Kansas City Cardiomyopathy Questionnaire Administered to Hospitalized Patients With Heart Failure

BACKGROUND AND PURPOSE

The psychometric properties of the Kansas City Cardiomyopathy Questionnaire (KCCQ) have been examined primarily in community-dwelling patients with heart failure (HF). The objective of this research was to examine the properties of the KCCQ administered to patients hospitalized with HF (N = 233).

METHODS

Confirmatory factor analysis, Cronbach's alphas, and correlations were performed to examine the scale's dimensions, reliability, and validity.

RESULTS

Confirmatory factor analysis indicated a 5-factor solution (63.6% of the variance). The Cronbach's alpha levels were greater than .70, except for the self-efficacy dimension (.60). Convergent validity was not verified between the KCCQ and several illness severity measures.

CONCLUSIONS

The psychometric properties of the KCCQ may be different based on the population in which the KCCQ is administered, which may have clinical implications.

Living with advanced heart failure or COPD: experiences and goals of individuals nearing the end of life

The last phase of life of patients with end-stage heart failure (HF) or chronic obstructive pulmonary disease (COPD) is marked by high symptom burden and uncertainty about the future. Few enroll in hospice, and their preferences for care remain unknown. The purpose of this qualitative study was to describe the experiences and goals for care of patients with end-stage HF and COPD who were recently discharged from the hospital. Forty semi-structured interviews were completed with 20 participants. Despite conditions considered life-threatening by clinicians, participants believed they still had time. They hoped that their illnesses would remain stable, although specific experiences made them think they might be worsening. All expected that their doctors would tell them when their illnesses became life-threatening.

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

PURPOSE

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

METHODS

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

RESULTS

Four main themes resulted.

PARTICIPANTS

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

CONCLUSION

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

Who is attending? End-of-life decision making in the intensive care unit

PURPOSE

Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM.

METHODS

Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units.

RESULTS

The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer.

CONCLUSIONS

Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.

Family members' informal roles in end-of-life decision making in adult intensive care units

BACKGROUND

To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process.

OBJECTIVE

To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units.

METHODS

Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit.

PARTICIPANTS

Health care clinicians, patients, and family members.

RESULTS

Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains.

CONCLUSIONS

These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.

Abstract P107: Comparing Perceptions of Chronic Heart Failure Patients' Health Status Prior to Hospitalization by Patients and Their Family Caregiver/Significant Others

PURPOSE: Little is known if family caregivers/significant others (FC/SOs) have similar or different perceptions of the patients' health status. FC/SO perception may influence care decisions and affect patient outcomes. The purpose of this study was to compare chronic HF patients' and FC/SOs' perception of the patients' health status prior to hospitalization and relationship to time to seek care.

METHODS: Participants were 144 hospitalized chronic HF patients and 144 FC/SOs recruited to complete the Kansas City Cardiomyopathy Questionnaire (KCCQ). The questionnaire was administered to both patients and their FC/SOs during the patients' hospitalization to measure perceptions of the patients' health status 2 weeks before hospitalization. The KCCQ is a validated questionnaire that quantifies physical limitation, symptoms, social limitation, self-efficacy, and QOL for patients with HF; lower scores meaning worse perceived health status. The questionnaire with modified wording was used for FC/SOs to respond about their perceptions of the patients' health status and reliability was evaluated. Patient participants were primarily white males with a mean age of 66.2 (SD=15.3). Mean LVEF was 33.3 % (SD=18.3). The FC/SO participants were primarily family members and white females; mean age of 58.2 years (SD=14.3).

RESULTS: Paired t-test correlation analysis revealed the responses from patients and FC/SOs as significant (p<.001) and highly correlated on their perceptions of the patient’s physical limitation ( r =.63), symptom frequency ( r =.68), symptom burden ( r =.61), social limitation ( r =.59); and moderately correlated on perceptions of QOL ( r =.38), self-efficacy ( r =.38), and symptom stability ( r =.44).Cronbach's alphas for patient KCCQ and FC/SO KCCQ were .91 and .90, respectively. Overall health status summary scores were highly correlated ( r =.70) but the patients' overall score was significantly inversely related to days to hospitalization ( B =−.031, p =.01).

CONCLUSIONS: The health status of chronic HF patients is perceived similarly by both patients and FC/SOs as poor and is associated with longer time to seek care. Further research is needed to understand how these perceptions influence decision making to seek appropriate and timely care.

Intensive care unit cultures and end-of-life decision making

PURPOSE

Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM.

MATERIALS AND METHODS

Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit.

RESULTS

The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM.

CONCLUSIONS

As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.

Symptom clusters in acute myocardial infarction: a secondary data analysis

BACKGROUND

Early recognition of acute myocardial infarction (AMI) symptoms and reduced time to treatment may reduce morbidity and mortality. People having AMI experience a constellation of symptoms, but the common constellations or clusters of symptoms have yet to be identified.

OBJECTIVES

To identify clusters of symptoms that represent AMI.

METHODS

This was a secondary data analysis of nine descriptive, cross-sectional studies that included data from 1,073 people having AMI in the United States and England. Data were analyzed using latent class cluster analysis, an a theoretical method that uses only information contained in the data.

RESULTS

Five distinct clusters of symptoms were identified. Age, race, and sex were statistically significant in predicting cluster membership. None of the symptom clusters described in this analysis included all of the symptoms that are considered typical. In one cluster, subjects had only a moderate to low probability of experiencing any of the symptoms analyzed.

DISCUSSION

Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters identified in this study included all of the symptoms that are included typically as symptoms of AMI (chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness). These AMI symptom clusters must be communicated clearly to the public in a way that will assist them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior. Symptom clusters for AMI must also be communicated to the professional community in a way that will facilitate assessment and rapid intervention for AMI.

Delay in seeking care for symptoms of acute myocardial infarction: Applying a theoretical model

Thirty percent of people who experience symptoms of acute myocardial infarction (AMI) do not seek care until more than 2-6 hours after onset of symptoms, increasing their risk for morbidity and mortality. Using a model based on two frameworks, the common sense model of illness representation (CSM) and goal expectancy, variables associated with delay were examined to identify the most salient predictors of delay in seeking care for AMI. Hierarchical regression analysis revealed that the set of illness representation components from the CSM was a significant predictor of time to seek care, but individually, only recognition of symptoms as being caused by the heart was significant. Providing accurate information on symptoms of AMI may lead to early recognition, reduced delay, and reduced morbidity and mortality.

Perception of risk for coronary heart disease in women undergoing coronary angiography

BACKGROUND

Even though coronary heart disease (CHD) is the leading cause of death among women in the United States, most women underestimate their risk of developing CHD.

DESIGN

Survey to examine the relationship between women's recollection of being told they were at risk for CHD and the presence of risk factors.

SETTING/PARTICIPANTS

A convenience sample of 450 women undergoing coronary angiography at 1 university hospital.

MAIN OUTCOME MEASURES

Self-recollection of being told one was at risk for CHD and presence of CHD risk factors.

RESULTS

Most women (83.6%) had 3 or more risk factors, 12.2% had 1 or 2 risk factors, and 0.9% had no risk factors. Only 35% of women recalled being told that they were at risk for CHD. Few relationships were found between being told one was at risk for CHD and the presence of individual risk factors. No difference was found in the mean number of risk factors among women who did and did not recall being told they were at risk. In logistic regression analysis, only 5% of the variance in recollection of being told one was at risk was predicted, with only age, education, and having a high cholesterol level significantly contributing to the equation.

CONCLUSIONS

Even though women may not remember conversations with their health care provider about CHD risk, the possibility that risk factors were not adequately assessed cannot be discounted. Patient-provider conversations about CHD risk factors should be encouraged as the first step toward successful risk reduction.

Reasons for use of hormone replacement therapy in women undergoing coronary angiography

The recommendation has been made that all women be counseled about the risks and benefits of hormone replacement therapy (HRT). Use of HRT among women undergoing coronary angiography was explored to assess whether patterns of use were similar to data drawn from community samples. Using a descriptive design, a convenience sample of 414 postmenopausal women was interviewed. Fifty-eight percent had never used HRT, 18.3% were past users, and 23.7% were currently using HRT. The primary reason given for ever using HRT was for symptoms of menopause. Less than 14% of women cited coronary heart disease (CHD) or osteoporosis as their primary reason for using HRT. The most common reasons for stopping HRT were side effects and fear of cancer. The most common reasons given for never having used HRT were that their healthcare provider had never talked about it and that they had never thought about it. Use of HRT among women undergoing coronary angiography is similar to that found in community samples. The challenge is to promote patient-provider interactions that include information about HRT based on the scientific model as well as attention to women's individual concerns.

Teaching the teachers: creating an effective critical care preceptor program

Staff nurse preceptors are integral members of effective critical care orientation programs. Much of the success of the orientation experience and orientee satisfaction depends on them. A critical care preceptor workshop containing a review of the orientation program and the application of educational principles in critical care settings has been found to be an effective method for assisting preceptors and for enhancing our orientation program.

Preserving the mission. Sponsors and lay leaders must collaborate to maintain the Church's presence in healthcare

As the number of women and men religious involved in healthcare decreases, the Church faces the task of sustaining and expanding its institutional presence in the healthcare world. Both the Gospels and Church teaching support the claim that the Church should be involved in social institutions such as healthcare. Documents such as the Second Vatican Council's Pastoral Constitution on the Church in the Modern World stress the Church's concern with the impact of God's kingdom on all dimensions of human life. Pope Paul VI's Evangelization in the Modern World clearly affirms that the Gospel cannot be complete until it is interrelated with social life. Jesus' ministries of teaching and humble service are also paradigmatic for Catholic healthcare. To preserve and extend its institutional presence, Catholic healthcare will have to meet a number of challenges in the coming years. Catholic healthcare facilities must be prepared to relinquish their autonomy and work with others, providers will have to become attuned to what is distinctively Catholic about their facilities, and the Church must commit itself to preparing lay leaders for the Catholic healthcare ministry.

Analysis of gait patterns in normal school-aged children

The continuing development of gait in 60 children aged 7-16 years was studied with plantar surface-attached transducers to describe the time pressure profiles of foot segments during stance. Decreased pronation/supination of the subtalar and midtarsal joints was shown by simultaneous onset and simultaneous peak on medial and lateral heel sensors. The resultant midstance showed a rapid lateral-to-medial loading of the forefoot. The foot-flat position with decreased rotation about the longitudinal axis of the foot persists even after the temporal parameters of gait attain mature values.

Platelet inhibitors and hydroxyethyl starch: safe and cost-effective interventions in coronary artery surgery

This study evaluated the cost-effectiveness and clinical safety of utilizing hetastarch in pump prime solutions and for colloid replacement postoperatively in conjunction with the platelet inhibitors, aspirin and Persantine (dipyridamole). Sixty-four adult patients undergoing a coronary artery bypass operation were divided into two groups. Group 1 (N = 32) received only Persantine (75 mg three times a day) on the day prior to operation. Group 2 (N = 32) received the same Persantine dose plus aspirin (325 mg). In both groups, aspirin and Persantine were continued postoperatively and hetastarch was used as the colloid of choice. All patients were evaluated for blood loss, coagulation profiles, cost of blood and colloid replacement, and clinical course. Group 2 patients demonstrated significantly greater blood loss (p less than 0.05) but the same postoperative coagulation profiles as Group 1. The transfusion requirement (3.6 units versus 1.3 units) and cost basis ($252 versus $91) for patient care were higher in Group 2. Hetastarch had no effect on blood loss and was not associated with any adverse clinical reactions. Annual institutional savings based on utilization of hetastarch were calculated at $33,500 to $40,500 per 500 patients. We conclude that preoperative administration of aspirin (325 mg) is associated with increased perioperative blood loss and higher patient costs, two variables not demonstrable with Persantine only. Use of hetastarch combined with postoperative platelet inhibition was clinically safe and was a cost-effective method of colloid replacement.

The public debate on social justice and health care: an opportunity for evangelization

The most difficult moral choices arise at the point where social justice questions and medical-moral questions intersect. In an age of increasing technological advances and government intervention, Catholic health care facilities ought to shape a coherent moral policy that affirms human dignity and conforms to the Church's moral teaching.