Characteristics and views of family carers of older people with heart failure

Empowered But Isolated: A Qualitative Research on Experiences of Family Caregivers of Patients With Acute Heart Failure in China

BACKGROUND

Family caregivers play crucial roles in the self-management of patients with heart failure (HF). However, little is known about caregiving experiences of Chinese family caregivers during acute HF.

OBJECTIVE

The aim of this study was to describe Chinese family caregivers' experiences in symptom management and care-seeking during acute HF.

METHODS

This is an exploratory, qualitative study using the Consolidated Criteria for Reporting Qualitative Research guidelines. Data were collected through semistructured interviews and analyzed with thematic analysis.

FINDINGS

A total of 21 family caregivers of patients with acute HF were enrolled in this study. "Empowered but isolated" was identified as the overarching theme during data analysis, including 3 themes and 6 subthemes: (1) "Responsible symptom managers: leading the home-based symptom management," including 2 subthemes, "Proxy in symptom management" and "Only knowing the surface, instead of the truth"; (2) "Powerless anchors: care-seeking is a torturous journey," including 2 subthemes, "Facing discrepancies in care-seeking" and "Seeing a doctor is the last choice"; (3) "Carrying the weight forward: responsibility combing with emotional burnout," including 2 subthemes, "Living on tenterhooks" and "Submitting to fate."

CONCLUSIONS

In this study, we described Chinese family caregivers' experiences in symptom management and care-seeking during acute HF. Although empowered as proxy, they were also isolated bearing a great burden, receiving insufficient support from patients, family, and the medical system.

Experiences on Providing Home Care for A Relative with Heart Failure: A Qualitative Study

PURPOSE

The aim of this study was to explore and describe the lived experiences of persons providing home care for community-dwelling relative with heart failure (HF) in Jordan. Design: It was a phenomenological study. Methods: Data were collected through interviews with 29 participants and analyzed using a thematic analysis approach. Findings: Four core themes have emerged: caregiving as a mandatory responsibility, positive experiences, negative experiences, and factors influencing the quality of the experiences. Conclusion: Although the hallmark of the participants' experience was negative, they showed a strong commitment to caring for their ill relatives. Clinical Evidence: The findings underscore the need for frequent assessment and support of family caregivers.

Changes in Social Support and Relational Mutuality as Moderators in the Association Between Heart Failure Patient Functioning and Caregiver Burden

BACKGROUND

Caregivers to patients with heart failure (HF) may experience substantial burden in their roles, yet little is known about factors that exacerbate caregiver burden over time.

OBJECTIVES

We test the moderating role of changes in caregivers' social support and patient-caregiver relationship mutuality in the association between HF patient functioning and caregiver burden.

METHODS

Data were analyzed using Stata 13.1 for 100 HF primary caregivers, the majority of whom were female (81%), living with the patient (87%), and married or partnered to the patient (70%). Patients reported on dyspnea, disability level, and symptom severity, and caregivers reported on patient-caregiver mutuality, social support, and perceived caregiver burden at both baseline and a 12-month follow-up.

RESULTS

Regression analyses using the Structural Equation Modeling framework revealed that declines in caregiver-patient mutuality over the 12 months of the study amplified the association between patient functioning (ie, dyspnea, symptom severity, and disability) and caregiver burden. Change in social support did not significantly moderate the association between any of the patient functioning variables and caregiver burden.

CONCLUSIONS

Caregivers' relationships with their care recipient shape how they respond to and interpret the demands of caregiving, and relationships experiencing negative changes over time contribute to caregiver burden. Promoting and sustaining positive social relationships within the caregiver-patient dyad is thus a promising avenue for interventions aimed at reducing the burden experienced by caregivers to patients with HF.

Informal carers' experiences of caring for a person with heart failure in a community setting

Heart failure (HF) is a life-limiting condition with a poor prognosis and unpredictable disease trajectory. HF brings physical and emotional challenges for patients and their carers. Predominantly the informal carer population consists of older females, however, caring is evolving as longevity increases and complex conditions are becoming more commonplace. Consequently, more men and younger people are contributing to daily care. The aim of this study was to explore the positive as well as negative dimensions of caring in HF across a range of carer characteristics. Fourteen semi-structured interviews were conducted with informal carers of people with HF in the UK (median age 71; female 10). Interviews were transcribed verbatim and analysed with the assistance of NVivo10 using Interpretative Phenomenological Analysis. Findings from the study demonstrated that most participants considered caring as integral to their relationships. Dimensions facilitating positivity in caring included compassion, thoughtfulness and understanding. An ability to cope was influenced by a range of attributes including quality of relationships in the carer/patient dyad and with formal social care providers who offered access to tailored and timely information and support. The unpredictable HF disease trajectory influenced the carer experience and enhanced the challenges encountered. The information needs of carers were not always adequately met and younger adult carers expressed particular difficulties with appropriate information and support. Expectations of our informal carer population are increasing and evolving. Health and social care policy requires innovative proposals for the funding and delivery of health and social care that has the contribution made by informal carers at its core.

Depressive symptoms in the family caregivers of patients with heart failure: an integrative review

AIMS

Identify the occurrence of depressive symptoms in family caregivers of patients with heart failure and the correlation of other variables with depressive symptoms.

DESIGN/METHOD

The literature review was conducted in the Web of Science, Medline, LILACS and PubMed databases in March 2017. Papers published between 2004 and 2016, written in English, Spanish or Portuguese were included. The descriptors used were health, heart failure, depression, caregivers, and family.

RESULTS

26 papers were selected. 6% to 64% reported depressive symptoms. Depressive symptoms were associated with patients' and caregivers' characteristics. In most cases, depressive symptoms were greater among family caregivers than in the general population and were mainly associated with care burden and quality of life.

CONCLUSIONS

The studies report depressive symptoms in caregivers of patients with heart failure.

Caregiver Well-being and Patient Outcomes in Heart Failure: A Meta-analysis

BACKGROUND

Despite evidence from the broader caregiving literature about the interdependent nature of the caregiving dyad, few studies in heart failure (HF) have examined associations between caregiver and patient characteristics.

OBJECTIVE

The aim of this study is to quantitatively synthesize the relationships between caregiver well-being and patient outcomes.

METHODS

The MEDLINE, PsycINFO, and CINAHL databases were searched for studies of adult HF patients and informal caregivers that tested the relationship between caregiver well-being (perceived strain and psychological distress) and patient outcomes of interest. Summary effects across studies were estimated using random effects meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 15 articles meeting inclusion criteria were included in the meta-analysis. Taking into account differences across studies, higher caregiver strain was associated significantly with greater patient symptoms (Fisher z = 0.22, P < .001) and higher caregiver strain was associated significantly with lower patient quality of life (Fisher z = -0.36, P < .001). Relationships between caregiver psychological distress and both patient symptoms and quality of life were not significant. Although individual studies largely found significant relationships between worse caregiver well-being and higher patient clinical event-risk, these studies were not amenable to meta-analysis because of substantial variation in event-risk measures.

CONCLUSIONS

Clinical management and research approaches that acknowledge the interdependent nature of the caregiving dyad hold great potential to benefit both patients and caregivers.

Family caregiving for persons with heart failure at the intersection of heart failure and palliative care: a state-of-the-science review

Many of the 23 million individuals with heart failure (HF) worldwide receive daily, unpaid support from a family member or friend. Although HF and palliative care practice guidelines stipulate that support be provided to family caregivers, the evidence base to guide care for this population has not been comprehensively assessed. In order to appraise the state-of-the-science of HF family caregiving and recommend areas for future research, the aims of this review were to summarize (1) how caregivers influence patients, (2) the consequences of HF for caregivers, and (3) interventions directed at HF caregivers. We reviewed all literature to December 2015 in PubMed and CINAHL using the search terms "heart failure" AND "caregiver." Inclusion criteria dictated that studies report original research of HF family caregiving. Articles focused on children or instrument development or aggregated HF with other illnesses were excluded. We identified 120 studies, representing 5700 caregivers. Research on this population indicates that (1) caregiving situations vary widely with equally wide-ranging tasks for patients to help facilitate their health behaviors, psychological health and relationships, and quality of life (QoL); (2) caregivers have numerous unmet needs that fluctuate with patients' unpredictable medical status, are felt to be ignored by the formal healthcare system, and can lead to distress, burden, and reduced QoL; and (3) relatively few interventions have been developed and tested that effectively support HF family caregivers. We provide recommendations to progress the science forward in each of these areas that moves beyond descriptive work to intervention development and clinical trials testing.

"Sometimes we can't fix things": a qualitative study of health care professionals' perceptions of end of life care for patients with heart failure

BACKGROUND

Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care.

METHODS

A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK - the Midlands, South Central and South West.

RESULTS

The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients' lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished.

CONCLUSIONS

The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included.

Te Pākeketanga: living and dying in advanced age--a study protocol

BACKGROUND

The number of people dying in advanced old age is increasing rapidly and building the evidence base regarding end - of - life care for older people has been identified as an international policy priority. The unique opportunity to link longitudinal studies of ageing with studies exploring the end of life circumstances of older people remains under-exploited internationally. Very little is known about the specific circumstances, cultural needs and care preferences of indigenous older people, including Māori, at end - of - life and the needs of their whānau/ extended family carers.

METHODS

We will use rigorous qualitative methods to conduct post-bereavement interviews with bereaved whānau and family of 50-60 people who died >80 years; approximately half of participants will be Maori. The older decedents were participants in the first longitudinal study of older people involving a specific indigenous cohort internationally: Te Puāwaitanga O Ngā Tapuwae Kia Ora Tonu, Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ). Prior to death, they completed a questionnaire regarding their end-of-life preferences and nominated a family or whānau member to participate in this separate study exploring end-of-life circumstances of those in advanced age.

DISCUSSION

Recommendations to improve care will be formulated in collaboration with participants and their local hapū (sub-tribe). Ultimately this study has the potential to inform better outcomes for the growing numbers of people dying in advanced old age both in New Zealand and internationally, as well as their whānau and family caregivers. It also highlights the ability to generate an in-depth understanding of end-of-life circumstances by appending studies of palliative and end-of-life care onto existing longitudinal studies.

A new instrument to measure quality of life of heart failure family caregivers

BACKGROUND AND PURPOSE

Family caregivers of heart failure (HF) patients experience poor physical and mental health leading to poor quality of life. Although several quality-of-life measures exist, they are often too generic to capture the unique experience of this population. The purpose of this study was to evaluate the psychometric properties of the Family Caregiver Quality of Life (FAMQOL) Scale that was designed to assess the physical, psychological, social, and spiritual dimensions of quality of life among caregivers of HF patients.

SAMPLE AND METHODS

Psychometric testing of the FAMQOL with 100 HF family caregivers was conducted using item analysis, Cronbach α, intraclass correlation, factor analysis, and hierarchical multiple regression guided by a conceptual model. Caregivers were predominately female (89%), white, (73%), and spouses (62%).

RESULTS

Evidence of internal consistency reliability (α=.89) was provided for the FAMQOL, with item-total correlations of 0.39 to 0.74. Two-week test-retest reliability was supported by an intraclass correlation coefficient of 0.91. Using a 1-factor solution and principal axis factoring, loadings ranged from 0.31 to 0.78, with 41% of the variance explained by the first factor (eigenvalue=6.5). With hierarchical multiple regression, 56% of the FAMQOL variance was explained by model constructs (F8,91=16.56, P<.001). Criterion-related validity was supported by correlations with SF-36 General (r=0.45, P<.001) and Mental (r=0.59, P<.001) Health subscales and Bakas Caregiving Outcomes Scale (r=0.73, P<.001). Evidence of internal and test-retest reliability and construct and criterion validity was provided for physical, psychological, and social well-being subscales.

CONCLUSIONS

The 16-item FAMQOL is a brief, easy-to-administer instrument that has evidence of reliability and validity in HF family caregivers. Physical, psychological, and social well-being can be measured with 4-item subscales. The FAMQOL scale could serve as a valuable measure in research, as well as an assessment tool to identify caregivers in need of intervention.

A qualitative study of informal caregivers' perspectives on the effects of idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a life-shortening lung disease that leads to significant morbidity in patients. The devastation IPF imposes extends beyond patients: it affects their spouses, loved ones and any other person who might take on the role of informal caregiver (IC) to the patient.

OBJECTIVE

The aim of this study was to capture ICs' perspectives on how they are affected by having a loved one with IPF. Given ICs' vantage, data were also collected on their perceptions of how IPF impacted their patient-loved ones over the course of the disease.

METHODS

Reflexive team analysis was used to analyse the transcripts from semistructured focus groups conducted with ICs of patients with IPF. Based on the analyses, a conceptual framework of the IC's journey with a patient with IPF was developed and includes suggestions for interventions that might ease the burdens ICs endure while caring for their patient-loved ones.

RESULTS

14 ICs included in this study experienced several hardships throughout the course of their loved ones' illness, from emotional devastation at the time of diagnosis to living with an 'impatient,' 'cranky' loved one and being forced to exist in a 'smaller world' because of the physical limitations IPF imposed on their partners. The threat of patients needing supplemental oxygen was central to creating angst among patients and ICs, and supplemental oxygen use by patients prohibited them and their ICs from living the 'normal', carefree lives they desired.

CONCLUSIONS

Being an IC to a patient with IPF is extremely challenging (as 1 IC put it: "…harder on the spouse than the patient in some ways"). As patients attempt to adapt to the 'sick person' role, ICs face a struggle between performing their duties as caregiver and maintaining their own identities and independence.

Family caregivers of patients with heart failure: a longitudinal study

BACKGROUND

The family caregivers of patients with heart failure (HF) report burden and poor quality of life, but little is known about changes in their perceptions over time.

OBJECTIVES

The aims of this study were (1) to evaluate changes in caregiver burden (perceived time spent and difficulty with caregiving tasks), perceived control, depressive symptoms, anxiety, perceived life changes, and physical and emotional health-related quality of life; (2) to determine differences in perceptions between caregivers of patients with low HF symptoms (New York Heart Association class I and II) and caregivers of patients with high HF symptoms (New York Heart Association class III and IV); and (3) to the estimate time spent performing caregiving tasks.

METHODS

Sixty-three HF patients and 63 family caregivers were enrolled; 53 caregivers completed the longitudinal study. Data were collected from medical records and interviews conducted by advanced practice nurses at baseline and 4 and 8 months later.

RESULTS

Caregivers who completed the study had significant improvements in perceived time spent on and difficulty of caregiving tasks from baseline to 4 and 8 months, and depressive symptoms decreased from baseline to 8 months. Perceived life changes resulting from caregiving became more positive from baseline to 4 and 8 months. Perceived control, anxiety, and health-related quality of life did not change. Compared with caregivers of patients with low symptoms, caregivers of patients with high symptoms perceived that they spent more time on tasks and that tasks were more difficult, had higher anxiety, and had poorer physical health-related quality of life. Estimated time in hours spent providing care was high.

CONCLUSIONS

In this sample, perceptions of the caregiving experience improved over 8 months. Health-related quality of life was moderately poor over the 8 months. Caregivers of patients with more severe HF symptoms may be particularly in need of interventions to reduce time and difficulty of caregiving tasks and improve physical health-related quality of life.

One size does not fit all: the different experiences of those with chronic heart failure, type 2 diabetes and chronic obstructive pulmonary disease

INTRODUCTION

The Australian federal government is developing a policy response to chronic disease in Australia. The Serious and Continuing Illness Policy and Practice Study examined the experience of individuals with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or type 2 diabetes mellitus (diabetes) in the Australian Capital Territory (ACT) and Western Sydney. This paper describes the disease-specific experiences of people interviewed.

METHODS

We conducted semi-structured interviews with 40 individuals aged 45-85 years with CHF, COPD or diabetes in 2008. Interviews were recorded and transcribed. Qualitative content analysis was performed, assisted by QSR Nvivo 8 qualitative data software.

RESULTS

Participants with CHF (n=9) came to terms with the prospect of unpredictable sudden death. Participants with COPD (n=15) were angry about limitations it imposed on their lives. Participants with diabetes (n=16) experienced a steep learning curve in self-management of their condition surrounded by high levels of uncertainty.

CONCLUSION

Although people with chronic illness share many experiences, a person's overall experience of living with chronic illness is significantly shaped by the nature of their specific dominant disease. Policies for patient-centred care must take account of both generic and disease-specific elements.

Living with breathlessness: a survey of caregivers of breathless patients with lung cancer or heart failure

BACKGROUND

Breathlessness is a common, distressing symptom in patients with advanced disease. With increasing focus on home death for patients, carers are expected to support breathless people at home. Little is known about how carers experience breathlessness and the differences in caring for someone with breathlessness and malignant or non-malignant disease.

AIM

To compare experiences of caring for a breathless patient with lung cancer versus those with heart failure and to examine factors associated with caregiver burden and positive caring experiences.

DESIGN

Cross-sectional survey of caregivers of breathless patients.

SETTING/PARTICIPANTS

Participants were recruited from two London hospitals.

INCLUSION CRITERIA

caregivers of patients with breathlessness and heart failure or lung cancer. Measures included self-completion of Short Form version of Zarit Burden Interview, a 'positive caring experiences' scale and Palliative Care Outcome Scale. We compared caregiver reports between heart failure and lung cancer. Multiple regression analyses were used to examine factors related to burden and positive caring experiences.

RESULTS

In total, 51 heart failure and 50 lung cancer caregivers were recruited. Most were spouses (72%) and women (80%). Severity of patient breathlessness was similar in both groups. Caregiver concerns were mostly similar across conditions. Higher burden was associated with poorer 'quality of patient care' and worse carer psychological health (R (2) = 0.37, F = 12.2, p = 0.01). Caregiver depression and looking after more breathless patients were associated with fewer positive caring experiences (R (2) = 0.15, F = 4.4, p = 0.04).

CONCLUSIONS

Those who care for breathless patients report high levels of unmet needs and burden, equally severe for heart failure and lung cancer caregivers. Caregivers of patients with more severe breathlessness report fewer positive caring experiences and should be targeted by services with increased support in managing this symptom.

Tools to measure quality of life and carer burden in informal carers of heart failure patients: a narrative review

BACKGROUND

Heart failure is a complex cardiac syndrome prevalent in an older population. Caring for heart failure patients through the disease trajectory presents physical and emotional challenges for informal carers. Carers have to deal with clinically unstable patients, the responsibility of managing and titrating medication according to symptoms and frequent admissions to acute care. These challenges compound the demands on caregivers' physical and psychosocial well-being. Alongside the negative impact of being a carer, positive aspects have also been demonstrated; carers describe feelings of shared responsibility of caring with professional carers and the reward of supporting a loved one, which creates a new role in their relationship.

AIM

This review explores the dimensions that impact caregiver burden and quality of life in carers of patients with heart failure and highlights both the negative and positive aspects of being an informal carer for heart failure patients.

DESIGN

This review followed the processes recommended for a narrative review. Studies identified were selected systematically following the PRISMA guidelines.

DATA SOURCES

Searches were conducted using the Medical Subject Headings (MeSH) and keywords of the following search engines: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO and Cochrane for literature published until January 2012.

RESULTS

Quality assessment of the studies was conducted using quality indicators, and the studies included in this review were categorised as fair or good according to the criteria. Of the 1008 studies initially identified, 16 studies met the inclusion criteria. A thematic synthesis was undertaken, and the following themes were identified Perceived carer control; Mental and emotional well-being; Types and impact of caregiving tasks; Impact of patients' physical condition; Impact of age/gender/demographic factors; Positive aspects of caregiving.

CONCLUSIONS

This review highlights evidence that informal carers supporting patients with heart failure face many challenges impacting their physical and mental well-being. The studies described provide an insight into the individual dimensions that make a carer particularly vulnerable, namely, younger carers, female carers and carers with existing physical and emotional health issues. Additionally, there are external influences that increase risk of burden, including New York Heart Association Score status of the patient, if the patient has had recurrent emergency admissions or has recently been discharged home and the level of social support available to the carer. A further finding from conducting this review is that there are still limited measures of the positive aspects of caregiving.

Patient and family members' perceptions of palliative care in heart failure

PURPOSE

To describe patients with HF and their family members' (FMs) experiences with, and perceptions of, inpatient PC consultations.

METHODS

40 semi-structured interviews were completed with 24 patients with late-stage HF and/or 16 designated FMs. Content analysis was used to derive themes from the data.

RESULTS

Four main themes resulted.

PARTICIPANTS

1) were generally ill-prepared for the PC consult; 2) pursued a plan that reflected their own understanding of patient prognosis, rather than that of the clinician; 3) described a primarily supportive role for PC; 4) often rejected or deferred PC services if they viewed hospice and PC as synonymous.

CONCLUSION

Lack of awareness of PC and the conflation of PC and hospice were barriers to PC, and many participants felt that PC services are needed to fill the gaps in their care. A collaborative model of care may best meet the complex needs of this group.

Informal caregivers' experiences of caring for patients with chronic heart failure: systematic review and metasynthesis of qualitative studies

BACKGROUND

Increasing evidence suggests that family support for patients with chronic heart failure (CHF) contributes greatly to the disease management of CHF. In addition, the quality of the CHF patient's close personal relationships can influence CHF outcomes. However, caregivers cannot provide care alone and need guidance, support, and skills to manage care that is often complex. In this article, we provide a review of studies that have explicitly investigated these issues of informal caregivers to CHF patients.

OBJECTIVE

The objective of this study was to explore informal caregivers' views and experiences of caring for patients with CHF.

METHODS

This is a systematic review and synthesis of qualitative studies describing informal caregivers' experiences in home-based care. Data sources were published literature written in English from electronic databases: PubMed, CINAHL (1982-2009), PsycINFO (1967-2009), EMBASE (1980-2009), and the Cochrane Library Database. Ten primary studies met the inclusion criteria.

RESULTS

A number of themes emerged. Five key themes were identified from synthesis of the studies: sharing of caring, suffering from anxiety, being isolated, enjoying a good relationship, and searching for support.

CONCLUSIONS

Caring for persons with CHF can affect the well-being of their informal caregivers, which may ultimately have consequences for the CHF patient's health. Further studies are needed to clarify these issues and to examine the role of informal caregivers in the management of CHF.

Caregiving for patients with heart failure: impact on patients' families

BACKGROUND

Factors that affect the impact of caregiving on patients' family members who provide care to patients with heart failure have not been adequately addressed. In addition, social support and positive aspects of caregiving have received little attention.

OBJECTIVE

To identify factors associated with the impact of caregiving.

METHODS

Self-report data were collected from 76 dyads of patients with heart failure and their family caregivers. Clinical data were obtained from medical records.

RESULTS

A sense of less family support for caregiving was associated with a higher New York Heart Association class of heart failure, being a nonspousal caregiver, lower caregivers' perceived control, and less social support. More disruption of caregivers' schedules was associated with higher class of heart failure, more care tasks, and less social support. Greater impact of caregiving on caregivers' health was related to more recent patient hospitalization, lower caregivers' perceived control, and less social support. Nonwhite caregivers and caregivers whose family member had fewer emergency department visits felt more positive about caregiving than did other caregivers. Social support had a moderating effect on the relationship between patients' comorbid conditions and positive aspects of caregiving.

CONCLUSIONS

Caregiving has both positive and negative effects on family caregivers of patients with heart failure. The findings suggest the need for interventions to increase caregivers' sense of control and social support. Family caregivers may need additional support immediately after patient hospitalizations to minimize the negative impact of caregiving.

Family caregiving for patients with heart failure: types of care provided and gender differences

BACKGROUND

Knowledge about the potential burden for family caregivers related to the care of patients with heart failure (HF) is limited. The aims of the study were to compare the kind and amount of care provided by partners of HF patients and partners of healthy individuals and to examine the associations between gender and the performance of caregiving tasks.

METHODS AND RESULTS

Caregiving tasks performed by 338 partners of HF patients were compared with those performed by 1202 partners of healthy individuals. Partners (age 70 +/- 9, 76% female) of HF patients were more likely to provide personal care compared with partners (age 65 +/- 7, 66% female) of healthy individuals after controlling for their age. However, the magnitude of the odds ratios (OR) differed by gender of partners (OR for male 6.7; 95% confidence interval [CI] 3.9-11.4; OR for female 3.7; 95% CI 2.7-5.1). Partners of HF patients were more likely to provide emotional care than partners of healthy individuals, controlling for age and gender (OR 2.4; 95% CI 1.5-3.6). Male partners of HF patients were more likely to provide personal care compared to female partners of HF patients (OR 1.9; 95% CI 1.1-3.2).

CONCLUSIONS

The care performed by partners of HF patients is above and beyond normal spousal assistance. The study underscores the crucial role of family caregivers in the care of HF patients and encourages health care providers to address the needs of both HF patients and their caregivers.

Difficult conversations and chronic heart failure: do you talk the talk or walk the walk?

PURPOSE OF REVIEW

Effective communication is critical for palliative and supportive care in heart failure. This article contains a review of available information to assist clinicians in undertaking discussions regarding prognosis, treatment decisions and advance care planning.

RECENT FINDINGS

Emerging from a range of studies at the end of life is that patients and their families appreciate honesty and do not want to be abandoned by healthcare providers. Further, the receptivity of patients and their carers to information is highly variable, underscoring the importance of an individualized approach.

SUMMARY

When having these difficult conversations, clinicians need to assess the individual's need and wishes for information as well as their social and cultural background. They also need to consider the setting, timing and content of the discussion, as well as strategies to promote coping and adjustment. Most importantly, patients need a treatment plan to address palliative and supportive care needs to be implemented at the time of breaking this bad news, so that they and their families do not feel abandoned. Learning effective communication skills, implementing strategies for debriefing and the fostering of a team approach, may minimize burden on health providers and improve palliative and supportive care for people with heart failure.

Psychological, social and spiritual distress at the end of life in heart failure patients

PURPOSE OF REVIEW

Chronic heart failure patients have palliative care needs that include psychosocial and spiritual support, particularly towards the end of life, when breathlessness and resultant immobility become increasingly severe. This review informs clinicians of the importance of understanding, assessing and managing patients' psychosocial and spiritual needs.

RECENT FINDINGS

The high prevalence of depression (9-77.5%) among chronic heart failure patients is well documented. Clinical assessment and treatment of depression and anxiety are key to good patient care, although no model for assessment has been agreed. Evidence suggests that social support and spiritual belief are important coping resources, but there is a dearth of research into social and spiritual distress in chronic heart failure. Patients rarely access social services support, and family carers experience considerable burden. Little is known about how psychosocial and spiritual variables influence each other, and the impact of social and spiritual distress on outcomes such as quality of life.

SUMMARY

We hope this review will inform cardiac and palliative care staff about the prevalence of psychosocial and spiritual distress in advanced chronic heart failure, and highlight the importance of their assessment and management. There is an urgent need for research in this field, including the rigorous development and evaluation of service models and nonpharmacological interventions.

Family influences on heart failure self-care and outcomes

Many patient education guidelines for teaching heart failure patients recommend inclusion of the family; however, family-focused interventions to promote self-care in heart failure are few. This article reviews the state of the science regarding family influences on heart failure self-care and outcomes. The literature and current studies suggest that family functioning, family support, problem solving, communication, self-efficacy, and caregiver burden are important areas to target for future research. In addition, heart failure patients without family and those who live alone and are socially isolated are highly vulnerable for poor self-care and should receive focused attention. Specific research questions based on existing science and gaps that need to be filled to support clinical practice are posed.

Self-perceived symptoms and care needs of patients with severe to very severe chronic obstructive pulmonary disease, congestive heart failure or chronic renal failure and its consequences for their closest relatives: the research protocol

Background

Recent research shows that the prevalence of patients with very severe chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic renal failure (CRF) continues to rise over the next years. Scientific studies concerning self-perceived symptoms and care needs in patients with severe to very severe COPD, CHF and CRF are scarce.

Consequently, it will be difficult to develop an optimal patient-centred palliative care program for patients with end-stage COPD, CHF or CRF. The present study has been designed to assess the symptoms, care needs, end-of-life care treatment preferences and communication needs of patients with severe to very severe COPD, CHF or CRF. Additionally, family distress and care giving burden of relatives of these patients will be assessed.

Methods/design

A cross-sectional comparative and prospective longitudinal study in patients with end-stage COPD, CHF or CRF has been designed. Patients will be recruited by their treating physician specialist. Patients and their closest relatives will be visited at baseline and every 4 months after baseline for a period of 12 months. The following outcomes will be assessed during home visits: self-perceived symptoms and care needs; daily physical functioning; general health status; end-of-life care treatment preferences; end-of-life care communication and care-giver burden of family caregivers. Additionally, end-of-life care communication and prognosis of survival will be assessed with the physician primarily responsible for the management of the chronic organ failure. Finally, if patients decease during the study period, the baseline preferences with regard to life-sustaining treatments will be compared with the real end-of-life care.

Discussion

To date, the symptoms, care needs, caregiver burden, end-of-life care treatment preferences and communication needs of patients with very severe COPD, CHF or CRF remain unknown. The present study will increase the knowledge about the self-perceived symptoms, care-needs, caregiver burden, end-of-life care treatment preferences and communication needs from the views of patients, their loved ones and their treating physician. This knowledge is necessary to optimize palliative care for patients with COPD, CHF or CRF. Here, the design of the present study has been described. A preliminary analysis of the possible strengths, weaknesses and clinical consequences is outlined.

Self-perceived symptoms and care needs of patients with severe to very severe chronic obstructive pulmonary disease, congestive heart failure or chronic renal failure and its consequences for their closest relatives: the research protocol

BACKGROUND

Recent research shows that the prevalence of patients with very severe chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic renal failure (CRF) continues to rise over the next years. Scientific studies concerning self-perceived symptoms and care needs in patients with severe to very severe COPD, CHF and CRF are scarce.Consequently, it will be difficult to develop an optimal patient-centred palliative care program for patients with end-stage COPD, CHF or CRF. The present study has been designed to assess the symptoms, care needs, end-of-life care treatment preferences and communication needs of patients with severe to very severe COPD, CHF or CRF. Additionally, family distress and care giving burden of relatives of these patients will be assessed.

METHODS/DESIGN

A cross-sectional comparative and prospective longitudinal study in patients with end-stage COPD, CHF or CRF has been designed. Patients will be recruited by their treating physician specialist. Patients and their closest relatives will be visited at baseline and every 4 months after baseline for a period of 12 months. The following outcomes will be assessed during home visits: self-perceived symptoms and care needs; daily physical functioning; general health status; end-of-life care treatment preferences; end-of-life care communication and care-giver burden of family caregivers. Additionally, end-of-life care communication and prognosis of survival will be assessed with the physician primarily responsible for the management of the chronic organ failure. Finally, if patients decease during the study period, the baseline preferences with regard to life-sustaining treatments will be compared with the real end-of-life care.

DISCUSSION

To date, the symptoms, care needs, caregiver burden, end-of-life care treatment preferences and communication needs of patients with very severe COPD, CHF or CRF remain unknown. The present study will increase the knowledge about the self-perceived symptoms, care-needs, caregiver burden, end-of-life care treatment preferences and communication needs from the views of patients, their loved ones and their treating physician. This knowledge is necessary to optimize palliative care for patients with COPD, CHF or CRF. Here, the design of the present study has been described. A preliminary analysis of the possible strengths, weaknesses and clinical consequences is outlined.

Predicting mortality among a general practice-based sample of older people with heart failure

OBJECTIVE

To identify factors available to general practitioners (GPs) that are predictive of mortality within a general practice-based population of heart failure patients, and to report the sensitivity and specificity of prognostic information from GPs.

METHODS

Five hundred and forty-two heart failure patients aged >60 years were recruited from 16 UK GP surgeries. Patients completed quality-of-life and services use questionnaires every 3 months for 24 months or until death. Factors with independent significant association with survival were identified using Cox proportional hazards regression analysis.

RESULTS

Women had a 58% lower risk of death. Patients self-reporting New York Heart Association Classification III or IV had an 81% higher risk of death. Patients aged 85+ years had over a five-fold risk of death as compared with those aged <65 years. Patients with a co-morbidity of cancer had a 78% higher risk of death. Of the 14 patients who died in a 12-month period, the GPs identified 11 (sensitivity 79%). They identified 133 of the 217 who did not die (specificity 61%).

DISCUSSION

Predictors readily available to GPs, such as patient characteristics, are easy to adapt to use in general practice, where most heart failure patients are diagnosed and treated. Identifying factors likely to influence death is useful in primary care, as this can initiate discussion about end-of-life care.

Patient views of social service provision for older people with advanced heart failure

The objective of the present paper is to explore levels of social service provision, the barriers to receiving these services and the experiences of social service provision amongst older people with heart failure. Five hundred and forty-two people aged over 60 years with heart failure were recruited from UK general practices in four areas of the UK, and these subjects completed quality-of-life and service-use questionnaires every 3 months for 24 months, or until death. Forty patients participated in in-depth interviews. Data collection was conducted between September 2003 and March 2006. Only 24% (n = 127) of the 460 participants who had provided information about social services contact reported having received social services during the past 24 months. Significant associations between the level of social services contact and participant characteristics were identified, with women, participants over 75 years of age, participants living alone, and those with two or more comorbidities being more likely to report receipt of social services. The qualitative data identified key barriers to using social services, including: access problems; not wanting additional help; the negative experiences of friends; and carers substituting for statutory services. The few participants interviewed who had received social services reported mixed experiences, including problems with inappropriate and insufficient services. This study indicates that only a minority of older people with heart failure have contact with social services. Improving provision for this group involves tackling the barriers to access identified above, as well as ensuring that their views influence service planning and delivery.

Palliative care in stroke: a critical review of the literature

The aim of this literature review was to identify the palliative care needs of stroke patients. Stroke results in high levels of mortality and morbidity, yet very little is known about the nature and extent of palliative care services that are available to this patient group, and the ways in which such services could be delivered. A critical review of the international literature found only seven papers that attempted to identify the palliative care needs of patients diagnosed with stroke. The results of the review showed that the preferences of stroke patients and their families in relation to palliative care services are largely unknown. The review also indicated the paucity of data in regard to the distinction between provision of palliative care services for patients who die in the acute phase of stroke and for those patients who die later. Establishing reliable assessments of need are central to designing and implementing effective interventions and further research is required in this area. Further data on how the input of palliative care experts and expertise could be of benefit to patients, and the most effective ways these inputs could be targeted and delivered is required.