Heart Failure Illness Trajectory Research Articles

Overactive Bladder is a Distress Symptom in Heart Failure

The prevalence of Heart failure (HF) is expected to increase worldwide with the aging population trend. The numerous symptoms of and repeated hospitalizations for HF negatively affect the patient’s quality of life and increase the patient’s economic burden. Up to 50% of patients with HF suffer from urinary incontinence (UI) and an overactive bladder (OAB). However, there are limited data about the relationship between UI, OAB, and HF. The association between HF and urinary symptoms may be directly attributable to worsening HF pathophysiology. A comprehensive literature review was conducted for all publications between January 2000 and November 2017 using the PubMed, Embase, and Cochrane databases. HF represents a major and growing public health problem, with an increased risk of UI and an OAB as comorbidities. Possible effects of HF on urinary problems may be mediated by the prescription of medications for symptomatic relief. Although diuretics are typically used to relieve congestion, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve survival, these classes of drugs have been suggested to worsen urinary symptoms in the presence of HF. Further research is required to understand the impact of UI and an OAB on the HF illness trajectory.

Supporting Self-Care Across the Heart Failure Illness Trajectory: Exploring the Clinical Practice of Specialist Heart Failure Nurses Across Metropolitan and Regional New South Wales

Supporting Self-Care Across the Heart Failure Illness Trajectory: Exploring the Clinical Practice of Specialist Heart Failure Nurses Across Metropolitan and Regional New South Wales

Self-Care Support Needs of Patients and their Carers Across the Heart Failure Illness Trajectory: A Mixed-Methods Longitudinal Study

Background: Heart failure is a chronic, progressive condition that requires patients and their carers to engage in self-care behaviours over the course of the illness experience.

164 - Teaching Providers Serious Illness Communication Skills in Heart Failure

Background: The increasing prevalence, high symptom burden, associated co-morbidities and medical advances that often prolong the advanced phase of heart failure (HF) mandate an organized and thoughtful approach to medical decision-making in this population. However, many clinicians have difficulty discussing prognosis and goals of care with patients. Barriers include disease- and therapy-specific prognostication challenges in HF and a lack of evidence-based palliative care education initiatives for HF clinicians. To have effective discussions, providers need advanced training. Purpose: The purpose of this study was to develop and study the effect of a brief clinician educational intervention to review prognostication and teach communication skills along the HF illness trajectory. Methods: A 45-minute training module was developed, which consisted of a case-based small group session and a HF communication guide. The curriculum highlights prognostication challenges in HF and introduces an illness trajectory-based framework to cue iterative goals of care conversations. Specific skills taught include assessing patients' illness understanding and information-sharing preferences, exploring goals and values, making prognostic disclosures, and making medical recommendations for goal-concordant care. We piloted this learning module with 46 CCU-based internal medicine residents and interdisciplinary palliative care fellows in groups of 2–15, and obtained anonymous quantitative and qualitative post-session learner survey data. Results: Clinicians rated the session highly. One hundred percent of learners either strongly agreed or agreed the session was clinically useful. Learners unanimously found the teaching methods effective and the majority felt they could easily apply these skills to their clinical work: 96% felt this session would change or improve their practice. In open-ended feedback solicited, learners said the session gave them a better understanding of the HF illness trajectory, an improved framework for discussing goals of care with HF patients, and specific language to use when having these discussions. Conclusions: A short communication skills teaching session was highly valued by both general and specialty-level clinicians in training. This represents a new paradigm for teaching and learning prognostication and serious illness communication skills in HF, in which illness trajectory guides timing and content of goals of care conversations. This tool can be used to help clinicians who are not trained in palliative care elicit the goals and values of patients with heart failure.

Prognosis, Communication, and Advance Care Planning in Heart Failure: A Module for Students, Residents, Fellows, and Practicing Clinicians.

The increasing prevalence, high symptom burden, and medical advances that often prolong the advanced phase of heart failure mandate an organized and thoughtful approach to medical decision making. However, many clinicians have difficulty discussing prognosis and goals of care with patients. Barriers include disease- and therapy-specific prognostication challenges in heart failure and a lack of evidence-based primary palliative care education initiatives. In response, we developed this 45-minute training module, which consists of a case-based small-group session and a communication guide. The curriculum highlights prognostication challenges in heart failure and introduces an illness trajectory-based framework to cue iterative goals of care conversations. We piloted this learning module with 46 internal medicine residents and interdisciplinary palliative care fellows in groups of three to 15 and obtained anonymous quantitative and qualitative postsession learner survey data to examine feasibility and acceptability. Trainees rated the session highly. One hundred percent of learners either strongly agreed or agreed the session was clinically useful. Learners unanimously found the teaching methods effective, and most felt they could easily apply these skills to their clinical work. In open-ended feedback, learners said the session gave them a better understanding of the heart failure illness trajectory, an improved framework for discussing goals of care with heart failure patients, and specific language to use when having these discussions. This module represents a new paradigm for teaching both prognostication and advance care planning in heart failure in which illness trajectory guides timing and content of goals of care conversations.

Uncertainties of the Heart

Chronic heart failure (HF) is a growing public health concern in Western nations. Incidence of HF increases with age, and demographics in the United States support a growing HF population. Annually, more than 100,000 people are admitted to hospitals because of HF. Patients with chronic HF experience a highly morbid and life-limiting illness while suffering from substantial physical and psychosocial burdens. What is the state of the science regarding the use of palliative care for community-dwelling adult patients with HF? A review of the scientific literature was conducted using the key words "palliative care" and "heart failure" in several electronic databases (CINAHL, Medline, Proquest) from October 15 to November 15, 2011. Eleven of the 16 articles found indicated that palliative care is underused by HF patients. There is a large unmet care need for adults with chronic HF and their family caregivers. Home healthcare professionals develop and maintain relationships with community-dwelling patients with chronic HF over the course of their HF illness trajectory. Home healthcare professionals are in a unique position to identify HF patients who may benefit from palliative care programs delivered across care settings in the community. By developing ongoing relationships with patients and their family caregivers, we are able to focus on the complete care needs of this patient population and assist them with advanced care planning, psychological and social issues, and symptom management. We can also improve communication among care providers and patients/families to identify goals of care along the trajectory of HF illness.

Review Article: A Model of Palliative Care for Heart Failure

The heart failure illness trajectory is both complex and unpredictable, which makes providing palliative care services to patients with heart failure a challenge. As a result, although services are needed, few tend to be offered beyond basic medical management. The traditional model of palliative care is typically based on palliative care being considered a system of care delivery most appropriate for patients with a predictable illness/death trajectory, such as terminal cancer. This type of model, which is based on the ability to predict the course of a terminal disease, does not fit the heart failure trajectory. In this article, we propose a new model of palliative care that conceptualizes palliative care as a philosophy of care that encompasses the unpredictable nature of heart failure.

Preparing for the Worst While Hoping for the Best

Patients with heart failure have higher mortality rates than those with most malignant diseases. The heart failure illness trajectory is one of gradual decline characterized by unpredictable events such as acute decompensation of heart failure or a sudden cardiac death. Health professionals have an obligation to give patients and their families concise and honest information concerning their prognosis. The challenge exists to give what ostensibly may seem a bleak prognosis within a context of hope and optimism. To explore the role of hope in heart disease and the potential utility of this construct in the development of nursing interventions. The electronic databases CINAHL, MEDLINE, EmBASE, and PSYCHlit were searched from 1982 to August 2004 using the key words "hope," "hopelessness," "heart disease," and "heart failure." Articles were subsequently sorted to meet the inclusion criteria of (1) a philosophical discussion of the construct of hope and/or (2) investigation of hope in heart disease. This search retrieved 768 articles, and 24 met the inclusion criteria. Key findings from the review indicate that "hope" and "hopelessness" are underdeveloped, yet important constructs and conceptually linked with depression and spirituality. Intriguing findings from descriptive, observational studies have demonstrated the positive impact of expression of hope on cardiovascular outcomes. These findings need to be validated in randomized controlled trials. This critical literature review has determined that "hope" is strongly associated with the individual's future orientation. Increased understanding of this concept may assist in refining patient-focused interventions and developing therapeutic strategies to enhance hope.

Maintaining Hope in Transition

Theoretical frameworks provide a structure for the planning and delivery of nursing care and for research. Heart failure (HF), a condition of increasing prevalence in communities internationally, is responsible for high rates of morbidity, mortality, and great societal burden. The HF illness trajectory can be unpredictable and uncertain. Markers of transition, such as functional decline and increasing dependence, can signal the need for transition to a more palliative approach. This transition challenges clinicians to deliver information and interventions and to support patients and their families not only in relation to their physical status but also in the social, psychological, and existential dimensions. This article describes a theoretical framework, Maintaining Hope in Transition, informed by transition theory, to assist patients to cope with a diagnosis of HF and to guide development of nursing interventions. Transition theory provides a useful context to assist clinicians, patients, and their families adjust to the challenges inherent in a diagnosis of HF and negotiating the illness trajectory. Key factors acknowledged in the Maintaining Hope in Transition framework that determine its utility in models of care for HF patients are (1) acknowledging the changing of life circumstances, (2) restructuring reality, (3) dealing with vulnerability, (4) achieving normalization, and (5) resolving uncertainty. It is likely that incorporation of these factors in care planning, information, and interventions can facilitate patients' and their families' abilities to negotiate the HF illness trajectory, particularly in the advanced stages.

Two-year follow-up of quality of life in patients referred for heart transplant

Assessment of physical and mental health has become one of the ultimate tests of health-related quality of life (HRQOL) for patients with advanced heart failure. Little is known, however, about the comparative effects of surgical or medical treatment on the HRQOL of these chronically ill patients over time. We examined 77 patients (74% of whom were male), aged 56.1 +/- 12.7 years who were referred for heart transplant evaluation at a single heart failure center to describe the effects of time and treatment status on changes in HRQOL scores (physical and mental health and depression) using the Short Form-12 and the Beck Depression Inventory at 2 time points during their illness trajectory. The 2 evaluations on average were 2 years apart (mean 24.5 +/- 2.8 months). All patients were evaluated at baseline, and 3 groups were identified at the time of the 2-year follow-up: transplant recipients (n = 17), transplant candidates (n = 13), and medically stable patients considered too well to receive a transplant (n = 47). Nonparametric statistics were used to analyze group differences in HRQOL scores. The significance level was set at a P value less than .05. Demographic and HRQOL scores were not significantly different among the 3 groups at baseline. During follow-up, physical health and depression scores significantly improved over time in all patients, but changes in mental health were minimal. Group comparisons showed that although all patients continued to have low HRQOL scores at the time of follow-up evaluation, medically stable patients had higher mental health scores and less depressive symptoms than their counterparts. Our results support the need for ongoing HRQOL assessment with an emphasis on timely recognition and treatment of psychologic distress throughout the heart failure illness trajectory. Heart transplant recipients and candidates equally need special attention and follow-up because they both seem to have emotional and psychologic repercussions.