It's Time to Talk: Challenges in Providing Integrated Palliative Care in Advanced Congestive Heart Failure. A Narrative Review

Setting Regional Priorities for Palliative and End-of-Life Care Research Using a Delphi Technique Approach

OBJECTIVE

Identifying research priorities is very important for palliative and end-of-life care to ensure research is focused on evidence gaps. This project aimed to identify and prioritise palliative and end-of-life care research areas within the West Midlands region in United Kingdom (UK).

METHODS

A modified Delphi technique approach was used with palliative care stakeholders. The first round was item generation via rapid interviews. Data were analysed using content analysis and all the items were grouped into main categories. For round two, an online survey was conducted to present all the items from round one, and stakeholders were asked to rate the priority of items on a Likert-type scale (1 = not a priority to 7 = essential priority). Items that achieved consensus in round two were presented to the third round, where stakeholders ranked them in descending order.

RESULTS

We completed and analysed 56 rapid interviews which resulted in 158 research items under 15 categories. The research items were rated by 30 stakeholders and seven items which reached consensus were subsequently ranked in order by 45 stakeholders. The highest ranked item was 'Integrated care systems to prevent crisis', followed by three research items related to 'equity' in palliative care.

CONCLUSIONS

Our research priorities, although unique for our region, mirror previously research priorities from other regions and countries. This suggests issues of integration and equity in palliative and end-of-life care remain unresolved, despite ongoing initiatives and research to address these issues.

Characteristics associated with the intention to complete advance directives and end-of-life preferences in Brazilians with heart failure

OBJECTIVE

To identify characteristics associated with an intention to complete advance directives (ADs) and end-of-life treatment preferences for outpatients with heart failure (HF).

METHODS

A cross-sectional, analytical study. Sociodemographic and clinical data were collected from 108 patients with HF in an outpatient clinic in São Paulo, SP, Brazil. Quality of life (QoL) was assessed using the Minnesota Living with Heart Failure Questionnaire; knowledge about HF and the intention to complete ADs were assessed using a script. The relationships among variables were assessed through the chi-square and Mann-Whitney tests, with p < 0.05 considered significant.

RESULTS

The intention to complete ADs was significantly associated with reporting adherence to pharmacological recommendations (99% vs. 88.1%, p = 0.02), worse QoL (29.7 ± 18.2 vs. 20.9 ± 11.0; p = 0.0336), perceived knowledge about HF (89.7% vs. 63.6%, p = 0.0495), not wishing the healthcare providers would decide about treatment (27.3% vs. 2.15, p = 0.0026), and considering ADs useful (91.8% vs. 27.3%, p < 0.001). End-of-life treatment preferences included living as long as possible (50.5%), not being sedated (37.1%), and staying close to family and friends for as long as possible (32.0%).

CONCLUSIONS

Characteristics associated with an intention to complete ADs and end-of-life treatment preferences were identified in patients with HF.

IMPLICATIONS FOR NURSING PRACTICE

These results can help facilitate patients' completion of their ADs or activate their intention to maximize opportunities to exercise autonomy.

Outcomes following cardiac resynchronisation therapy in older people

INTRODUCTION

Older patients may be less likely to receive cardiac resynchronisation therapy (CRT) for the management of heart failure. We aimed to describe the differences in clinical response, complications, and subsequent outcomes following CRT implantation compared to younger patients.

METHODS

We conducted a retrospective cohort study of unselected, consecutive patients implanted with CRT devices between March 2008 and July 2017. We recorded complications, symptomatic and echocardiographic response, hospitalisation for heart failure, and all-cause mortality comparing patients aged <70, 70-79 and ≥ 80 years.

RESULTS

Five hundred and seventy-four patients (median age 76 years [interquartile range 68-81], 73.3% male) received CRT. At baseline, patients aged ≥80 years had worse symptoms, were more likely to have co-morbidities, and less likely to be receiving comprehensive medical therapy, although left ventricular function was similar. Older patients were less likely to receive CRT-defibrillators compared to CRT-pacemakers. Complications were infrequent and not more common in older patients. Age was not a predictor of symptomatic or echocardiographic response to CRT (67.2%, 71.2% and 62.6% responders in patients aged <70, 70-79 and ≥ 80 years, respectively; P = 0.43), and time to first heart failure hospitalisation was similar across age groups (P = 0.28). Ten-year survival was lower for older patients (49.9%, 23.9% and 6.8% in patients aged <70, 70-79 and ≥ 80 years, respectively; P < 0.001).

CONCLUSIONS

The benefits of CRT on symptoms and left ventricular function were not different in older patients despite a greater burden of co-morbidities and less optimal medical therapy. These findings support the use of CRT in an ageing population.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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Key Words

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

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MESH Headings

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

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Affiliation(s)

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

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Palliative Care for Patients With Heart Failure: An Integrative Review

Palliative care should be integrated into routine disease management for all patients with serious illness, regardless of settings or prognosis. The purposes of this integrative review were to identify the features of randomized controlled trials for adult patients with heart failure and to provide basic references for the development of future trials. Using Whittemore and Knafl's integrative literature review method, comprehensive searches of the PubMed, Cochrane Library, CINAHL, EMBASE, and Korean databases were conducted, integrating keywords about heart failure and palliative care interventions. Quality appraisal was assessed using Cochrane risk-of-bias tools. In total, there were 6 trials providing palliative care interventions integrating team-based approaches between palliative care specialists and nonpalliative clinicians, such as a cardiologist, cardiac nurse, and advanced practice nurse across inpatient and outpatient settings. The different types of interventions included home visits, symptom management via phone calls or referral to a specialist team, and the establishment of treatment planning. Patient-reported outcome measures included positive effects of palliative interventions on symptom burden and quality of life. Given that most of the selected studies were conducted in Western countries, palliative care should be culturally tailored to assist heart failure patients worldwide.

Case Study of an African American Woman With Heart Failure: Ethical and Palliative Care Considerations

Heart failure affects an estimated 6.2 million adults in the United States. African Americans have a higher incidence of heart failure at an earlier age and more rapid disease progression than other ethnicities. African Americans also often receive lower-quality, end-of-life care and less often receive palliative and advanced-care planning than Whites. Several barriers exist for effective heart failure evaluation and treatment among African Americans, including ineffective patient-provider communication, mistrust, health care providers' lack of understanding of palliative care services, and potential downstream effects of social determinants of health (eg, access barriers to healthy food and community health promotion resources). Despite the recognized benefits of palliative care, few adults with heart failure are receiving early discussions about palliative and advanced care planning to ensure delivery of goal-concordant care. This article presents a fictitious case study focused on an African American woman, Ms T, with heart failure who has been given 6 months to live. Racial inequities are presented surrounding Ms T's inadequate access to necessary health care resources and in receiving delayed communication about palliative and advanced care services. The case study also highlights ethical principles of concern, the role of an interdisciplinary team approach for patients with heart failure, and the advocacy role of nurses.

Nurses' symptom management and views on death and caring for heart failure and chronic obstructive pulmonary disease

BACKGROUND

The number of older adult patients in Japan is increasing and symptom management is needed not only for cancer patients, but also non-cancer patients.

AIMS

This study investigated nurses' symptom management and their views on death and caring for heart failure (HF) and chronic obstructive pulmonary disease (COPD).

METHODS

A cross-sectional survey using a questionnaire was conducted. Survey items were implementation of assessment and non-pharmacological interventions for 14 symptoms at the end-of-life stage, participation in palliative care training courses and attitude toward death and caring, as assessed by the Frommelt attitude toward care of the dying (FATCOD) Scale.

RESULTS

A total of 266 (78.5%) nurses responded. More than 90% implemented symptom assessment of dyspnea and cough for both HF and COPD. The mean FATCOD score was 114.7, participation in on-the-job palliative care training courses (p<0.01), and difficulty with near-death issues (p<0.01) were significantly associated with the FATCOD.

CONCLUSION

These results suggest that nurses assessed the major symptoms of HF and COPD. Training courses are important to promote palliative care for non-cancer patients.

Elements of Integrated Palliative Care in Chronic Heart Failure Across the Care Continuum: A Scoping Review

BACKGROUND

Individuals with chronic heart failure experience high symptom burden, reduced quality of life and high health care utilisation. Although there is growing evidence that a palliative approach, provided concurrently with usual treatment improves outcomes, the method of integrating palliative care for individuals living with chronic heart failure across the care continuum remains elusive.

AIM

To examine the key elements of integrated palliative care recommended for individuals living with chronic heart failure across the care continuum.

DESIGN

Scoping review.

DATA SOURCES

Databases searched were CINAHL, Ovid MEDLINE, Scopus and OpenGrey. Studies written in English and containing key strategic elements specific to chronic heart failure were included. Search terms relating to palliative care and chronic heart failure and the Joanna Briggs Institute methodology for scoping reviews was used.

RESULTS

Seventy-nine (79) articles were selected that described key elements to integrate palliative care for individuals with chronic heart failure. This review identifies four levels of key strategic elements: 1) clinical; 2) professional; 3) organisational and 4) system-level integration. Implementing strategies across these elements facilitates integrated palliative care for individuals with chronic heart failure.

CONCLUSIONS

Inter-sectorial collaborations across systems and the intersection of health and social services are essential to delivering integrated, person-centred palliative care. Further research focussing on patient and family needs at a system-level is needed. Research with strong theoretical underpinnings utilising implementation science methods are required to achieve and sustain complex behaviour change to translate key elements.

Supportive and Palliative Care Indicators Tool prognostic value in older hospitalised patients: a prospective multicentre study

BACKGROUND

An increasing number of older patients are hospitalised. Prognostic uncertainty causes hospital doctors to be reluctant to make the switch from cure to care. The Supportive and Palliative Care Indicators Tool (SPICT) has not been validated for prognostication in an older hospitalised population.

AIM

To validate SPICT as a prognostic tool for risk of dying within one year in older hospitalised patients.

DESIGN

Prospective multicentre study. Premorbid SPICT and 1-year survival and survival time were assessed.

SETTING/PARTICIPANTS

Patients 75 years and older admitted at acute geriatric (n=209) and cardiology units (CUs) (n=249) of four hospitals.

RESULTS

In total, 59.3% (124/209) was SPICT identified on acute geriatric vs 40.6% (101/249) on CUs (p<0.001). SPICT-identified patients in CUs reported more functional needs and more symptoms compared to SPICT non-identified patients. On acute geriatric units, SPICT-identified patients reported more functional needs only.The HR of dying was 2.9 (95% CI 1.1 to 8.7) in SPICT-identified versus non-identified after adjustment for hospital strata, age, gender and did not differ between units. One-year mortality was 24% and 22%, respectively, on acute geriatric versus CUs (p=0.488). Pooled average sensitivity, specificity and partial area under the curve differed significantly between acute geriatric and CUs (p<0.001), respectively, 0.82 (95%CI 0.66 to 0.91), 0.49 (95%CI 0.40 to 0.58) and 0.82 in geriatric vs 0.69 (95% CI 0.42 to 0.87), 0.66 (95% CI 0.55 to 0.77) and 0.65 in CUs.

CONCLUSIONS

SPICT may be used as a tool to identify older hospitalised patients at risk of dying within 1 year and who may benefit from a palliative care approach including advance care planning. The prognostic accuracy of SPICT is better in older patients admitted at the acute geriatric versus the CU.

Referral Practices of Cardiologists to Specialist Palliative Care in Canada

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Downgrade of cardiac defibrillator devices to pacemakers in elderly heart failure patients: clinical considerations and the importance of shared decision-making

Implantable cardioverter defibrillators are implanted on a large scale in patients with heart failure (HF) for the prevention of sudden cardiac death. There are different scenarios in which defibrillator therapy is no longer desired or indicated, and this is occurring increasingly in elderly patients. Usually device therapy is continued until the device has reached battery depletion. At that time, the decision needs to be made to either replace it or to downgrade to a pacing-only device. This decision is dependent on many factors, including the vitality of the patient and his/her preferences, but may also be influenced by changes in recommendations in guidelines. In the last few years, there has been an increased awareness that discussions around these decisions are important and useful. Advanced care planning and shared decision-making have become important and are increasingly recognised as such. In this short review we describe six elderly patients with HF, in whose cases we discussed these issues, and we aim to provide some scientific and ethical rationale for clinical decision-making in this context. Current guidelines advocate the discussion of end-of-life options at the time of device implantation, and physicians should realise that their choices influence patients’ options in this critical phase of their illness.

The need for palliative and support care services for heart failure patients in the community

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.

Professionals guidance about palliative medicine in chronic heart failure: a mixed-method study

INTRODUCTION

Healthcare professionals (HCPs) experience difficulties in timely recognising and directing palliative care (PC) needs of their patients with chronic heart failure (CHF). The aim of this study was to develop a comprehensive tool to enable HCPs in timely recognising and directing PC needs in CHF.

METHODS

A four-stage mixed-method study was performed. Stage 1: identification of needs and questions of patients and families; stage 2: prioritisation and refinement of the needs and questions; stage 3a: testing and online feedback on V.1; stage 3b: selecting and refining care recommendations; stage 4: testing and review of V.2. Iterative reviews followed each step in the development process to ensure a wide range of stakeholder input. In total, 16 patients, 12 family members and 54 HCPs participated.

RESULTS

A comprehensive set of 13 PC needs was identified, redefined and tested. The resulting tool, called Identification of patients with HeARt failure with PC needs (I-HARP), contains an introduction prompt with open questions to start the conversation, 13 closed screening questions with additional in-depth questions, and recommendations on actions for identified needs.

CONCLUSION

I-HARP contains an evidence-based set of questions and palliative CHF care suggestions for HCPs in the Netherlands. The resulting tool, approved by HCPs, patients and family members, is a promising guidance for HCP to timely recognise and direct PC needs in CHF.

Palliative Care in Heart Failure: A Public Health Emergency

BACKGROUND

Palliative care (PC) is the holistic care of patients with life-limiting illnesses focused on relief of suffering and maximizing quality of life for patients and their families. Patients with heart failure (HF) are the largest group eligible for PC services, but only a small percentage of them receive PC.

AREAS OF UNCERTAINTY

The optimal content and method of delivery of PC interventions to HF patients in resource-limited countries remain unknown. The integration of PC into existing HF disease management continues to be a challenge.

DATA SOURCES

PUBMED was searched to identify articles on the topic published in the last 5 years (2014-April 2019). One hundred thirty-six articles were identified-14 articles out of were included in the revision.

THERAPEUTIC ADVANCES

Research concerning PC in HF is still scarce and comes predominantly from developed countries. PC in HF improves patients' and caregivers' outcomes in terms of dyspnea, sleep, depression, communication, coping, and care-giving burden. Specialized home-based PC services have a positive impact on patients' physical and emotional wellbeing while decreasing utilization of medical services. Fatigue, dyspnea, and pain are frequent symptoms. Evidence concerning use of opioids for dyspnea is increasing. Family caregivers offer a considerable amount of care during the disease trajectory. There is often incongruence between the carer's and the patient's wishes in terms of treatment decisions and preferences. Carers should be assessed for risk and supported in their roles in care management and care coordination.

CONCLUSIONS

Because of the unpredictability of the disease and difficulty in prognostication, PC should be introduced at the point of diagnosis of HF. Basic education in PC needs to be introduced early in the training of cardiology staff, focused on concept definition, differencing PC and terminal care, symptom management, communication, and decision-making.

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

Background

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

Methods

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

Results

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

Conclusions

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

cBIN1 Score (CS) Identifies Ambulatory HFrEF Patients and Predicts Cardiovascular Events

BACKGROUND

Cardiac Bridging Integrator 1 (cBIN1) is a membrane deformation protein that generates calcium microdomains at cardiomyocyte t-tubules, whose transcription is reduced in heart failure, and is released into blood. cBIN1 score (CS), an inverse index of plasma cBIN1, measures cellular myocardial remodeling. In patients with heart failure with preserved ejection fraction (HFpEF), CS diagnoses ambulatory heart failure and prognosticates hospitalization. The performance of CS has not been tested in patients with heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

CS was determined from plasma of patients recruited in a prospective study. Two comparative cohorts consisted of 158 ambulatory HFrEF patients (left ventricular ejection fraction (LVEF) ≤ 40%, 57 ± 10 years, 80% men) and 115 age and sex matched volunteers with no known history of HF. N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations were also analyzed for comparison. CS follows a normal distribution with a median of 0 in the controls, which increases to a median of 1.9 (p < 0.0001) in HFrEF patients. CS correlates with clinically assessed New York Heart Association Class (p = 0.007). During 1-year follow-up, a high CS (≥ 1.9) in patients predicts increased cardiovascular events (43% vs. 26%, p = 0.01, hazard ratio 1.9). Compared to a model with demographics, clinical risk factors, and NT-proBNP, adding CS to the model improved the overall continuous net reclassification improvement (NRI 0.64; 95% CI 0.18-1.10; p = 0.006). Although performance for diagnosis and prognosis was similar to CS, NT-proBNP did not prognosticate between patients whose NT-proBNP values were > 400 pg/ml.

CONCLUSION

CS, which is mechanistically distinct from NT-proBNP, successfully differentiates myocardial health between patients with HFrEF and matched controls. A high CS reflects advanced NYHA stage, pathologic cardiac muscle remodeling, and predicts 1-year risk of cardiovascular events in ambulatory HFrEF patients. CS is a marker of myocardial remodeling in HFrEF patients, independent of volume status.

Perceptions of Palliative Care Nurses Related to Death and Palliative Care Practices

This study has been conducted with the purpose of identifying the perceptions of palliative nurses about death and determining palliative care practices. We conducted qualitative interviews with 23 palliative care nurses in Turkey. Content analysis was used in the evaluation of the data. Three themes have been identified about perception of death. Furthermore, three themes have been identified about palliative care practices. It was concluded that the palliative nurses perceive death as a natural and inevitable process and that as long as their working period increases, they become desensitized. It was identified that the participants generally perform the following procedures in palliative care practices.

Screening and Initiating Supportive Care in Patients With Heart Failure

Background: Patients with heart failure (HF) experience a major symptom burden and an overall reduction of quality of life. However, supportive care (SC) remains an under-utilized resource for these patients. Among the many existing barriers to integrating SC into routine care, identifying patients with SC needs remains challenging. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is an important predictor of SC needs in patients with HF.

Methods and Results: We used the shortened version KCCQ-12 as a screening tool for SC need in our ambulatory HF patient population using a KCCQ-12 summary score of <29 as the cut-off. Of the 456 patients who completed the KCCQ-12, 41 (9%) were predicted to have SC needs. Demographics, medical history, biochemical parameters, echocardiographic assessment and medical treatment were similar between the two groups of patients. However, patients with KCCQ-12 <29 were more symptomatic based on both New York Heart Association (NYHA) classification and American Heart Association (AHA) staging with a higher prevalence of depression. We established a multidisciplinary SC clinic and the profile and outcomes of patients with SC needs that were referred and followed at our SC clinic were also evaluated. Twenty-three patients were referred to our SC clinic: 2 died before being seen, 1 refused SC and 20 received SC. Of these 20 patients, 11 died and 9 are currently being followed. Median survival after starting the SC clinic is 3 months. In the original SC cohort of 23, 17 patients had available KCCQ-12 summary scores. However, only 6 out of 17 (35%) had KCCQ-12 scores <29, indicating the need for additional assessment tools in this patient population.

Conclusions: The magnitude of unmet supportive care needs in patients with HF is significant. While the KCCQ-12 questionnaire is a useful tool to identify patients with SC, serial clinical evaluation, establishment of a SC clinic and prompt referral are essential for patients needing supportive care.

Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure

AIMS

Estimating survival is challenging in the terminal phase of advanced heart failure. Patients, families, and health-care organizations would benefit from more reliable prognostic tools. The Palliative Performance Scale Version 2 (PPSv2) is a reliable and validated tool used to measure functional performance; higher scores indicate higher functionality. It has been widely used to estimate survival in patients with cancer but rarely used in patients with heart failure. The aim of this study was to identify prognostic cut-points of the PPSv2 for predicting survival among patients with heart failure receiving home hospice care.

METHODS AND RESULTS

This retrospective cohort study included 1114 adult patients with a primary diagnosis of heart failure from a not-for-profit hospice agency between January 2013 and May 2017. The primary outcome was survival time. A Cox proportional-hazards model and sensitivity analyses were used to examine the association between PPSv2 scores and survival time, controlling for demographic and clinical variables. Receiver operating characteristic curves were plotted to quantify the diagnostic performance of PPSv2 scores by survival time. Lower PPSv2 scores on admission to hospice were associated with decreased median (interquartile range, IQR) survival time [PPSv2 10 = 2 IQR: 1-5 days; PPSv2 20 = 3 IQR: 2-8 days] IQR: 55-207. The discrimination of the PPSv2 at baseline for predicting death was highest at 7 days [area under the curve (AUC) = 0.802], followed by an AUC of 0.774 at 14 days, an AUC of 0.736 at 30 days, and an AUC of 0.705 at 90 days.

CONCLUSIONS

The PPSv2 tool can be used by health-care providers for prognostication of hospice-enrolled patients with heart failure who are at high risk of near-term death. It has the greatest utility in patients who have the most functional impairment.

The Provision of Palliative Care for Noncancer Patients With Advanced Disease: Equity Does Matter

According to the World Health Organization, the main mission of palliative care is to optimize the quality of life of patients with serious chronic disease, as well as their caregivers, by providing biopsychosociospiritual care. However, historically, the primary focus of palliative care is on providing care only for cancer diseases. Based on the current literature, it is assumed that palliative care is not provided for many chronic diseases on a regular basis and in many cases, a clinical guideline does not exist for providing palliative care.

Current Trends and Possibilities of Providing Medical Palliative Care in Chronic Heart Failure

Chronic heart failure (CHF) is an important healthcare problem because of high prevalence, morbidity and mortality rates. Treatment resistant symptoms, need for communication and support, unite patients with CHF and oncological diseases but despite that CHF patients rarely receive specialized palliative care (SPC). This review is devoted to the need and possible ways of providing SPC to patients with CHF and their families. We discuss here variants of CHF course in terminal phase, the term end of life appropriate care, various specialists' concepts of SPC delivering to CHF patients in accordance with their preferences.

End-of-life situations in cardiology: a qualitative study of physicians' and nurses' experience in a large university hospital

BACKGROUND

Professional societies call for integration of end-of-life discussions early in the trajectory of heart failure, yet it remains unclear where current practices stand in relation to these recommendations. We sought to describe the perceptions and attitudes of caregivers in cardiology regarding end-of-life situations.

METHODS

We performed a qualitative study using semi-directive interviews in the cardiology department of a university teaching hospital in France. Physicians, nurses and nurses' aides working full-time in the department at the time of the study were eligible. Participants were asked to describe how they experienced end-of-life situations. Interviews were recorded, transcribed and coded using thematic analysis to identify major and secondary themes.

RESULTS

All physicians (N = 16)(average age 43.5 ± 13 years), 16 nurses (average age 38.5 ± 7.6 years) and 5 nurses' aides (average age 49 ± 7.8 years) participated. Interviews were held between 30 March and 17 July 2017. The main themes to emerge from the physicians' discourse were the concept of cardiology being a very active discipline, and a very curative frame of mind was prevalent. Communication (with paramedical staff, patients and families) was deemed to be important. Advance directives were thought to be rare, and not especially useful. Nurses also reported communication as a major issue, but their form of communication is bounded by several factors (physicians' prior discourse, legislation). They commonly engage in reconciling: between the approach (curative or palliative) and the reality of the treatment prescribed; performing curative interventions in patients they deem to be dying cases causes them distress. The emergency context prevents nurses from taking the time necessary to engage in end-of-life discussions. They engage in comfort-giving behaviors to maximize patient comfort.

CONCLUSION

Current perceptions and practices vis-à-vis end-of-life situations in our department are individual, heterogeneous and not yet aligned with recommendations of professional societies.

New Dimensions in Palliative Care Cardiology

The landscape of patient care at the beginning of the 19th century was dramatically different than it is today. With few good treatment options, illness courses were generally brief. Near the end of life, patients were attended to by spiritual advisors, not health care professionals. Death typically occurred at home, surrounded by friends and family. Moving to the present time, decades of medical advances have significantly improved life expectancy. Cardiology has particularly benefited from many of these advances. Cardiac patients are initiated on optimal medication regimens. As disease burdens progress, interventions such as implantable defibrillators and cardiac resynchronization pacing systems become options for many patients. With further clinical deterioration, select patients might be candidates for ventricular assist devices and heart transplants. These advances have unquestionably improved the prognosis with advanced cardiovascular illnesses. However, they have also changed patient and family attitudes about death and dying, to the point where we have effectively "medicalized our mortality." The importance of introducing palliative care to the cardiac patient population is now well recognized, with the major cardiovascular societies incorporating palliative care principles into their guideline and consensus statement documents. However, despite this recognition, few cardiac patients get access to palliative care and other resources such as hospice. In this article the existing literature on this topic is reviewed and opportunities for developing and fostering a more collaborative relationship between the disciplines of cardiology and palliative care are discussed.