and psychological uncertainties during transitions out of the hospital. Family caregivers often take on responsibilities to ensure patient safety, quality of care, and extend palliative care principles, but often without support or training, potentially compromising their health and well-being.

OBJECTIVES

This study tested an eight-week intervention using video visits between palliative care nurse interventionists and caregivers to assess changes in caregiver outcomes and patient quality of life.

METHODS

This randomized controlled trial, conducted from 2018 to 2022, enrolled adult caregivers in rural or medically underserved areas in Minnesota, Wisconsin, and Iowa. Eligible caregivers included those caring for patients who received inpatient palliative care and transitioned out of the hospital. The intervention group received teaching, guidance, and counseling from a palliative care nurse before and for eight weeks after hospital discharge. The control group received monthly phone calls but no intervention. Caregiver outcomes included changes in depression, burden, and quality of life, and patient quality of life, as reported by the caregiver.

RESULTS

Of those consented, 183 completed the intervention, and 184 completed the control arm; 158 participants had complete baseline and eight-week data. In unadjusted analyses, the intervention group and their care recipients showed statistically significant improvements in quality of life compared to the control group. Improvements persisted in adjusted analyses, and depression significantly improved. No differences in caregiver burden were observed.

CONCLUSION

Addressing rural caregivers' needs during transitions in care can enhance caregiver outcomes and improve patient quality of life.

Effectiveness of interventions for informal caregivers of people with end-stage chronic illness: a systematic review

BACKGROUND

People living with advanced, non-malignant chronic conditions often have extensive and complex care needs. Informal or family caregivers often provide the care and support needed by those with advanced chronic conditions at home. These informal caregivers experience many challenges associated with their caring role, which can impact their own wellbeing. Whilst there is growing evidence around the impact on carers, guidance on support for informal caregivers of patients with advanced, non-malignant, chronic conditions is lacking, with little evidence available on effective psychosocial carer interventions. This systematic review explored existing interventions for caregivers of those with advanced, non-malignant, chronic illness, in order to assess the effectiveness of these interventions in improving psychosocial outcomes.

METHODS

Electronic databases, Medline, CINAHL, EMBASE, and PsycINFO, were searched up to the end of March 2023. Studies meeting the inclusion criteria, focusing on interventions to improve psychosocial outcomes, such as depression, anxiety, quality of life, and caregiver burden, in this cohort of caregivers were included. Data were extracted regarding study setting, design, methods, intervention components, and outcomes. Risk of bias and quality assessment were conducted.

RESULTS

A total of 5281 articles were screened, ultimately identifying 12 studies for inclusion, reported in 13 publications. A narrative synthesis revealed mixed results. Psychosocial interventions resulted in more significant improvements in psychosocial outcomes than psychoeducational or support interventions, with interventions for carer-patient dyads also reflecting more positive outcomes for caregivers. Evidence-based interventions, guided by an appropriate theoretical model, were reportedly more effective in improving caregiver outcomes. Differences in outcomes were related to intervention development, design, delivery, and outcome assessment.

CONCLUSIONS

This review, to our knowledge, is the first to explore the effectiveness of interventions in improving psychosocial outcomes for caregivers of those with advanced, non-malignant, chronic conditions. The review highlights the need for more robust, sufficiently powered, high-quality trials of evidence-based interventions for caregivers of people with advanced chronic illness. Optimal intervention duration and frequency of sessions are unclear and need further exploration.

Improving Benefit and Reducing Burden of Informal Caregiving for Patients With Heart Failure: A Mixed Methods Study

BACKGROUND

Few randomized clinical trials test the effect of interventions on heart failure caregiver well-being.

OBJECTIVE

The aim of this study was to determine the effect of a patient-focused symptom and psychosocial collaborative care intervention (Collaborative Care to Alleviate Symptoms and Adjust to Illness) on heart failure caregiver depression, burden, and benefit-finding.

METHODS

A sequential explanatory mixed-method design was used in the context of a multisite, randomized clinical trial. Self-reported caregiver depression, burden, and benefit-finding were assessed at baseline and 12 months. Thematic analysis was conducted on social worker documentation of a psychosocial intervention with caregivers.

RESULTS

One hundred one caregivers were randomized to usual care or Collaborative Care to Alleviate Symptoms and Adjust to Illness. There were no significant differences in caregiver depression, burden, or benefit-finding between usual care and Collaborative Care to Alleviate Symptoms and Adjust to Illness. Caregiver outcomes were discussed in 42% of intervention notes, highlighting varied and complex caregiver experiences. Inductive analysis reaffirmed the complexity and range of caregiver needs and experiences.

CONCLUSION

A patient symptom/psychosocial intervention did not impact caregiver well-being. Interventions should target specific needs of caregivers.

Palliative and End-of-Life Family Caregiving in Rural Areas: A Scoping Review of Social Determinants of Health and Emotional Well-Being

Introduction: Due to their remote location, rural-dwelling family caregivers (FCGs) experience geographic and psychosocial challenges when providing home-based palliative and end-of-life (PEOL) care for their care recipient. Limited research has evaluated the social and environmental factors that may compound FCG burden and contribute to adverse emotional health outcomes among rural-dwelling PEOL FCGs. Objective: To characterize the social determinants of health (SDOH) that affect the provision of PEOL care among rural-dwelling FCGs, along with symptoms of anxiety and depression. Methods: A scoping review was conducted using Arksey and O'Malley's Framework. Searches were conducted in PubMed, CINAHL, PsycINFO, and Cochrane, and 511 articles published between 2010 and 2023 were screened. Keywords included "rural," "PEOL care," and "FCG." Inclusion criteria included FCGs, ages ≥18 years; findings reported on SDOH, anxiety, and/or depressive symptoms; within a rural context; and U.S. based. Findings: In this review, 18 studies met eligibility and were included. Apart from six studies that specifically investigated Black and Latinx FCGs, most FCGs were middle-aged White female spouses. SDOH impacting PEOL care provision included: limited access to PEOL services due to remote distance and travel needs for services; low health literacy in medical terminology and patient symptom management; limited English-language proficiency; perceived clinician racial and ethnic discrimination; financial vulnerabilities affecting health care coverage; and underdeveloped infrastructure. These barriers negatively impacted decision making, communication with clinicians, and patient symptom management. FCGs reported emotional distress related to patients' symptom management and limited opportunities for respite. There was a limited investigation of emotional well-being and minimal interventions aimed toward improving rural-dwelling FCG emotional health. The presence of community support promoted hospice use and facilitated the provision of care. Conclusions: FCGs are vulnerable to adverse emotional health when providing home-based PEOL care. Research is needed to develop supportive interventions (e.g., digital health) for rural-dwelling FCGs.

Reliability and validity of the Self-Efficacy in Palliative Care Scale among nurses

OBJECTIVES

To provide appropriate palliative care, nurses should have appropriate level of self-efficacy in palliative care, but the levels among nurses were low. To improve the levels effectively, self-efficacy in palliative care should be assessed using reliable and valid instruments. The purpose of this study was to examine the reliability and validity of the Self-Efficacy in Palliative Care Scale in Korean nurses.

METHODS

In this cross-sectional, observational study, 272 nurses (mean age: 30 years) were enrolled from 6 university-affiliated medical centers or community hospitals in South Korea. Data on self-efficacy and demographic characteristics were collected. Validity was assessed by exploratory and confirmatory factor analyses (SPSS and Mplus). Reliability and homogeneity were assessed by Cronbach's alpha and item analyses (SPSS), respectively.

RESULTS

The exploratory and confirmatory factor analyses supported the 4-factor structure (communication, assessment and symptom management, psychosocial and spiritual management of patient and family, and multiprofessional teamworking) with factor loadings >.60 and with good model fit: root mean square error of approximation =.07, Tucker-Lewis index =.94, comparative fit index =.95, and standardized root mean square residual =.04. Cronbach's alphas for the total scale and each of the subscales ranged from .883 to .965. The corrected item-total correlation coefficients of all items ranged from .61 to .90.

SIGNIFICANCE OF RESULTS

The findings of this study supported the reliability and validity of this instrument among Korean nurses. This instrument can be used to assess nurses' self-efficacy in palliative care and to test intervention effects on it.

Do Interventions Meet the Needs of Caregivers of Cardiac Patients?: A Scoping Review

BACKGROUND

Interventions targeting the needs of caregivers of cardiac patients are few, and in most cases, no effect is found on caregivers' well-being. A closer look at the existing interventions will provide a solid foundation for future efforts to develop effective interventions targeted at caregivers of cardiac patients.

OBJECTIVE

The study's objective was to scrutinize and discuss interventions targeting caregivers of cardiac patients and contribute to reflections that will improve future interventions.

METHODS

Systematic scoping of the literature within the field was conducted through a literature search in PubMed, EMBASE, CINAHL, PsycINFO, and Cochrane Library from January 2011 to May 2022. The development of search terms and inclusion criteria was inspired by the Patient problem/population, Intervention, Comparison/Control, and Outcome approach, and the Medical Research Council framework for developing and evaluating complex interventions served as the underlying basis for the analysis.

RESULTS

Eleven articles were included. The interventions reported in the articles were generally not systematically developed and did not include field-specific, methodological, and theoretical reflections. Furthermore, the development process behind the studies seemed not to be transparent.

CONCLUSIONS

Lack of systematic methodology and methodological transparency in the reviewed studies hinders further testing of interventions and might explain lack of evidence for effective interventions within the field. More systematic, needs-based, and well-documented interventions targeting caregivers of various kinds of cardiac patients are needed to develop the field to the benefit of caregivers, patients, and society.

Project EPIC (Empowering People to Independence in COPD): Study protocol for a hybrid effectiveness-implementation pilot randomized controlled trial of telephonic, geriatrics-palliative care nurse-coaching in older adults with COPD and their family caregivers

BACKGROUND

EPIC (Empowering People to Independence in COPD) is a geriatric-palliative care telephonic, nurse coach intervention informed by Baltes' Theory of Successful Aging and adapted from the ENABLE (Educate, Nurture, Advise, Before Life Ends) intervention. EPIC, focused on improving independence, mobility, well-being, and COPD symptoms, has undergone formative and summative evaluation for adults with COPD.

METHODS

The primary study aim is to assess the refined EPIC intervention's feasibility and acceptability via a pilot hybrid effectiveness-implementation randomized control trial in community-dwelling older adults with moderate to severe COPD and their family caregivers. The secondary aim is to explore the impact of EPIC on patient and caregiver outcomes. Older adults with COPD and their family caregivers (target N = 60 dyads) will be randomized to EPIC (intervention) or usual COPD care (control). EPIC includes six patient and four family caregiver weekly, telephone-based nurse coach sessions using a manualized curriculum (Charting Your Course), plus three monthly follow-up calls. Feasibility will be measured as completion of EPIC intervention and trial components (e.g., recruitment, retention, data collection). Acceptability will be evaluated using satisfaction surveys and post-study feedback interviews. A blinded data collector will assess exploratory outcomes (e.g., Life-Space mobility, quality of life, caregiver burden, emotional symptoms, loneliness, cognitive impairment, functional status, healthcare utilization) at baseline, 12, and 24 weeks.

DISCUSSION

This intervention fills a gap in addressing the geriatrics and palliative care needs and equity for adults with COPD and their family caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05040386.

Impact of Caring for Individuals With Heart Failure in the United States: A Systematic Literature Review

BACKGROUND

Given the functional impairments and complex care routines associated with heart failure (HF), patients often rely on the support of informal caregivers. Although the importance of caregivers' roles is widely recognized, the intensity and time required for care duties may negatively impact caregiver health and well-being, potentially precipitating their own need for care.

OBJECTIVE

The aim of this study was to synthesize estimates of economic, clinical, burden, and health-related quality-of-life impact among caregivers of those with HF in the United States.

METHODS

A systematic review was conducted to identify studies reporting estimates of caregiver impact. Abstract and full-text review as well as data extraction were performed according to established guidelines. Patient and caregiver characteristics were summarized, as well as estimates of impact of caring for those with HF.

RESULTS

From 3680 abstracts, 44 studies reporting caregiver burden estimates were included. Mean caregiver age ranged from 41.4 to 71.4 years; caregivers were primarily female (range, 49%-100%) and the patient's spouse/partner (21%-100%). Time spent caregiving (6 studies) ranged from 2 to 52 h/wk, and depression was identified in up to 40% of caregivers (9 studies). Numerous instruments were used to measure burden, which consistently documented the high impact of caregiving.

CONCLUSIONS

This review demonstrates the multifaceted impact of caregiving for patients with HF. Despite limited data, notable findings included the considerable burden to caregivers, variability in time spent caregiving, and frequent experience of depression among caregivers, possibly leading to increased healthcare resource use. Future research is needed to better characterize the caregiving impact in HF, including evaluating the drivers of burden.

Caregivers' Perspectives on Ethical Challenges and Patient Safety in Tele-Palliative Care: An Integrative Review

Tele-palliative care enables people with a life-limiting illness to consult with palliative care staff without having to leave their homes but requires commitment from all stakeholders, particularly on ethical challenges and patient safety issues. When using telecommunications and virtual technology, ethical challenges and patient safety aspects must be taken into account. The aim was to describe formal and informal caregivers' opportunities in tele-palliative care and the associated ethical and safety challenges using a Whittemore and Knafl integrative review method. Ethical and patient safety perspectives were extracted from studies reporting on tele-palliative care interventions. Content on ethically considerable information on the intervention was coded, categorized, and summarized into a matrix developed in advance from literature on socio-technical arrangements and eHealth applications. Nine studies from experimental and nonexperimental research were included. Four studies reported exclusively on the perspective of formal caregivers, 3 studies addressed the perspective of patients and informal caregivers, and 2 studies covered the perspectives of both. Studies of tele-palliative care interventions implicate effects on patient-caregiver relationships but also show that technology is not seen as a replacement of holistic palliative care. However, the authors do not address other relevant ethical issues (eg, sustainability) or consider aspects of patient safety. There is a need for further research to assess privacy, data security, and patient safety in tele-palliative care from the perspective of caregivers as telehealth becomes increasingly important.

The impact of an integrated early palliative care telehealth intervention on the quality of life of heart failure patients: a randomized controlled feasibility study

BACKGROUND

While palliative care for patients with heart failure has gained global attention, in Iran most palliative care interventions have focused only on cancer patients. The purpose of this study is to determine the feasibility and acceptability of a telehealth palliative care intervention to improve the quality of life in patients with heart failure in Iran.

METHODS

This single-site, pilot randomized controlled trial of a telehealth palliative care intervention versus usual care was conducted on patients with New York Heart Association class II/III heart failure recruited from a heart failure clinic in Iran. Under the supervision of a nurse interventionist, intervention participants received 6 weekly educational webinars and concurrent WhatsApp® group activities, with 6 weeks of follow-up. Feasibility was assessed by measuring recruitment, attrition, and questionnaire completion rates; acceptability was assessed via telephone interviews asking about satisfaction and attitudes. Secondary outcomes measured at baseline and 6 weeks included quality of life (PKCCQ and FACIT-Pal-14), anxiety and depression (HADS), and emergency department visits.

RESULTS

We recruited and randomized 50 patients (mean age 47.5 years, 60% men). Among those approached for consent, 66% of patients agreed to participate and total study attrition was 10%. Also 68% of patients successfully completed at least 4 out of the 6 webinar sessions. Acceptability: 78% of patient participants expressed willingness to participate in the present study again or recommend other patients to participate. There was a trend towards improvement in anxiety and depression scores in the intervention group though the study was not powered to detect a statistical difference.

CONCLUSION

This nurse-led, early telehealth-palliative care intervention demonstrated evidence of feasibility, acceptability, and potential improvement on quality of life in patients with heart failure in Iran.

TRIAL REGISTRATION

The study was registered at the Iranian Registry of Clinical Trials (IRCT) at 14 November, 2021, and can be found on the Iranian Registry of Clinical Trials Platform. IRCT registration number: IRCT20100725004443N29.

A scoping review and intersectionality-based analysis of heart failure telehealth interventions for vulnerable populations

AIMS

To map the existing body of heart failure (HF) telehealth interventions for vulnerable populations, and to conduct an intersectionality-based analysis utilizing a structured checklist.

DESIGN

A scoping review and intersectionality-based analysis.

DATA SOURCES

The search was conducted in March 2022 in the following databases: MEDLINE, CINAHL, Scopus and the Cochrane Central Register of Controlled Trials, ProQuest Dissertations and Theses Global.

REVIEW METHODS

First, the titles and abstracts were screened, and then the entire articles were screened against the inclusion criteria. Two of the investigators screened the articles independently in Covidence. The studies included and excluded at various stages of screening were depicted through a PRISMA flow diagram. The quality of the included studies was assessed based on the mixed methods appraisal tool (MMAT). Each study was read thoroughly and the intersectionality-based checklist by Ghasemi et al. (2021) was applied, whereby a yes/no response was marked for each question on the checklist and the relevant supporting data were extracted.

RESULTS

A total of 22 studies were included in this review. About 42.2% of the responses indicated that studies incorporated the principles of intersectionality at the 'problem identification' stage, followed by 42.9% and 29.44% responses indicating incorporation of these principles at the 'design and implementation' and 'evaluation' stages respectively.

CONCLUSIONS

The findings suggest that the research around HF telehealth interventions for vulnerable populations is not adequately grounded in appropriate theoretical underpinning. The principles of intersectionality have been applied mostly to the problem identification and the intervention development and implementation stages, and not so much at the evaluation stage. Future research must fill the identified gaps in this area of research.

NO PATIENT OR PUBLIC CONTRIBUTION

Since this was a scoping, there was no patient contribution to this work; however, based on this study's findings, we are undertaking patient-centred studies with patient contribution.

Evaluation of a Study Protocol of the Application of Humor Interventions in Palliative Care Through a First Pilot Study

Background

Humor and laughter might have an alleviating effect on pain threshold and enhance coping and building relationships. However, randomized controlled studies in palliative care have struggled with high percentages of attrition and missing values.

Objectives

We aimed to evaluate a study protocol through a pilot study for the evaluation of a multistage humor intervention with psychological and physiological outcome parameters that may be applied successfully in a palliative care environment.

Design

This pilot study utilized a pre-post design. The inclusion of a control group for the final study setting recruiting 120 patients is planned.

Setting/Subjects

The study was a monocenter study in a clinic for palliative care in Germany. All patients were eligible for recruitment. Seven patients were recruited for the pilot study.

Measurements

Interventions were developed using a humor training for psychiatric patients. Quantitative sensory testing for pain threshold testing and questionnaires on humor as a character trait, pain intensity, life satisfaction, and symptom burden were planned to be evaluated before and after three humor interventions.

Results

The feasibility of the original study design was re-evaluated after pilot testing. Only two out of the seven patients were able to complete two interventions, requiring modification. Fewer questionnaires, less complex physiological testing, and reduction from three to two interventions were then planned.

Conclusion

The initial planned research methodology must be adjusted for patients with high symptom burden. In the experimental group of the final study setting, the effects of one to two interventions will be evaluated measuring oxytocin levels in saliva and using standardized questionnaires to determine cheerfulness, life satisfaction and symptom burden, as well as assessing as-needed medication.

Trial registration

DRKS00028978 German Registry of Clinical Studies.

Decision support training for advanced cancer family caregivers: Study protocol for the CASCADE factorial trial

BACKGROUND

Patients with advanced cancer face numerous decisions when diagnosed and often receive decision support from family caregivers. The CASCADE (CAre Supporters Coached to be Adept DEcision partners) factorial trial intervention aims to train caregivers in skills to provide effective decision support to patients and identify most effective intervention components.

METHODS

This is a 2-site, single-blind, 24 factorial trial to test components of the CASCADE decision support training intervention for family caregivers of patients with newly-diagnosed advanced cancer delivered by specially-trained, telehealth, palliative care lay coaches over 24 weeks. Family caregivers (target N = 352) are randomly assigned to one of 16 combinations of four components with two levels each: 1) psychoeducation on effective decision partnering principles (1 vs. 3 sessions); 2) decision support communication training (1 session vs. none); 3) Ottawa Decision Guide training (1 session vs. none) and 4) monthly follow-up (1 call vs. calls for 24 weeks). The primary outcome is patient-reported decisional conflict at 24 weeks. Secondary outcomes include patient distress, healthcare utilization, caregiver distress, and quality of life. Mediators and moderators (e.g., sociodemographics, decision self-efficacy, social support) will be explored between intervention components and outcomes. Results will be used to build two versions of CASCADE: one with only effective components (d ≥ 0.30) and another optimized for scalability and cost.

DISCUSSION

This protocol describes the first factorial trial, informed by the multiphase optimization strategy, of a palliative care decision-support intervention for advanced cancer family caregivers and will address the field's need to identify effective components that support serious illness decision-making.

TRIAL REGISTRATION

NCT04803604.

Between a Rock and a Hard Place: The Challenges of Caregiving During a Pandemic for Parkinson's Family Care Partners

Aim: To understand Parkinson's Disease (PD) care partners' a) specific challenges that led to worsening strain and b) their suggestions for supports to help them during the ongoing pandemic. Method: Using a qualitative descriptive design, semi-structured interviews with family care partners (n = 19) were completed. Participants were recruited from 10 sites across the United States that varied in size, demographics of patient population served, and geographic location (urban, suburban, rural). Interviews were audio-recorded, de-identified, transcribed verbatim, and coded in a phased manner. The research team analyzed the data and identified themes. Results: During the pandemic, the already difficult task of caregiving was made worse by having to choose between poor options. Five themes exemplified PD care partner experiences: (1) Managing risks and benefits of medical care in settings outside the home vs meeting these needs at home; (2) Struggling to maintain employment benefits with the costs of care and risks of bringing in outside caregivers; (3) Struggling to balance caregiving and self-care; (4) Struggling to be supportive and taking on new caregiving roles in the face of less support services; and (5) Wanting social connections and feeling pressured to maintain isolation. Care partners wanted timely access to, and guidance from healthcare teams to help them. Conclusions: Care partner burden was worsened by lack of guidance when confronted by choices that could lead to negative outcomes. Movement disorder and palliative care providers may be able to alleviate some care partner burden through building systems for timely access and guidance.

Specialist Palliative Care Referral Practices Among Oncologists, Cardiologists, Respirologists: A Comparison of National Survey Studies

CONTEXT

Although patients with nonmalignant diseases have palliative care needs similar to those of cancer patients, they are less likely to receive specialist palliative care (SPC). Referral practices of oncologists, cardiologists, and respirologists could provide insight into reasons for this difference.

OBJECTIVES

We compared referral practices to SPC among cardiologists, respirologists, and oncologists, discerned from surveys (the Canadian Palliative Cardiology/Respirology/Oncology Surveys).

METHODS

Descriptive comparison of survey studies; multivariable linear regression analysis of association between specialty and referral frequency. Surveys for each specialty were disseminated to physicians across Canada in 2010 (oncologists) and 2018 (cardiologists, respirologists).

RESULTS

The combined response rate of the surveys was 60.9% (1568/2574): 603 oncologists, 534 cardiologists, and 431 respirologists. Perceived availability of SPC services was higher for cancer than for noncancer patients. Oncologists were more likely to make a referral to SPC for a symptomatic patient with a prognosis of

CONCLUSION

For cardiologists and respirologists in 2018, perceived availability of SPC services was poorer, timing of referral later, and frequency of referral lower than among oncologists in 2010. Further research is needed to identify reasons for differences in referral practices and to develop interventions to overcome them.

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Key Words

• Palliative care
• cancer
• chronic obstructive pulmonary disease
• health care disparity
• heart failure
• referral

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MESH Headings

• Humans
• Palliative Care
• Cardiologists
• Attitude of Health Personnel
• Practice Patterns, Physicians'
• Canada
• Neoplasms/therapy
• Referral and Consultation
• Oncologists

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Affiliation(s)

Michael Bonares Division of Palliative Medicine (M.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Palliative Medicine (M.B., C.Z.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Lisa W Le Department of Biostatistics (L.W.L.), Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
Camilla Zimmermann Division of Palliative Medicine (M.B., C.Z.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Supportive Care (C.Z., K.W.), University Health Network, Toronto, Ontario, Canada
Kristen Wentlandt Department of Supportive Care (C.Z., K.W.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Care (K.W.), Department of Community and Family Medicine, University of Toronto, Toronto, Ontario, Canada

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Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure

CONTEXT

Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described.

OBJECTIVES

This study describes the PC needs of community dwelling, physically frail persons with HF.

METHODS

We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs.

RESULTS

Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001).

CONCLUSION

Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.

Differences in family caregiver experiences and expectations of end-of-life heart failure care across providers and settings: a systematic literature review

Heart failure impacts patients' quality of life and life expectancy and significantly affects the daily behaviours and feelings of family caregivers. At the end-of-life, the burden for family caregivers depends on their emotional and sentimental involvement, as well as social costs.

OBJECTIVES

The aim of this work is to determine whether and how family caregivers' experiences and expectations vary in relation to the places of care and teams involved in heart failure management.

METHODS

A systematic literature review was conducted, by screening manuscripts dealing with the experience of Family Care Givers' (FCGs) of patients with Advanced Heart failure. Methods and results were reported following the PRISMA rules. Papers were searched through three databases (PubMed, Scopus and Web of Science). Seven topics were used to synthetize results by reporting qualitative information and quantitative evidence about the experience of FCGs in places of care and with care teams.

RESULTS

Thirty-one papers, dealing with the experience of 814 FCGs, were selected for this systematic review. Most manuscripts came from the USA (N = 14) and European countries (N = 13) and were based on qualitative methods. The most common care setting and provider profile combination at the end of life was home care (N = 22) and multiprofessional teams (N = 27). Family caregivers experienced "psychological issues" (48.4%), impact of patients' condition on their life (38,7%) and "worries for the future" (22.6%). Usually, when family caregivers were unprepared for the future, the care setting was the home, and there was a lack of palliative physicians on the team.

DISCUSSION

At the end-of-life, the major needs of chronic patients and their relatives are not health related. And, as we observed, non-health needs can be satisfied by improving some key components of the care management process that could be related to care team and setting of care. Our findings can support the design of new policies and strategies.

Project EPIC (Early Palliative Care In COPD): A Formative and Summative Evaluation of the EPIC Telehealth Intervention

CONTEXT

Early, concurrent palliative care interventions in chronic obstructive pulmonary disease (COPD) are limited. Project EPIC (Early Palliative Care In COPD) is a multiphase mixed methods study working to fill this gap.

OBJECTIVES

To conduct a formative and summative evaluation of EPIC, a telephonic nurse coach-led early palliative care intervention for COPD adapted from the ENABLE© intervention in cancer.

METHODS

Phase I Formative Evaluation: Patients with moderate-to-very-severe COPD, family caregivers, and pulmonary and palliative care clinicians rated the acceptability and feasibility of EPIC (≥4 out of five on a Likert-scale survey). Phase II Summative Evaluation: Patients and family caregivers in Phase I participated in a pilot of the three month EPIC prototype to evaluate intervention and data collection feasibility (≥70% completion) and to seek qualitative feedback.

RESULTS

Phase I Formative Evaluation: Patients (n=10), family caregivers (n=10), pulmonary clinicians (n=6), and palliative care clinicians (n=6) found EPIC acceptable and feasible to support adaptation, while priority early palliative care needs in COPD from our prior research mapped well to the EPIC prototype. Phase II Summative Evaluation: Patients (n=5; ages 49-72, 40% moderate COPD, 40% Black) and their family caregivers (n=5; ages 51-73, 40% Black) completed 100% of EPIC prototype components, including weekly telephone sessions, a one month follow-up call, Advance Directive, palliative care clinic attendance, and 95% of monthly phone data collection sessions. Feedback from participants about EPIC was all positive.

CONCLUSION

EPIC was acceptable and feasible in patients with COPD and their family caregivers. Larger feasibility and effectiveness trials are warranted.

The feasibility and acceptability of an early tele-palliative care intervention to improve quality of life in heart failure patients in Iran: A protocol for a randomized controlled trial

Background

Heart failure (HF) has become a global health problem that has affected the quality of life of millions of people. One approach to improving patients’ quality of life (QoL) with chronic diseases such as HF is palliative care. In Iran, the bulk of palliative care research is directed to patients with cancer, with the primary focus on the physical aspect rather than the psychosocial and spiritual aspects of palliative care. To address this gap, this study aims to determine the feasibility and acceptability of this early tele-palliative care intervention to improve quality of life in heart failure patients in Iran.

Methods

The early tele-palliative care versus usual care study is designed as a single-centre, randomised, feasibility trial of 50 patients with heart failure aged 18 to 65 and clinician-determined New York Heart Association class II/III or American College of Cardiology stage B/C HF, recruited in Imam Khomeini Hospital Complex, Tehran, Iran. This intervention contains 6 weekly educational webinars and concurrent WhatsApp® group activities. Program feasibility and acceptability will be assessed by measuring the recruitment, attrition, and questionnaire completion rates; satisfaction and attitudes about the intervention will be measured via a telephone-based interviews. Secondary outcomes of Qol, mood status and number of emergency department visits will be measured with validated instruments. Participants in both groups will be followed up for 6 weeks, and the measures will be re-administered. Appropriate statistical tests will be used to analyse the data.

Conclusion

This is the first early tele-palliative care intervention designed for heart failure patients in Iran. The intervention has been developed by a multidisciplinary team of academic and clinical professionals with patient stakeholder input to create a rigorous and culturally responsive approach for palliative care delivery for heart failure patients in Iran.

Trial registration

IRCT registration number - IRCT20100725004443N29.

Nurse-led heart failure educational interventions for patient and informal caregiver dyads: An integrative review

BACKGROUND

Heart failure is a major health problem with significant economic burden in the United States. Educating heart failure dyads (heart failure patient and informal caregiver) is a relatively new domain and is being proposed by providers, policy makers, and third-party payors. Nurse-led dyad education can improve quality of life and reduce hospital admissions in the heart failure population.

OBJECTIVES

This integrative literature review focused on evaluating design, delivery content, and outcomes of nurse-led dyadic educational interventions.

METHODS

PubMed, CINAHL, Cochrane, and Google Scholar databases (1999 -2022) were searched for quantitative and qualitative studies that included these search terms: heart failure, dyads, nonmedical caregivers, caregivers, randomized controlled trials, nurse-led education, education.

RESULTS

The search yielded 92 articles. The results included seven randomized controlled trials and one pilot study conducted from 2005 to 2017. Sample sizes ranged from 20 to 155 dyads. Dyads who received education interventions had positive outcomes. Face-to-face coaching provided stronger outcomes. Interventions varied in length from baseline to three months, with post-intervention follow-ups from one to 12 months.

CONCLUSIONS

A paucity of studies of nurse-led heart failure dyadic educational interventions have been reported in the literature. To advance the science and decrease heart failure readmissions, greater efforts to study and incorporate education and support for heart failure dyads is needed, along with assessment of both patient and caregiver outcomes.

African American Recruitment in Early Heart Failure Palliative Care Trials: Outcomes and Comparison With the ENABLE CHF-PC Randomized Trial

BACKGROUND

Palliative care trial recruitment of African Americans (AAs) is a formidable research challenge.

OBJECTIVES

Examine AA clinical trial recruitment and enrollment in a palliative care randomized controlled trial (RCT) for heart failure (HF) patients and compare patient baseline characteristics to other HF palliative care RCTs.

METHODS

This is a descriptive analysis the ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends: Comprehensive Heartcare for Patients and Caregivers) RCT using bivariate statistics to compare racial and patient characteristics and differences through recruitment stages. We then compared the baseline sample characteristics among three palliative HF trials.

RESULTS

Of 785 patients screened, 566 eligible patients with NYHA classification III-IV were approached; 461 were enrolled and 415 randomized (AA = 226). African Americans were more likely to consent than Caucasians (55%; P FDR = .001), were younger (62.7 + 8; P FDR = .03), had a lower ejection fraction (39.1 + 15.4; PFDR = .03), were more likely to be single (P FDR = .001), and lack an advanced directive (16.4%; P FDR < .001). AAs reported higher goal setting (3.3 + 1.3; P FDR = .007), care coordination (2.8 + 1.3; P FDR = .001) and used more "denial" coping strategies (0.8 + 1; P FDR = .001). Compared to two recent HF RCTs, the ENABLE CHF-PC sample had a higher proportion of AAs and higher baseline KCCQ clinical summary scores.

CONCLUSION

ENABLE CHF-PC has the highest reported recruitment rate and proportion of AAs in a palliative clinical trial to date. Community-based recruitment partnerships, recruiter training, ongoing communication with recruiters and clinician co-investigators, and recruiter racial concordance likely contributed to successful recruitment of AAs. These important insights provide guidance for design of future HF palliative RCTs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Survival time to complications of congestive heart failure patients at Felege Hiwot comprehensive specialized referral hospital, Bahir Dar, Ethiopia

BACKGROUNDS

Congestive heart failure is a serious chronic condition when the heart's muscles become too damaged and a condition in which one or both ventricles cannot pump sufficient blood to meet the metabolic needs of the body. This study aimed to identify factors affecting the complications time of congestive heart failure patients treated from January 2016 to December 2019 at Felege Hiwot comprehensive specialized referral hospital in Bahir Dar, Ethiopia.

METHODS

A hospital-based retrospective data collection was collected from the medical charts of 218 randomly selected congestive heart failure patients. The Kaplan-Meier curve and the Cox proportional hazards model were used to compare and identify the factors associated with time to complication in patients with congestive heart failure.

RESULTS

The median complication time of congestive heart failure patients was 22 months [95% CI: 21.98-28.01]. About 194 (88.99%) of the patients were complicated. The Kaplan-Meier curve depicts the survival probability of complicated patients decreasing as the complication time increases. The hazard ratios for serum sodium concentration, left ventricular ejection fraction, patients from rural areas, age of patients, serum hemoglobin concentration, and New York heart association classes I, II, and III were given 0.94 [95% CI: 0.90-1.00], 0.74 [95% CI: 0.65-0.85], 0.75 [95% CI: 0.68-0.84], 1.28 [95% CI: 1.12-1.46], 0.89 [95% CI: 0.85-0.94], 0.44 [95% CI: 0.36-0.53], 0.54 [95% CI: 0.47-0.62] and 0.73 [95% CI: 0.65-0.81] respectively, and they are statistically associated with the complication time of congestive heart failure patients.

CONCLUSIONS

The median complication time of congestive heart failure patients was 22 months. This study strongly suggests that healthcare awareness should be strengthened earlier about the potential complications for patients with lower serum sodium concentrations below the threshold and aged congestive heart failure patients to reduce the risk of developing complications.

Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study

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.

Behavioral Interventions for the Patient-Caregiver Unit in Patients with Chronic Heart Failure: A Systematic Review of Caregiver Outcomes

Background

Chronic heart failure (CHF) is a debilitating condition that affects millions worldwide. It is accompanied by a myriad of adverse consequences, such asdiminishing of quality of life and deterioration of mental health. Caregivers play a pivotal role in helping CHF patients manage their conditions and symptoms, as a result the physical, mental and emotional state of caregivers have a direct impact on CHF patients and the management of this condition.

Purpose

This systematic review aims to synthesize data about the effectiveness of behavioral interventions targeted at patients with chronic heart failure (CHF) and/or informal caregivers of CHF patients to improve overall management and treatment of CHF in the population.

Patients and Methods

Three databases were searched for published studies and studies that included evaluated outcomes of interventions that targeted CHF patients or informal caregivers. All randomized controlled trials, trials of either experimental or quasi-experimental design were included. Studies that only involved formal caregivers, patient populations of adolescents/young adults and patients with non-chronic conditions were excluded.

Results

Across the 21 included studies, no study reported a significant improvement in all three domains of quality of life (QoL), depression and loneliness of caregivers while only three studies reported a significant improvement in two outcomes. Within each domain, heterogeneity in measures limited quantitative pooling.

Conclusion

This review provides data on the efficacy of interventions targeted at CHF patients and/or informal caregivers. It also highlights successful interventions and its features. Following this, additional resources need to be invested and directed towards implementing these interventions.

Examining Adherence and Dose Effect of an Early Palliative Care Intervention for Advanced Heart Failure Patients

CONTEXT

Research priority guidelines highlight the need for examining the "dose" components of palliative care (PC) interventions, such as intervention adherence and completion rates, that contribute to optimal outcomes.

OBJECTIVES

Examine the "dose" effect of PC intervention completion vs. noncompletion on quality of life (QoL) and healthcare use in patients with advanced heart failure (HF) over 32 weeks.

METHODS

Secondary analysis of the ENABLE CHF-PC intervention trial for patients with New York Heart Association (NYHA) Class III/IV HF. "Completers" defined as completing a single, in-person outpatient palliative care consultation (OPCC) plus 6 weekly, PC nurse coach-led telehealth sessions. "Non-completers" were defined as either not attending the OPCC or completing <6 telehealth sessions. Outcome variables were QoL and healthcare resource use (hospital days; emergency department visits). Mixed models were used to model dose effects for "completers" vs "noncompleters" over 32 weeks.

RESULTS

Of 208 intervention group participants, 81 (38.9%) were classified as "completers" with a mean age of 64.6 years; 72.8% were urban-dwelling; 92.5% had NYHA Class III HF. 'Completers' vs. "non-completers"" groups were well-balanced at baseline; however "noncompleters" did report higher anxiety (6.0 vs 7.0, P < 0.05, d = 0.28). Moderate, clinically significant, improved QoL differences were found at 16 weeks in "completers" vs. "non-completers" (between-group difference: -9.71 (3.18), d = 0.47, P = 0.002) but not healthcare use.

CONCLUSION

Higher intervention completion rates of an early PC intervention was associated with QoL improvements in patients with advanced HF. Future work should focus on identifying the most efficacious "dose" of intervention components and increasing adherence to them.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Referral Practices of Cardiologists to Specialist Palliative Care in Canada

BACKGROUND

Patients with heart failure have palliative care needs that can be effectively addressed by specialist palliative care (SPC). Despite this, SPC utilization by this patient population is low, suggesting barriers to SPC referral. We sought to determine the referral practices of cardiologists to SPC.

METHODS

Cardiologists across Canada were invited to participate in a survey about their referral practices to SPC. Associations between referral practices and demographic, professional, and attitudinal factors were analyzed using multiple and logistic regression.

RESULTS

The response rate was 51% (551 of 1082). Between 35.1% and 64.2% of respondents were unaware of referral criteria to local SPC services. Of the respondents, 29% delayed SPC referral because of prognostic uncertainty, and 46.8% believed that SPC prioritizes patients with cancer. In actual practice, nearly three-fourths of cardiologists referred late. Referral frequency was associated with greater availability of SPC services for patients with nonmalignant diseases (P = 0.008), a higher number of palliative care settings accepting patients receiving continuous infusions or pursuing acute care management (P < 0.001), satisfaction with services (P < 0.001), and less equation of palliative care with end-of-life care (P < 0.001). Early timing of referral was associated with greater availability of SPC services for patients with nonmalignant diseases and less equation of palliative care with end-of-life care.

CONCLUSIONS

The findings suggest that barriers to timely SPC referral include an insufficiency of services for patients with nonmalignant diseases especially in the outpatient setting, the perception that SPC services do not accept patients receiving cardiology-specific treatments, and a misperception about the identity of palliative care.

Telehealth in Palliative Care: Communication Strategies From the COVID-19 Pandemic

Palliative care was once believed to be too high-touch to be delivered via telehealth. However, numerous studies have demonstrated the positive effects of palliative care delivered through telehealth. Because the COVID-19 pandemic has quickly shifted how health care is delivered to patients with cancer, particularly because of their immunocompromised status and the risks associated with unnecessary exposures in the clinic, previous lessons from palliative care research studies can be used to inform practice. This article presents a case study that illustrates evidence and best practices for continuing to deliver palliative care via telehealth after COVID-19 restrictions are lifted.

Development and protocol for a nurse-led telephonic palliative care program

Background

The COVID-19 pandemic has resulted in a profound transformation of health care delivery toward telemedicine models.

Purpose

We present the structure of a nurse-led telephonic palliative program and operational metrics to influence further development of tele-palliative programs.

Methods

The nurses engage with seriously ill patients for 6 months with the goal of discussing advance care planning (ACP) and addressing self-identified issues related to their illness.

Findings

Of the first 100 program graduates, 78% were actively engaged and 51% named a health care agent and/or engaged in ACP. Of the 18 patients who died during the study, 13 (72%) were enrolled in hospice services.

Discussion

Our preliminary results indicate that seriously ill patients are willing to engage with nurses and to participate with discussions on ACP.

Conclusion

Given the gaps in health care exposed by the COVID-19 pandemic, this innovative program serves as an important model for bringing palliative care directly to patients.

Impact of a Palliative Care Education Module in Patients With Heart Failure

Background:

Heart failure (HF) impacts 6.2 million American adults. With no cure, therapies aim to prevent progression and manage symptoms. Inclusion of palliative care (PC) helps improve symptoms and quality of life. Heart failure guidelines recommend the inclusion of PC in HF therapy, but referrals are often delayed.

Objective:

Introduce PC to patients with HF and examine the impact on PC consults, readmission, mortality, and intensive care unit (ICU) transfers.

Methods:

Patients (n = 60) admitted with HF to an academic hospital were asked to view a PC educational module. A number of PC consults, re-admissions, mortality, and transfers to the ICU were compared among participants and those who declined.

Results:

Nine patients in the intervention group (n = 30) requested a PC consult ( P = .042) versus 2 in the usual care group (n = 30; P = .302). There was no statistically significant difference in readmissions, mortality, or ICU transfers between groups.

Conclusions:

Palliative care education increases the likelihood of PC utilization but in this short-term project was not found to statistically impact mortality, re-admissions, or transfers to higher levels of care.

The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers

BACKGROUND

Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families.

SEARCH METHODS

We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available.

MAIN RESULTS

We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I² = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I² = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I² = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I² = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I² = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision.

AUTHORS' CONCLUSIONS

Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.

Rethinking the Meaning of Palliation in Heart Failure

PURPOSE OF REVIEW

Palliative care follows a philosophy of care that focuses upon the quality of life in patients with chronic or life-threatening illness. It also focuses upon the needs of their families which is a wider scope of care. Cardiovascular disease, and specifically heart failure, affects millions of patients and family members who have a symptom burden that exceeds that of many cancers and other chronic diseases.

RECENTLY FINDINGS

Historically palliative care has been viewed as an alternative to curative therapies, but over time, it is now recognized that it should be implemented earlier in the course of chronic diseases. Although non-oncologic patients now comprise over half of the patient seen by palliative care, patients with cardiovascular disease are still not being referred to palliative care. Palliative care goes beyond advance directives and end of life planning. There is a need to continue to expand the view of palliative care to encompass interventions that help improve the overall health of these patients, including their psychosocial well-being and quality of life. The collection of papers in this journal provides insight into the breadth of palliative care for patients with heart failure and other cardiovascular diseases.

Effect of an Early Palliative Care Telehealth Intervention vs Usual Care on Patients With Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial

IMPORTANCE

National guidelines recommend early palliative care for patients with advanced heart failure, which disproportionately affects rural and minority populations.

OBJECTIVE

To determine the effect of an early palliative care telehealth intervention over 16 weeks on the quality of life, mood, global health, pain, and resource use of patients with advanced heart failure.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, intervention vs usual care randomized clinical trial was conducted from October 1, 2015, to May 31, 2019, among 415 patients 50 years or older with New York Heart Association class III or IV heart failure or American College of Cardiology stage C or D heart failure at a large Southeastern US academic tertiary medical center and a Veterans Affairs medical center serving high proportions of rural dwellers and African American individuals.

INTERVENTIONS

The ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers) intervention comprises an in-person palliative care consultation and 6 weekly nurse-coach telephonic sessions (20-40 minutes) and monthly follow-up for 48 weeks.

MAIN OUTCOMES AND MEASURES

Primary outcomes were quality of life (as measured by the Kansas City Cardiomyopathy Questionnaire [KCCQ]: score range, 0-100; higher scores indicate better perceived health status and clinical summary scores ≥50 are considered "fairly good" quality of life; and the Functional Assessment of Chronic Illness Therapy-Palliative-14 [FACIT-Pal-14]: score range, 0-56; higher scores indicate better quality of life) and mood (as measured by the Hospital Anxiety and Depression Scale [HADS]) over 16 weeks. Secondary outcomes were global health (Patient Reported Outcome Measurement System Global Health), pain (Patient Reported Outcome Measurement System Pain Intensity and Interference), and resource use (hospital days and emergency department visits).

RESULTS

Of 415 participants (221 men; baseline mean [SD] age, 63.8 [8.5] years) randomized to ENABLE CHF-PC (n = 208) or usual care (n = 207), 226 (54.5%) were African American, 108 (26.0%) lived in a rural area, and 190 (45.8%) had a high-school education or less, and a mean (SD) baseline KCCQ score of 52.6 (21.0). At week 16, the mean (SE) KCCQ score improved 3.9 (1.3) points in the intervention group vs 2.3 (1.2) in the usual care group (difference, 1.6; SE, 1.7; d = 0.07 [95% CI, -0.09 to 0.24]) and the mean (SE) FACIT-Pal-14 score improved 1.4 (0.6) points in the intervention group vs 0.2 (0.5) points in the usual care group (difference, 1.2; SE, 0.8; d = 0.12 [95% CI, -0.03 to 0.28]). There were no relevant between-group differences in mood (HADS-anxiety, d = -0.02 [95% CI, -0.20 to 0.16]; HADS-depression, d = -0.09 [95% CI, -0.24 to 0.06]).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial with a majority African American sample and baseline good quality of life did not demonstrate improved quality of life or mood with a 16-week early palliative care telehealth intervention. However, pain intensity and interference (secondary outcomes) demonstrated a clinically important improvement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Nonhospice Palliative Care Within the Treatment of End-Stage Liver Disease

Palliative care (PC) that has evolved from a focus on end-of-life care to an expanded form of holistic care at an early stage for patients with serious illnesses and their families is commonly referred to as nonhospice PC (or early PC). Patients with end-stage liver disease (ESLD) suffer from a high symptom burden and a deteriorated quality of life (QOL), with uncertain prognosis and limited treatment options. Caregivers of these patients also bear an emotional and physical burden similar to that of caregivers for patients with cancer. Despite the proven benefits of nonhospice PC for other serious illnesses and cancer, there are no evidence-based structures and processes to support its integration within the routine care of patients with ESLD and their caregivers. In this article, we review the current state of PC for ESLD and propose key structures and processes to integrate nonhospice PC within routine hepatology practice. Results found that PC is highly underutilized within ESLD care, and limited prospective studies are available to demonstrate methods to integrate PC within routine hepatology practices. Hepatology providers report lack of training to deliver PC along with no clear prognostic criteria on when to initiate PC. A well-informed model with key structures and processes for nonhospice PC integration would allow hepatology providers to improve clinical outcomes and QOL for patients with ESLD and reduce health care costs. Educating hepatology providers about PC principles and developing clear prognostic criteria for when and how to integrate PC on the basis of individual patient needs are the initial steps to inform the integration. The fields of nonhospice PC and hepatology have ample opportunities to partner clinically and academically.

Effects of a Telehealth Early Palliative Care Intervention for Family Caregivers of Persons With Advanced Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial

IMPORTANCE

Family caregivers of persons with advanced heart failure perform numerous daily tasks to assist their relatives and are at high risk for distress and poor quality of life.

OBJECTIVE

To determine the effect of a nurse-led palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends Comprehensive Heart Failure for Patients and Caregivers [ENABLE CHF-PC]) on quality of life and mood of family caregivers of persons with New York Heart Association Class III/IV heart failure over 16 weeks.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind randomized clinical trial enrolled caregivers aged 18 years and older who self-identified as an unpaid close friend or family member who knew the patient well and who was involved with their day-to-day medical care. Participants were recruited from outpatient heart failure clinics at a large academic tertiary care medical center and a Veterans Affairs medical center from August 2016 to October 2018.

INTERVENTION

Four weekly psychosocial and problem-solving support telephonic sessions lasting between 20 and 60 minutes facilitated by a trained nurse coach plus monthly follow-up for 48 weeks. The usual care group received no additional intervention.

MAIN OUTCOMES AND MEASURES

The primary outcomes were quality of life (measured using the Bakas Caregiver Outcomes Scale), mood (anxiety and/or depressive symptoms measured using the Hospital Anxiety and Depression Scale), and burden (measured using the Montgomery-Borgatta Caregiver Burden scales) over 16 weeks. Secondary outcomes were global health (measured using the PROMIS Global Health instrument) and positive aspects of caregiving.

RESULTS

A total of 158 family caregivers were randomized, 82 to the intervention and 76 to usual care. The mean (SD) age was 57.9 (11.6) years, 135 (85.4%) were female, 82 (51.9%) were African American, and 103 (65.2%) were the patient's spouse or partner. At week 16, the mean (SE) Bakas Caregiver Outcomes Scale score was 66.9 (2.1) in the intervention group and 63.9 (1.7) in the usual care group; over 16 weeks, the mean (SE) Bakas Caregiver Outcomes Scale score improved 0.7 (1.7) points in the intervention group and 1.1 (1.6) points in the usual care group (difference, -0.4; 95% CI, -5.1 to 4.3; Cohen d = -0.03). At week 16, no relevant between-group differences were observed between the intervention and usual care groups for the Hospital Anxiety and Depression Scale anxiety measure (mean [SE] improvement from baseline, 0.3 [0.3] vs 0.4 [0.3]; difference, -0.1 [0.5]; d = -0.02) or depression measure (mean [SE] improvement from baseline, -0.2 [0.4] vs -0.3 [0.3]; difference, 0.1 [0.5]; d = 0.03). No between-group differences were observed in the Montgomery-Borgatta Caregiver Burden scales (d range, -0.18 to 0.0). Differences in secondary outcomes were also not significant (d range, -0.22 to 0.0).

CONCLUSIONS AND RELEVANCE

This 2-site randomized clinical trial of a telehealth intervention for family caregivers of patients with advanced heart failure, more than half of whom were African American and most of whom were not distressed at baseline, did not demonstrate clinically better quality of life, mood, or burden compared with usual care over 16 weeks. Future interventions should target distressed caregivers and assess caregiver effects on patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

A Comparison of Hospitalized Patients With Heart Failure and Cancer Referred to Palliative Care

IMPORTANCE

Growing evidence shows that palliative care (PC) improves treatment outcomes in patients with heart failure (HF), but few large-scale studies have prospectively evaluated the processes and outcomes associated with PC consultation for such patients in the real world.

OBJECTIVE

To characterize processes and outcomes of PC consultations for hospitalized patients with HF compared with patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of inpatient encounters at community and academic hospitals in the Palliative Care Quality Network enrolled participants between 2013 and 2017. Of a total of 135 197 patients, 57 272 adults with a primary diagnosis of HF or cancer receiving PC consultation were enrolled. Data analysis was performed from April 2018 to December 2019.

EXPOSURES

Primary diagnosis of HF or cancer.

MAIN OUTCOMES AND MEASURES

Symptom improvement and changes in care planning documentation after PC consultation.

RESULTS

At the time of consultation, patients with HF were older (mean age, 75.3 years [95% CI, 75.0-75.5 years] vs 65.2 years [95% CI, 65.0-65.3 years]; P < .001), had lower Palliative Performance Scale scores (mean, 35.6% [95% CI, 35.3%-35.9%] vs 42.4% [95% CI, 42.2%-42.6%]; P < .001), and were more likely to be in a critical care unit (5808 of 16 741 patients [35.3%] vs 4985 of 40 531 patients [12.5%]; P < .001) or a telemetry or step-down unit (5802 of 16 741 patients [35.2%] vs 7651 of 40 531 patients [19.2%]; P < .001) compared with patients with cancer. Patients with HF were less likely than patients with cancer to be referred to PC within 24 hours of admission (6773 of 16 741 patients [41.2%] vs 19 348 of 40 531 patients [49.0%]; P < .001) and had longer hospitalizations before receiving PC consultation requests (mean, 4.6 days [95% CI, 4.4-4.8 days] vs 3.9 days [95% CI, 3.8-4.0 days]; P < .001). Patients with HF were referred less frequently for symptoms other than pain (1686 of 16 488 patients [10.2%] vs 8587 of 39 609 patients [21.7%]; P < .001), but were equally likely to report improvements in anxiety (odds ratio, 0.85; 95% CI, 0.71-1.02; P = .08) and more likely to report improvements in dyspnea (odds ratio, 2.17; 95% CI, 1.83-2.57; P < .001) compared with patients with cancer. Patients with HF were less likely than those with cancer to be discharged alive (odds ratio, 0.78; 95% CI, 0.64-0.96; P = .02) or to be referred to hospice (odds ratio, 0.50; 95% CI, 0.47-0.53; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that PC referral comes late for patients with HF and is used primarily to discuss care planning. Practitioners caring for patients with HF should consider involving PC experts earlier for symptom management.

Multi-disciplinary palliative care is effective in people with symptomatic heart failure: A systematic review and narrative synthesis

BACKGROUND

Despite recommendations, people with heart failure have poor access to palliative care.

AIM

To identify the evidence in relation to palliative care for people with symptomatic heart failure.

DESIGN

Systematic review and narrative synthesis. (PROSPERO CRD42016029911).

DATA SOURCES

Databases (Medline, Cochrane database, CINAHL, PsycINFO, HMIC, CareSearch Grey Literature), reference lists and citations were searched and experts contacted. Two independent reviewers screened titles and abstracts and retrieved papers against inclusion criteria. Data were extracted from included papers and studies were critically assessed using a risk of bias tool according to design.

RESULTS

Thirteen interventional and 10 observational studies were included. Studies were heterogeneous in terms of population, intervention, comparator, outcomes and design rendering combination inappropriate. The evaluation phase studies, with lower risk of bias, using a multi-disciplinary specialist palliative care intervention showed statistically significant benefit for patient-reported outcomes (symptom burden, depression, functional status, quality of life), resource use and costs of care. Benefit was not seen in studies with a single component/discipline intervention or with higher risk of bias. Possible contamination in some studies may have caused under-estimation of effect and missing data may have introduced bias. There was no apparent effect on survival.

CONCLUSION

Overall, the results support the use of multi-disciplinary palliative care in people with advanced heart failure but trials do not identify who would benefit most from specialist palliative referral. There are no sufficiently robust multi-centre evaluation phase trials to provide generalisable findings. Use of common population, intervention and outcomes in future research would allow meta-analysis.

Compendium of Health and Wellness Coaching: 2019 Addendum

The 2019 Addendum, in conjunction with the original health and wellness coaching (HWC) Compendium, organizes HWC literature with the aim of assisting researchers while providing a resource for practitioners. The 2019 Addendum to the HWC Compendium extends the initial work by adding HWC-related literature published in the past 2 years. The 2019 Addendum divides articles retrieved into 8 categories, including a new miscellaneous section complementing categories examining HWC effects on cancer, cholesterol, diabetes, heart disease, hypertension, obesity, and wellness. The 2019 Addendum again provides in-depth information about the nature, quality, and results from each article in a detailed spreadsheet provided as an electronic appendix. The 2019 Addendum contributes another 104 peer-reviewed coaching-related articles to the HWC Compendium. This most recent research again describes HWC as a favorable intervention with treatment potential in all categories, though only 3 new cancer articles were included in the 2019 Addendum. Trends in HWC (ie, e-coaching and group coaching) are identified, and there is also discussion of future research needs. In conclusion, the field of HWC continues to grow, as does the research describing this clinical practice; the 2019 Addendum to the Compendium of HWC organizes and assists understanding of this literature.

Telephone interventions, delivered by healthcare professionals, for providing education and psychosocial support for informal caregivers of adults with diagnosed illnesses

BACKGROUND

Maintaining care for ill persons in the community is heavily dependent on support from unpaid caregivers. Many caregivers, however, find themselves in a caring role for which they are ill prepared and may require professional support. The telephone is an easily accessible method of providing support irrespective of geographical location.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of telephone support interventions, delivered by healthcare professionals, when compared to usual care or non-telephone-based support interventions for providing education and psychosocial support for informal caregivers of people with acute and chronic diagnosed illnesses, and to evaluate the cost-effectiveness of telephone interventions in this population.

SEARCH METHODS

We searched the following databases from inception to 16 November 2018: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; PsycINFO; ProQuest Dissertations and Theses A&I; and CINAHL Complete. We also searched 11 caregiver-specific websites, three conference links, and two clinical trial registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including cluster-RCTs) and quasi-RCTs. We excluded cross-over trials because of the high risk of carry-over effects from one intervention to another.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations against the review's inclusion criteria, extracted data, and assessed the included studies using the Cochrane 'Risk of bias' tool. The review's prespecified primary (quality of life and burden) and secondary outcomes (skill acquisition, psychological health, knowledge, health status and well-being, family functioning, satisfaction, and economic outcomes), where reported, were assessed at the end of intervention delivery and at short-term (≤ 3 months), medium-term (> 3 to ≤ 6 months) and longer-term time points (> 6 to 12 months) following the intervention. Where possible, meta-analyses were conducted, otherwise results were reported narratively.

MAIN RESULTS

We included 21 randomised studies involving 1,690 caregivers; 19 studies compared telephone support interventions and usual care, of which 18 contributed data to the analyses. Two studies compared telephone and non-telephone professional support interventions. Caregiver ages ranged from 19 years to 87 years across studies. The majority of participants were female (> 70.53%), with two trials including females only. Most caregivers were family members, educated beyond secondary or high school level or had the equivalent in years of education. All caregivers were based in the community. Overall risk of bias was high for most studies.The results demonstrated that there is probably little or no difference between telephone support interventions and usual care for the primary outcome of quality of life at the end of intervention (SMD -0.02, 95% CI -0.24 to 0.19, 4 studies, 364 caregivers) (moderate-certainty evidence) or burden at the end of intervention (SMD -0.11, 95% CI -0.30 to 0.07, 9 studies, 788 caregivers) (low-certainty evidence). For one study where quality of life at the end of intervention was reported narratively, the findings indicated that a telephone support intervention may result in slightly higher quality of life, compared with usual care. Two further studies on caregiver burden were reported narratively; one reported that telephone support interventions may decrease burden, the other reported no change in the intervention group, compared with usual care.We are uncertain about the effects of telephone support interventions on caregiver depression at the end of intervention (SMD -0.37, 95% CI -0.70 to -0.05, 9 studies, 792 caregivers) due to very low-certainty evidence for this outcome. Depression was reported narratively for three studies. One reported that the intervention may reduce caregiver depression at the end of intervention, but this effect was not sustained at short-term follow-up. The other two studies reported there may be little or no difference between telephone support and usual care for depression at the end of intervention. Six studies measured satisfaction with the intervention but did not report comparative data. All six reported high satisfaction scores with the intervention. No adverse events, including suicide or suicide ideation, were measured or reported by any of the included studies.Our analysis indicated that caregiver anxiety may be slightly reduced (MD -6.0, 95% CI -11.68 to -0.32, 1 study, 61 caregivers) and preparedness to care slightly improved (SMD 0.37, 95% CI 0.09 to 0.64, 2 studies, 208 caregivers) at the end of intervention, following telephone-only support interventions compared to usual care. Findings indicated there may be little or no difference between telephone support interventions and usual care for all of the following outcomes at the end of intervention: problem-solving, social activity, caregiver competence, coping, stress, knowledge, physical health, self-efficacy, family functioning, and satisfaction with supports (practical or social). There may also be little or no effect of telephone support interventions for quality of life and burden at short-term follow-up or for burden and depression at medium-term follow-up.Litttle or no difference was found between groups for any of the reported outcomes in studies comparing telephone and non-telephone professional support interventions. We are uncertain as to the effects of telephone support interventions compared to non-telephone support interventions for caregiver burden and depression at the end of intervention. No study reported on quality of life or satisfaction with the intervention and no adverse events were reported or noted in the two studies reporting on this comparison.

AUTHORS' CONCLUSIONS

Although our review indicated slight benefit may exist for telephone support interventions on some outcomes (e.g. anxiety and preparedness to care at the end of intervention), for most outcomes, including the primary outcomes, telephone-only interventions may have little or no effect on caregiver outcomes compared to usual care. The findings of the review were mainly based on studies with overall high risk of bias, and few participants. Further high-quality trials, with larger sample sizes are required.

Understanding and Measuring Symptom Burden in Heart Failure: A Concept Analysis

Heart failure is a common, complex, and costly condition accompanied by a high degree of symptom burden. The concept of heart failure symptom burden has been used and measured inconsistently in research. To develop effective symptom management and palliation strategies, a clear conceptual understanding is needed. Rodgers' evolutionary method of concept analysis was used to identify articles in CINAHL, Embase, Scopus, and PubMed focused on chronic heart failure. Analysis of 20 articles revealed key attributes (subjectivity, negative impact on daily life and/or overall functioning, synergistic symptom associations, and symptom exacerbation), related terms (symptom distress and symptom experience), a surrogate term (heart failure burden), antecedents (heart failure classification or stage), and consequences (increased morbidity/mortality, decreased functioning, increased symptom prevalence/severity, decreased quality of life, and recurrent hospital admissions). No gold standard for measurement was identified. Research is needed to validate heart failure symptom burden measurement strategies across populations.

Looking Back, Moving Forward: A Retrospective Review of Care Trends in an Academic Palliative and Supportive Care Program from 2004 to 2016

Objective: To examine a rural-serving HBPC program's 12-year experience and historical trends to inform future program direction and expansion. Background: There is limited information about longitudinal trends in mature hospital-based palliative care (HBPC) programs serving racially diverse rural populations. Methods: This is a retrospective cross-sectional study of operational and patient-reported outcomes from the University of Alabama at Birmingham (UAB) Center for Palliative and Supportive Care (CPSC) inpatient (n=11,786) and outpatient (n=315) databases from October 2004 to March 2016. Results: Inpatients were a mean age of 63.7 years, male (50.1%), white (62.3%), general medicine referred (19.5%), primarily for goals of care (84.4%); 47.1% had "do not resuscitate/do not intubate" status and 46.9% were transferred to the Palliative Care and Comfort Unit (PCCU) after consultation. Median time from admission to consultation was three days, median PCCU length of stay (LOS) was four days, and median hospital LOS was nine days. Increased emergency department and cardiology referrals were notable in later years. Outpatients' mean age was 53.02 years, 63.5% were female, 76.8% were white, and 75.6% had a cancer diagnosis. Fatigue, pain, and disturbed sleep were the most common symptoms at the time of the visit; 34.6% reported mild-to-moderate depressive symptoms. Of patients reporting pain (64.8%), one-third had 50% or less relief from pain treatment. Discussion: The CPSC, which serves a racially diverse rural population, has demonstrated robust growth. We are poised to scale and spread our lessons learned to underserved communities.

Service Delivery Models to Maximize Quality of Life for Older People at the End of Life: A Rapid Review

Policy Points We identified two overarching classifications of integrated geriatric and palliative care to maximize older people's quality of life at the end of life. Both are oriented to person-centered care, but with differing emphasis on either function or symptoms and concerns. Policymakers should both improve access to palliative care beyond just the last months of life and increase geriatric care provision to maintain and optimize function. This would ensure that continuity and coordination for potentially complex care needs across the continuum of late life would be maintained, where the demarcation of boundaries between healthy aging and healthy dying become increasingly blurred. Our findings highlight the urgent need for health system change to improve end-of-life care as part of universal health coverage. The use of health services should be informed by the likelihood of benefits and intended outcomes rather than on prognosis.

CONTEXT

In an era of unprecedented global aging, a key priority is to align health and social services for older populations in order to support the dual priorities of living well while adapting to a gradual decline in function. We aimed to provide a comprehensive synthesis of evidence regarding service delivery models that optimize the quality of life (QoL) for older people at the end of life across health, social, and welfare services worldwide.

METHODS

We conducted a rapid scoping review of systematic reviews. We searched MEDLINE, CINAHL, EMBASE, and CDSR databases from 2000 to 2017 for reviews reporting the effectiveness of service models aimed at optimizing QoL for older people, more than 50% of whom were older than 60 and in the last one or two years of life. We assessed the quality of these included reviews using AMSTAR and synthesized the findings narratively.

RESULTS

Of the 2,238 reviews identified, we included 72, with 20 reporting meta-analysis. Although all the World Health Organization (WHO) regions were represented, most of the reviews reported data from the Americas (52 of 72), Europe (46 of 72), and/or the Western Pacific (28 of 72). We identified two overarching classifications of service models but with different target outcomes: Integrated Geriatric Care, emphasizing physical function, and Integrated Palliative Care, focusing mainly on symptoms and concerns. Areas of synergy across the overarching classifications included person-centered care, education, and a multiprofessional workforce. The reviews assessed 117 separate outcomes. A meta-analysis demonstrated effectiveness for both classifications on QoL, including symptoms such as pain, depression, and psychological well-being. Economic analysis and its implications were poorly considered.

CONCLUSIONS

Despite their different target outcomes, those service models classified as Integrated Geriatric Care or Integrated Palliative Care were effective in improving QoL for older people nearing the end of life. Both approaches highlight the imperative for integrating services across the care continuum, with service involvement triggered by the patient's needs and likelihood of benefits. To inform the sustainability of health system change we encourage economic analyses that span health and social care and examine all sources of finance to understand contextual inequalities.

Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study

BACKGROUND

Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF).

OBJECTIVES

To describe evaluation practices and treatment recommendations made during protocol-driven OPCCs for advanced HF.

METHODS

We performed content analysis of OPCCs completed as part of ENABLE CHF-PC, an early palliative care HF intervention, conducted at sites in the Northeast and Southeast. T-tests, Fisher's exact, and Chi-square tests were used to evaluate sociodemographic, outcome measures, and site content differences.

RESULTS

Of 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast, n=27; Southeast, n=12). Social and medical history assessed most were close relationships (n=35, 90%), family support (n=33, 85%), advance directive status (n=33, 85%), functional status (n=30, 77%); and symptoms were mood (n= 35, 90%), breathlessness (n=28, 72%), and chest pain (n=24, 62%). Treatment recommendations focused on care coordination (n=13, 33%) and specialty referrals (n=12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%).

CONCLUSION

OPCCs for HF focused on evaluating medical and social history, along with goals of care and code status discussions. Symptom evaluation commonly included mood disorders, pain, dyspnea, and fatigue. Notable regional differences were found in topics evaluated and OPCC completion rates.

Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers (ENABLE CHF-PC): study protocol for a randomized controlled trial

BACKGROUND

Palliative care is specialized medical care for people with serious illness that is focused on providing relief from symptoms and stress and improving the quality of life (QOL) for patients and their families. To help the 6.5 million U.S. adults and families affected by heart failure manage the high symptom burden, complex decision-making, and risk of exacerbation and death, the early integration of palliative care is critical and has been recommended by numerous professional organizations. However, few trials have tested early outpatient community-based models of palliative care for patients diagnosed with advanced heart failure and their caregivers. To address this gap, through a series of formative evaluation trials, we translated an oncology early palliative care telehealth intervention for heart failure to create ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends, Comprehensive Heartcare for Patients and Caregivers).

METHODS/DESIGN

The primary objective of this multisite pragmatic randomized controlled trial is to test the efficacy of ENABLE CHF-PC plus usual heart failure care compared to usual care alone. Community-dwelling persons who are ≥50 years of age with New York Heart Association class III/IV or American Heart Association/American College of Cardiology stage C/D heart failure and their primary caregiver (if present) are being randomized to one of two study arms. The ENABLE CHF-PC intervention group receives usual heart failure care plus an in-person palliative care assessment by a board-certified palliative care provider (caregivers are invited to attend), a series of nurse coach-led, weekly psychoeducational 20 to 60 min phone sessions using a guidebook called Charting Your Course (patients: 6 sessions and caregivers: 4 sessions), and monthly check-in calls. Charting Your Course topical content includes problem-solving, coping, self-care and symptom management, communication, decision-making, advance care planning, and life review (patients only). Primary outcomes include patient QOL and mood (depressive symptoms/anxiety) and caregiver QOL, mood, and burden at 8 and 16 weeks after baseline. Outcomes will be examined using an intention-to-treat approach and mixed effects modeling for repeated measures.

DISCUSSION

This trial will determine whether the ENABLE CHF-PC model of concurrent heart failure palliative care is superior to usual heart failure care alone in achieving higher patient and caregiver QOL, improving mood, and lowering burden.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02505425 . Registered on 22 July 2015.