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Gitau K, Huang A, Isenberg SR, Stall N, Ailon J, Bell CM, Quinn KL. Association of patient sex with use of palliative care in Ontario, Canada: a population-based study. CMAJ Open 2023; 11:E1025-E1032. [PMID: 37935486 PMCID: PMC10635704 DOI: 10.9778/cmajo.20220232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use. METHODS We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient-physician sex concordance. RESULTS There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69-87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08-1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14-1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17-1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19-1.21) to have had a male referring physician. INTERPRETATION After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.
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Affiliation(s)
- Kevin Gitau
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Anjie Huang
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Sarina R Isenberg
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Nathan Stall
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Jonathan Ailon
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Chaim M Bell
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Kieran L Quinn
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.
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Remawi BN, Gadoud A, Preston N. The experiences of patients with advanced heart failure, family carers, and health professionals with palliative care services: a secondary reflexive thematic analysis of longitudinal interview data. BMC Palliat Care 2023; 22:115. [PMID: 37559111 PMCID: PMC10413510 DOI: 10.1186/s12904-023-01241-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 08/03/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Patients with heart failure have significant palliative care needs, but few are offered palliative care. Understanding the experiences of delivering and receiving palliative care from different perspectives can provide insight into the mechanisms of successful palliative care integration. There is limited research that explores multi-perspective and longitudinal experiences with palliative care provision. This study aimed to explore the longitudinal experiences of patients with heart failure, family carers, and health professionals with palliative care services. METHODS A secondary analysis of 20 qualitative three-month apart interviews with patients with heart failure and family carers recruited from three community palliative care services in the UK. In addition, four group interviews with health professionals from four different services were analysed. Data were analysed using 'reflexive thematic' analysis. Results were explored through the lens of Normalisation Process Theory. RESULTS Four themes were generated: Impact of heart failure, Coping and support, Recognising palliative phase, and Coordination of care. The impact of heart failure on patients and families was evident in several dimensions: physical, psychological, social, and financial. Patients developed different coping strategies and received most support from their families. Although health professionals endeavoured to support the patients and families, this was sometimes lacking. Health professionals found it difficult to recognise the palliative phase and when to initiate palliative care conversations. In turn, patients and family carers asked for better communication, collaboration, and care coordination along the whole disease trajectory. CONCLUSIONS The study provided broad insight into the experiences of patients, family carers, and health professionals with palliative care. It showed the impact of heart failure on patients and their families, how they cope, and how they could be supported to address their palliative care needs. The study findings can help researchers and healthcare professionals to design palliative care interventions focusing on the perceived care needs of patients and families.
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Affiliation(s)
- Bader Nael Remawi
- Lancaster Medical School, Lancaster University, Lancaster, LA1 4AT, UK.
- Doctor of Pharmacy Department, Birzeit University, Birzeit, Palestine.
| | - Amy Gadoud
- Lancaster Medical School, Lancaster University, Lancaster, LA1 4AT, UK
| | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, LA1 4AT, UK
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3
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Chay J, Huynh VA, Cheung YB, Kanesvaran R, Lee LH, Malhotra C, Finkelstein EA. The relationship between hope, medical expenditure and survival among advanced cancer patients. Front Psychol 2023; 14:1151976. [PMID: 37287770 PMCID: PMC10242009 DOI: 10.3389/fpsyg.2023.1151976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction Among those with advanced illness, higher levels of hope may offer physiological benefits. Yet, greater levels of hope may also encourage aggressive treatments. Therefore, higher levels of hope may lead to greater healthcare utilization, higher expenditure, and longer survival. We test these hypotheses among patients with advanced cancer. Methods A secondary data analysis from a cross-sectional survey of 195 advanced cancer patients with high mortality risk linked to subsequent healthcare utilization (outpatient, day surgeries, non-emergency admissions), health expenditures, and death records. The survey collected data on hope, measured generally by the Herth Hope Index (HHI) and more narrowly by two questions on illness-related hope. Generalized linear regression and Cox models were used to test our hypotheses. Results 142 (78%) survey participants died during the period of analysis, with close to half (46%) doing so within a year of the survey. Contrary to expectation, HHI scores did not have a significant association with healthcare utilization, expenditure or survival. Yet, illness-related hope, defined as those who expected to live at least 2 years, as opposed to the likely prognosis of 1 year or less as determined by the primary treating oncologist, had 6.6 more planned hospital encounters (95% CI 0.90 to 12.30) in the 12-months following the survey and 41% lower mortality risk (hazard ratio: 0.59, 95% CI 0.36 to 0.99) compared to those who were less optimistic. Secondary analysis among decedents showed that patients who believed that the primary intent of their treatment is curative, had higher total expenditure (S$30,712; 95% CI S$3,143 to S$58,282) in the last 12 months of life than those who did not have this belief. Conclusion We find no evidence of a relationship between a general measure of hope and healthcare utilization, expenditure, or survival among advanced cancer patients. However, greater illness-related hope is positively associated with these outcomes.
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Affiliation(s)
- Junxing Chay
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Vinh Anh Huynh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Yin Bun Cheung
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | | | - Lai Heng Lee
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
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Mirshahi A, Ghiasvandian S, Khoshavi M, Riahi SM, Khanipour-Kencha A, Bakitas M, Dionne-Odom JN, Wells R, Zakerimoghadam M. 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. Contemp Clin Trials Commun 2023; 33:101114. [PMID: 36993787 PMCID: PMC10041464 DOI: 10.1016/j.conctc.2023.101114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 03/28/2023] Open
Abstract
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.
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Affiliation(s)
- Arvin Mirshahi
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- USERN Care (TUMS) Office, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Ghiasvandian
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Meysam Khoshavi
- Department of Cardiology, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Riahi
- School of Medicine, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Tehran, Iran
| | - Ali Khanipour-Kencha
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- USERN Care (TUMS) Office, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Marie Bakitas
- School of Nursing, and Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB) and UAB Center for Palliative and Supportive Care, USA
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Masoumeh Zakerimoghadam
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author. Departments of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq., Post Code: 14197-33171, Tehran, Iran.
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Zehnder AR, Pedrosa Carrasco AJ, Etkind SN. Factors associated with hospitalisations of patients with chronic heart failure approaching the end of life: A systematic review. Palliat Med 2022; 36:1452-1468. [PMID: 36172637 PMCID: PMC9749018 DOI: 10.1177/02692163221123422] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Heart failure has high mortality and is linked to substantial burden for patients, carers and health care systems. Patients with chronic heart failure frequently experience recurrent hospitalisations peaking at the end of life, but most prefer to avoid hospital. The drivers of hospitalisations are not well understood. AIM We aimed to synthesise the evidence on factors associated with all-cause and heart failure hospitalisations of patients with advanced chronic heart failure. DESIGN Systematic review of studies quantitatively evaluating factors associated with all-cause or heart failure hospitalisations in adult patients with advanced chronic heart failure. DATA SOURCES Five electronic databases were searched from inception to September 2020. Additionally, searches for grey literature, citation searching and hand-searching were performed. We assessed the quality of individual studies using the QualSyst tool. Strength of evidence was determined weighing number, quality and consistency of studies. Findings are reported narratively as pooling was not deemed feasible. RESULTS In 54 articles, 68 individual, illness-level, service-level and environmental factors were identified. We found high/moderate strength evidence for specialist palliative or hospice care being associated with reduced risk of all-cause and heart failure hospitalisations, respectively. Based on high strength evidence, we further identified black/non-white ethnicity as a risk factor for all-cause hospitalisations. CONCLUSION Efforts to integrate hospice and specialist palliative services into care may reduce avoidable hospitalisations in advanced heart failure. Inequalities in end-of-life care in terms of race/ethnicity should be addressed. Further research should investigate the causality of the relationships identified here.
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Affiliation(s)
- Aina R Zehnder
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,Rautipraxis, Zürich, Switzerland
| | | | - Simon N Etkind
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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6
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Gula AL, Ramos J, Simpson JM, Jiang L, Martin E, Wice M, Erqou S, Wu WC, Rudolph JL. Utilization of Palliative Care in Veterans Admitted With Heart Failure Experiencing Homelessness. J Pain Symptom Manage 2022; 64:471-477. [PMID: 35901868 DOI: 10.1016/j.jpainsymman.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care. OBJECTIVES Determine if housing insecurity is associated with palliative care (PC) encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers. METHODS This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness, and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission. RESULTS Seventy thousand eight hundred fourty nine veterans were identified. Veterans were identified as at risk for homelessness (n=4039, 5.7%), experiencing homelessness (n=1967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75). CONCLUSION Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering PC and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.
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Affiliation(s)
- Annie Laurie Gula
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Jacob Ramos
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Jane M Simpson
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Edward Martin
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA
| | - Mitchell Wice
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA; Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA; Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - James L Rudolph
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA.
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7
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Higashitsuji A, Matsudo M, Majima T. Suffering and Attitudes Toward Death of Patients With Heart Failure in Japan: A Grounded Theory Approach. J Hosp Palliat Nurs 2021; 23:421-428. [PMID: 34369421 DOI: 10.1097/njh.0000000000000783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early palliative care is needed for patients with heart failure (HF). However, little is known about the suffering and attitudes toward death of these patients before they reach end-stage HF. This study aimed to identify the suffering and attitudes toward death of patients with early- and intermediate-stage HF. Our qualitative research process was guided with a grounded theory approach and consolidated criteria for reporting qualitative research. Participants were selected through theoretical sampling. Data were collected through semistructured interviews, participant observations, and medical records examination. The study included 10 patients. Analysis of the data revealed the core category of "evaluating whether HF hinders the current and future self." From this core category, 6 categories of causal conditions and 3 categories of consequences emerged. Participants with HF evaluated the causal conditions and suffering in the context of how they hindered the ideal state. After recognizing their own suffering, they expressed specific attitudes toward death. The 10 categories revealed in this study elucidate the process by which patients with HF form their attitudes toward death based on suffering. Health care professionals should consider these findings to help facilitate early palliative care interventions.
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8
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Ganz FD, Roeh K, Eid M, Hasin T, Harush C, Gotsman I. The need for palliative and support care services for heart failure patients in the community. Eur J Cardiovasc Nurs 2021; 20:138–146. [PMID: 33611419 DOI: 10.1177/1474515120951970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care is a care option considered appropriate for those with heart failure, but is uncommon partially due to a lack of timely identification of those needing palliative care. A standard mechanism that triggers which heart failure patients should receive palliative care is not available. The Gold Standards Framework (GSF) identifies those needing palliative care but has not been investigated with heart failure patients. OBJECTIVES To describe palliative care provided in the community and determine whether the GSF can identify heart failure patients in need of palliative care. METHODS Descriptive study. A total of 252 heart failure patients in the community completed a demographic characteristics questionnaire, the Edmonton symptom assessment scale-revised and the Minnesota living with heart failure questionnaire. Clinical data were collected from the medical chart and the primary physician completed the GSF prognostic indicator guidance. RESULTS Participants had a mean age of 76.9 years (standard deviation 10.9), most at New York Heart Association level III (n=152, 60%). Fewer than half received pain medications (n=76, 30%), anxiolytics (n=35, 14%), antidepressants (n=64, 25%) or sleep medications (n=65, 26%). Eight patients spoke with a psychologist or psychologist (3%). One had an advanced directive and 16 (6%) had a record of discussions with their family caregivers. Three (1%) had end-of-life discussions with their healthcare providers. Most healthcare providers responded 'no' to the 'surprise question' (n=160, 63%). Sensitivity and specificity of the gold standards framework was poor. CONCLUSIONS Few community dwelling heart failure patients received most aspects of palliative care. The gold standards framework was not a good indicator of those who should receive palliative care.
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Affiliation(s)
- Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing, Israel.,Jerusalem College of Technology, Israel
| | - Keshet Roeh
- Shaare Zedek Medical Center, Israel.,Hebrew University, Israel
| | - Muhammad Eid
- Hebrew University, Israel.,Clalit Health Services, Israel
| | - Tal Hasin
- Heart Failure Clinic, Shaare Zedek Medical Center, Israel
| | - Chen Harush
- Heart Failure Clinic, Shaare Zedek Medical Center, Israel
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Prevalence of advanced heart failure and use of palliative care in admitted patients: Findings from the EPICTER study. Int J Cardiol 2020; 327:125-131. [PMID: 33171167 DOI: 10.1016/j.ijcard.2020.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/01/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION AND AIM Palliative care in patients with advanced heart failure is strongly recommended by Clinical Practice Guidelines. We aimed to calculate the prevalence of advanced heart failure in admitted patients, to describe their management, and to analyse the factors that influence their referral to specialised palliative care. PATIENTS AND METHODS Cross-sectional, multicentre study that consecutively included patients admitted for heart failure in 74 Spanish hospitals. If they met criteria for advanced heart failure, their treatment, complications and procedures were recorded. RESULTS A total of 3153 patients were included. Of them, 739 (23%) met criteria for advanced heart failure. They were more likely to be women, older and to have a history of anaemia, chronic kidney disease and cognitive impairment. For their management, furosemide infusions (30%) and vasodilators (21%) were used. Refractory symptoms were treated with opioids (47%) and benzodiazepines (44%). Palliative care was only provided in the last hours of life in 48% of them. A multidisciplinary approach, involving palliative care specialists was sought in 15% of these patients. Treatment with furosemide infusions, an advanced New York Heart Association functional class, to meet advanced HF criteria and the presence of cancer were associated with the referral to specialised palliative care. CONCLUSIONS Almost one in four patients admitted with HF met criteria of advanced disease. They were older and had more comorbidities. Specialist palliative care services were involved in only a minority of patients, mainly those who were highly symptomatic or had cancer.
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Suzuki S, Motoki H, Kanzaki Y, Maruyama T, Hashizume N, Kozuka A, Yahikozawa K, Kuwahara K. A Predictive Model for 6-Month Mortality in Elderly Patients with Heart Failure. Int Heart J 2020; 61:325-331. [DOI: 10.1536/ihj.19-572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Yusuke Kanzaki
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Takuya Maruyama
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Naoto Hashizume
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Ayako Kozuka
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Kumiko Yahikozawa
- Department of Cardiovascular Medicine, Minaminagano Medical Center, Shinonoi General Hospital
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
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11
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Sahlollbey N, Lee CKS, Shirin A, Joseph P. The impact of palliative care on clinical and patient‐centred outcomes in patients with advanced heart failure: a systematic review of randomized controlled trials. Eur J Heart Fail 2020; 22:2340-2346. [DOI: 10.1002/ejhf.1783] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/25/2022] Open
Affiliation(s)
- Nick Sahlollbey
- McMaster University Hamilton Canada
- Population Health Research Institute (PHRI), Hamilton Health Sciences and McMaster University Hamilton Canada
| | | | | | - Philip Joseph
- McMaster University Hamilton Canada
- Population Health Research Institute (PHRI), Hamilton Health Sciences and McMaster University Hamilton Canada
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12
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Sugiura E, Dohi K, Tanimura M, Kumagai N, Ishikawa E, Ito M. Successful Peritoneal Dialysis for the Treatment of Inotrope-Dependent End-Stage Heart Failure. Int Heart J 2019; 60:1211-1218. [PMID: 31484857 DOI: 10.1536/ihj.18-550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Extra- and/or intracorporeal renal replacement therapy can improve the cardiorenal hemodynamics in patients with advanced heart failure (HF) refractory to medical therapy and renal failure. Here, we report the case of a 51-year-old woman with inotrope-dependent end-stage HF and chronic renal failure due to anthracycline-induced cardiomyopathy, in whom the induction of hemodiafiltration and subsequent chronic peritoneal dialysis (PD) provided a dramatic improvement of her cardiac hemodynamics from restrictive to almost normal physiology assessed by echocardiography and cardiac catheterization. The patient returned to office work with New York Heart Association functional class I-II symptoms for at least 3 years with continuous ambulatory PD after hospital discharge.
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Affiliation(s)
- Emiyo Sugiura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Muneyoshi Tanimura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Naoto Kumagai
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Eiji Ishikawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
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13
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Abstract
Cognitive behavioral therapy has emerged as an important approach to alleviate the depression of patients with heart failure. However, the use of cognitive behavioral therapy for heart failure has not been well established. We conduct a systematic review and meta-analysis to evaluate the efficacy of cognitive behavioral therapy for alleviating depression for heart failure.PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials (RCTs) assessing the influence of cognitive behavioral therapy on heart failure are included. Two investigators independently have searched articles, extracted data, and assessed the quality of included studies. Meta-analysis is performed using the random-effect model.Eight RCTs involving 480 patients are included in the meta-analysis. Compared with control intervention for heart failure, cognitive behavioral therapy can substantially decrease depression scale (Std. MD = -0.27; 95% CI = -0.47 to -0.06; P = 0.01), but has no substantial influence on the quality of life (Std. MD = 0.21; 95% CI = -0.01 to 0.42; P = 0.06), self-care scores (Std. MD = 0.12; 95% CI = -0.18 to 0.42; P = 0.44), and 6-minute walk test distance (Std. MD = 0; 95% CI = -0.28 to 0.28; P = 0.99).Cognitive behavioral therapy is associated with significantly decreased depression scale, but with no substantial impact on the quality of life, self-care scores, and 6-minute walk test distance for heart failure.
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Affiliation(s)
- Yan Peng
- Department of Cardiology, The University-Town Hospital of Chongqing Medical University
| | - Junjie Fang
- Department of Cardiology, The University-Town Hospital of Chongqing Medical University
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University
| | - Shu Qin
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University
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14
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Nakamura K, Kanzaki H, Okada A, Amaki M, Takahama H, Hasegawa T, Sugano Y, Yasuda S, Anzai T. Independent Prognostic Value of Pulmonary Diffusing Capacity in Nonsmoking Patients with Chronic Heart Failure. Int Heart J 2019; 60:366-373. [PMID: 30799383 DOI: 10.1536/ihj.18-420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The diffusing capacity of the lung for carbon monoxide (DLCO) is indicative of the alveolar-capillary membrane function. A reduced DLCO is associated with poor prognosis in chronic heart failure (HF). However, the significance of DLCO as an independent prognostic predictor has not been established. Here, we aimed to determine the prognostic value of DLCO in patients with chronic HF.We enrolled 214 patients (139 females, mean age: 63 ± 16 years, left ventricular ejection fraction [LVEF]: 45 ± 21%) with stable chronic HF who underwent pulmonary function tests. Only never smokers were included in the analysis because smoking can decrease DLCO.During a median follow-up period of 2.1 years, 52 patients (24.3%) experienced cardiac events, including unplanned HF admissions, left ventricular assist device (LVAD) implantations, all-cause deaths, and cardiopulmonary arrests (CPAs). The median percent predicted DLCO (%DLCO) was 87.3%. In a Cox regression analysis, a %DLCO of ≤87.3% was independently associated with the cardiac events, even after adjusting for age, sex, systolic blood pressure (SBP), LVEF, anemia, brain natriuretic peptide, estimated glomerular filtration rate (eGFR), and prior HF admission (hazard ratio [HR]: 1.87, 95% confidence interval: 1.03-3.53, P = 0.030).A reduced DLCO is an independent predictor of poor prognosis in nonsmoking patients with chronic HF.
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Affiliation(s)
- Kenji Nakamura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takuya Hasegawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuo Sugano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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15
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Alqahtani F, Balla S, Almustafa A, Sokos G, Alkhouli M. Utilization of palliative care in patients hospitalized with heart failure: A contemporary national perspective. Clin Cardiol 2018; 42:136-142. [PMID: 30447066 DOI: 10.1002/clc.23119] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/01/2018] [Accepted: 11/13/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Despite advances in therapy, heart failure (HF) patients have significant symptom burden and poor quality of life. However, data on palliative care (PC) utilization in this population are scarce. We sought to assess national trends in PC utilization in patients admitted with acute HF. METHODS Adults hospitalized with HF without acute coronary syndrome were identified in the National inpatient sample. PC was identified using ICD-9-CM-Code V66.7. Trends in PC utilization, its predictors and its association with length-of-stay and cost were assessed. RESULTS A total of 939 680 HF patients were hospitalized with HF between 2003 and 2014. Of those,1.2% received PC during the hospitalization, with an upward trend in the use of PC over time (0.12% in 2003 to 3.6% in 2014, P < 0.001). Compared with patients who did not receive PC, those who had PC were older (79 ± 12 vs 69 ± 16 years), and had higher prevalence of Caucasian race (73.4% vs 51.8%), coronary disease (45.6% vs 39.3%), chronic renal disease (79.3% vs 42.8%), and pulmonary hypertension (28.3% vs 15.1%) (P < 0.001). In-hospital mortality (35.2% vs 2.2%), length-of-stay (9 ± 13 days vs 6 ± 6, P < 0.001), cost ($19 984 ± 42 922 vs $11 921 ± 18 175), and non-home discharges (46% vs 19.2%) (P < 0.001) were higher in the PC group. In-hospital mortality in PC group trended downward over time (69% in 2003 vs 29% in 2014, P < 0.001). CONCLUSION PC is being utilized in an increasing but overall small number of patients hospitalized with HF. Further research is needed to identify the optimal role and timing of PC in HF patients.
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Affiliation(s)
- Fahad Alqahtani
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - Sudarshan Balla
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - Ahmad Almustafa
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - George Sokos
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - Mohamad Alkhouli
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia
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16
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Wells R, Stockdill ML, Dionne-Odom JN, Ejem D, Burgio KL, Durant RW, Engler S, Azuero A, Pamboukian SV, Tallaj J, Swetz KM, Kvale E, Tucker RO, Bakitas M. Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers (ENABLE CHF-PC): study protocol for a randomized controlled trial. Trials 2018; 19:422. [PMID: 30081933 PMCID: PMC6090835 DOI: 10.1186/s13063-018-2770-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Rachel Wells
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Macy L. Stockdill
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Kathryn L. Burgio
- Department of Medicine, Division of Gerontology, Geriatrics, Palliative Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
- Birmingham VA Medical Center, VAMC 11G, 700 19th St South, Birmingham, AL 35233-0001 USA
| | - Raegan W. Durant
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Sally Engler
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Salpy V. Pamboukian
- Department of Medicine, Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Keith M. Swetz
- Department of Medicine, Division of Gerontology, Geriatrics, Palliative Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
| | - Elizabeth Kvale
- Department of Medicine, Dell Medical School, University of Texas at Austin, 1501 Red River Street, Austin, TX 78712 USA
| | - Rodney O. Tucker
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-2041 USA
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
- Department of Medicine, Division of Gerontology, Geriatrics, Palliative Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-1210 USA
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17
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Akyar I, Dionne-Odom JN, Bakitas MA. Using Patients and Their Caregivers Feedback to Develop ENABLE CHF-PC: An Early Palliative Care Intervention for Advanced Heart Failure. J Palliat Care 2018; 34:103-110. [PMID: 29952216 DOI: 10.1177/0825859718785231] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE: Models of early, community-based palliative care for individuals with New York Heart Association (NYHA) class III/IV heart failure and their families are lacking. We used the Medical Research Council process of developing complex interventions to conduct a formative evaluation study to translate an early palliative care intervention from cancer to heart failure. METHOD: One component of the parent formative evaluation pilot study was qualitative satisfaction interviews with 8 patient-caregiver dyad participants who completed Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare For Patient and Caregivers (ENABLE CHF-PC) intervention. The ENABLE CHF-PC consists of an in-person palliative care assessment, weekly telehealth coaching sessions, and monthly follow-up. Subsequent to completing the coaching sessions, patient and caregiver participants were interviewed to elicit their experiences with ENABLE CHF-PC. Digitally recorded interviews were transcribed and analyzed using a thematic approach. RESULTS: Patients (n = 8) mean age was 67.3, 62.5% were female, 75% were married/living with a partner; caregivers (n = 8) mean age was 56.8, and 87.5% were female. Four themes related to experiences with ENABLE CHF-PC included "allowed me to vent," "gained perspective," "helped me plan," and "gained illness management and decision-making skills." Recommendations for intervention modification included (1) start program at diagnosis, (2) maintain phone-based approach, and (3) expand topics and modify format. CONCLUSION: Patients and caregivers unanimously found the intervention to be helpful and acceptable. After incorporating modifications, ENABLE CHF-PC is currently undergoing efficacy testing in a large randomized controlled trial.
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Affiliation(s)
- Imatullah Akyar
- 1 Faculty of Nursing, Hacettepe University, Ankara, Turkey.,2 School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Nicholas Dionne-Odom
- 2 School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA.,3 Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of Alabama at Birmingham Center for Palliative and Supportive Care, Birmingham, AL, USA
| | - Marie A Bakitas
- 2 School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA.,3 Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of Alabama at Birmingham Center for Palliative and Supportive Care, Birmingham, AL, USA
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