Cost-Savings of Do Not Resuscitate Orders Among Elderly Patients With Heart Failure in the United States.

Do-not-resuscitate (DNR) orders should preclude the use of cardiopulmonary resuscitation and may be associated with patient outcomes for patients hospitalized with heart failure (HF). This study examined the association between DNR and costs, mortality, and length of stay. The study cohort was a national sample of 700 922 hospital admissions of patients aged >65 with a primary diagnosis of HF. Elderly HF patients who died with a DNR had cost-savings of $5640 ( P < 0.001). Patients with a DNR order were 8.9% points more likely to die before discharge than patients without ( P < 0.001), and patients who died with a DNR had a significantly shorter hospital stay by 1.51 days ( P < 0.001). DNR orders among elderly patients with HF are associated with cost-savings, as well as a higher mortality and shorter length of stay. In addition to primary benefits, advance care planning may aid in containing costs of care at end of life for HF.

A Systematic Review of Interprofessional Palliative Care Education Programs.

CONTEXT: Interprofessional education (IPE) involving palliative and end-of-life content benefits learners by addressing interprofessional and palliative care (PC) competency needs. OBJECTIVES: A synthesis of educational approaches promoting interprofessional PC in academic and clinical settings would address research gaps and promote effective teaching. METHODS: A systematic review of interprofessional PC educational studies was conducted to summarize current approaches in PC IPE and to appraise teaching and research methods. Characteristics of excellence in interprofessional PC education established by Donesky et al. served as a framework for evaluating studies in this systematic review. RESULTS: A total of 39 articles met inclusion criteria for this review. Learners from medicine and nursing were the most included professions. University programs represented most studies, and evaluation methods demonstrated achievement of mostly self-reported outcomes like learner attitude and self-efficacy. While the effect of interprofessional collaboration on patient outcomes is well-documented, the effect of IPE on PC delivery is not. Although content spanned all interprofessional and PC domains, few studies addressed cultural aspects and fewer addressed well-being for the care provider. CONCLUSION: In light of the current healthcare landscape, there is an imminent need to address culture and provider well-being more directly through interprofessional PC education. Education and research must also move beyond university programs into health systems to support the professional development of clinicians for systems integration, sustainability, and impact on patient outcomes. Future evaluation of interprofessional PC education would be strengthened by multisite studies, randomized controlled trials, and repeated measures looking at outcomes over time.

A Systematic Review of Barriers and Facilitators of Pain Management in Persons with Dementia.

Approximately 50% of persons living with dementia experience pain, yet it is frequently undetected and inadequately managed resulting in adverse consequences. This review aims to synthesize evidence on the barriers and facilitators of pain management in persons living with dementia. PubMed, CINAHL, PsycINFO, and Web of Science datasets were used for article searching. Inclusion criteria were peer-reviewed original articles written in English that examined the barriers and facilitators of pain management for persons living with dementia. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies. A total of 26 studies were selected, including 18 qualitative and 3 quantitative (all high quality), as well as 5 mixed methods studies (low-to-high quality). Results were categorized into intrapersonal, interpersonal, environmental, and policy categories. Factors that impact pain management in dementia include cognitive and functional impairment, healthcare workers' knowledge, collaboration and communication, healthcare workers' understanding of patients' baseline behaviors, observation of behaviors, pain assessment tool use, pain management consistency, staffing level, pain guideline/policy, and training. Overall, pain management is challenging in persons living with dementia. The results indicate that there is a need for multi-component interventions that involves multidisciplinary teams to improve pain management in persons living with dementia at the intrapersonal, interpersonal, environmental, and policy levels. PERSPECTIVE: This review systematically synthesized barriers and facilitators of providing pain management in persons living with dementia. Results were presented in intrapersonal, interpersonal, environmental, and policy categories and suggests that multicomponent interventions involving multidisciplinary teams are needed to systematically improve pain management in persons living with dementia.

Disparities in Comorbidities in Lung Cancer: Findings From the Behavioral Risk Factor Surveillance System.

BACKGROUND: In persons with lung cancer, sex and race are independent predictors of comorbidities and are associated survival. It is unclear how comorbidity profiles differ across sex and race. OBJECTIVE: The objective was to examine comorbidity differences between men and women and Blacks and Whites. METHODS: Data from the 2014, 2016, 2017, and 2018 Behavioral Risk Factor Surveillance System were analyzed using descriptive statistics, χ2 test of independence, and multiple logistic regression. Variables included sociodemographics and comorbidities. RESULTS: Among individuals with lung cancer (N = 594), men were more likely to experience a heart attack (odds ratio [OR], 3.59; 95% confidence interval [CI], 1.62-7.96) and diabetes (OR, 2.83; 95% CI, 1.57-5.10) and less likely to experience depressive disorder (OR, 0.360; 95% CI, 0203-0.637). Black men (OR, 28.57; 95% CI, 9.22-88.55) and women (OR, 2.48; 95% CI, 1.02-6.05) were more likely to have a history of stroke. CONCLUSION: Findings show that there may be differences in patterns of comorbidities among individuals with lung cancer. As we continue to move toward individualized medicine in cancer care, future work in this area should examine social determinants of health and how they may influence the patterns of comorbidities. IMPLICATION FOR NURSES: Although nurses may be aware that certain groups have an increased risk for certain comorbid conditions, this study highlights what groups with lung cancer may be more likely to have certain comorbidities. Nurses can assess individuals for comorbidities and provide education on how to manage comorbidities during cancer treatment.

Engaging Families in Adult Cardiovascular Care: A Scientific Statement From the American Heart Association.

Family engagement empowers family members to become active partners in care delivery. Family members increasingly expect and wish to participate in care and be involved in the decision-making process. The goal of engaging families in care is to improve the care experience to achieve better outcomes for both patients and family members. There is emerging evidence that engaging family members in care improves person- and family-important outcomes. Engaging families in adult cardiovascular care involves a paradigm shift in the current organization and delivery of both acute and chronic cardiac care. Many cardiovascular health care professionals have limited awareness of the role and potential benefits of family engagement in care. Additionally, many fail to identify opportunities to engage family members. There is currently little guidance on family engagement in any aspect of cardiovascular care. The objective of this statement is to inform health care professionals and stakeholders about the importance of family engagement in cardiovascular care. This scientific statement will describe the rationale for engaging families in adult cardiovascular care, outline opportunities and challenges, highlight knowledge gaps, and provide suggestions to cardiovascular clinicians on how to integrate family members into the health care team.

Non-pharmacological interventions for pain in people with dementia: A systematic review.

CONTEXT: Pain commonly occurs in people living with dementia but is often undertreated. Non-pharmacological interventions are a safer first-line option for pain management, but evidence-based interventions for people living with dementia have not been established. An increasing number of studies have examined the effect of non-pharmacological interventions in pain management. However, the evidence that specifically focuses on people living with dementia has not been systematically reviewed. OBJECTIVES: This review aimed to systematically synthesize current evidence on non-pharmacological interventions to manage pain in people living with dementia. METHODS: A comprehensive search of the literature was conducted in PubMed, CINAHL, Scopus, and Web of Science databases. Studies were included if they were 1) peer-reviewed original quantitative research, 2) tested the effect of non-pharmacological interventions on pain in people with dementia, and 3) English language. Studies were excluded if they 1) included both pharmacological and non-pharmacological interventions and did not report separate results for the non-pharmacological interventions; 2) enrolled participants with and without dementia and did not have separate results reported for individuals with dementia; 3) tested dietary supplements as the intervention; and 4) were not original research, such as reviews, editorials, commentaries, or case studies. Title, abstract, and full text were screened. Quality assessment was conducted using the Cochrane Risk of Bias tool and Johns Hopkins Level of Evidence. Pain assessment tools, participant characteristics, study designs, intervention condition, and results were extracted. Results were synthesized through grouping the type of the interventions and weighting evidence based on quality and design of the studies. RESULTS: A total of 11 articles and 12 interventions were identified. A total of 486 participants were included. Interventions that have shown a positive impact on pain include ear acupressure, music therapy, reflexology, tailored pain intervention, painting and singing, personal assistive robot, cognitive-behavioral therapy, play activity, and person-centered environment program. Nevertheless, a majority of the interventions were only evaluated once. Moreover, most studies had similar sample characteristics and setting. CONCLUSION: Overall, the quality of included studies were mostly low to mixed quality and most participants only had mild to moderate baseline pain, which limits detection of the intervention's effect. Hence, these findings need to be duplicated in studies with a greater sample size, a more diverse population (race, gender, and settings), and a more rigorous design to validate the results.

Palliative Care: Oncology Nurses' Confidence in Provision to Patients With Cancer.

BACKGROUND: Oncology nurses are key providers of care to patients with cancer in all healthcare settings. However, little is known about oncology nurses' perceived confidence in providing all of the domains of palliative care. OBJECTIVES: The objectives of this study were to examine oncology nurses' perceived confidence in providing palliative care to patients with cancer and to identify the association between nurses' demographic and professional characteristics and their perceived confidence. METHODS: A descriptive correlational design was employed. The sample included RNs who provided care to patients with cancer and were members of the Oncology Nursing Society (ONS). Participants completed an online survey consisting of 14 demographic questions and a 50-item palliative care confidence scale. FINDINGS: Three hundred sixty-six ONS members completed the survey. Results showed that most oncology nurses were confident to very confident in providing palliative care to patients with cancer, but they lacked confidence in providing the psychosocial, spiritual, and legal and ethical aspects of care. Years of experience as an oncology nurse and palliative care training were significantly associated with perceived confidence in providing palliative care.

Longitudinal family caregiving experiences in heart failure: Secondary qualitative analysis of interviews.

BACKGROUND: Considering the potential impacts of family caregivers on heart failure management and the costs of healthcare, health professionals need to pay attention to the challenges faced by family caregivers. OBJECTIVE: This study longitudinally explored the caregiving experiences of family caregivers of persons with heart failure. METHODS: Serial interview scripts collected from 53 family caregivers were analyzed using a content analysis method. RESULTS: The following themes emerged: (1) accumulating knowledge and skills for caregiving; (2) losing a sense of control; (3) balancing an unstable life; (4) constructing illness memory; (5) centering the patient in daily life; (6) accepting the loss of a family member; (7) coping with grief by drawing on social support; (8) facing financial responsibility; and (9) rethinking hospice care. CONCLUSION: Family caregivers experience concern about unpredictable caregiving years, disease's fluctuating symptoms and poor prognosis. More educational opportunities, financial counseling programs, and palliative care consultations should be provided.

A Concept Analysis of Resistiveness to Care.

People with cognitive impairment often require assistance with activities of daily living. It is when providing assistance with these activities that many caregivers experience behaviors that have been categorized as disruptive or problematic and called resistiveness to care. These behaviors are considered to be a source of burden and job burnout for caregivers. Nurses wanting to help caregivers, who manage these trying situations, need to understand the concept of resistiveness to care and communicate this knowledge clearly with health care providers. Therefore, a literature search was conducted in 2012 within the databases CINAHL, Medline (PubMed), ProQuest, and PsychINFO. This produced 40 relevant articles. Because no concept analysis existed for resistiveness to care, a principle-based concept analysis was performed. The analysis helped construct a theoretically defined concept. Further analysis highlighted that more research is needed to advance the concept of resistiveness to care to enhance professional communication surrounding this phenomenon.

Do-not-resuscitate orders and readmission among elderly patients with heart failure in Pennsylvania: An observational study, 2011 - 2014.

BACKGROUND: Readmissions for patients with heart failure (HF) continues to be a target of value-based purchasing initiatives. Do-not-resuscitate (DNR) orders-one part of advance care planning (ACP)-have been shown to be related to other patient outcomes but has not been explored as a risk factor for HF readmission. OBJECTIVES: Examine the association between DNR and 30-day readmissions among elderly patients with HF admitted to hospitals in Pennsylvania. METHODS: Data included hospital discharges from 2011 to 2014 of patients 65+ years with a primary diagnosis of HF. Logistic regression was used to model the relationship between DNR and 30-day readmission. RESULTS: Among 107,806 patients, 20.9% were readmitted within 30 days. After controlling for covariates, patients with HF who had a DNR were less likely to be readmitted to the hospital (OR=0.85, 95% CI: 0.80-0.91, p<0.001). CONCLUSIONS: Documentation of a DNR may inform efforts to reduce readmissions among elderly patients with HF.

A longitudinal comparison of health-related quality of life in rural and urban recipients of left ventricular assist devices.

Left ventricular assist devices (LVAD) are a common treatment for advanced heart failure (HF) to improve ventricular function, symptoms, and health-related quality of life (HRQOL). Many LVAD recipients travel long distances from rural areas for LVAD implantation and follow-up care. Individuals with HF in rural settings who have not undergone LVAD implantation have reported poor HRQOL. However, to date, no studies have compared HF-specific or generic HRQOL in rural and urban LVAD recipients. The purpose of this study was to compare generic and HF-specific HRQOL longitudinally from preimplantation to 1-, 3-, and 6- months postimplant in a cohort of rural and urban LVAD recipients (n = 95; rural n = 32 and urban n = 63). We measured generic HRQOL using the European Quality of Life Visual Analog Scale and HF-specific HRQOL with the quality of life domain of the Kansas City Cardiomyopathy Questionnaire (KCCQ). Latent growth curve modeling identified two phases of change in generic and HF-specific HRQOL: the initial response to LVAD between preimplantation and 1-month postimplant and the subsequent change between 1- and 6-months postimplant. Comparable improvements in generic HRQOL were noted in rural and urban LVAD recipients during both phases of change. Urban LVAD recipients had greater initial improvements in HF-specific HRQOL (KCCQ) compared with rural recipients (13.0 ± 5.6, p = .02), but subsequent improvements were similar among rural and urban recipients. Ongoing assessment of generic and HF-specific HRQOL is necessary during LVAD therapy.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association.

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study (Data Supplement) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Family Caregiving for Individuals With Heart Failure: A Scientific Statement From the American Heart Association.

Many individuals living with heart failure (HF) rely on unpaid support from their partners, family members, friends, or neighbors as caregivers to help manage their chronic disease. Given the advancements in treatments and devices for patients with HF, caregiving responsibilities have expanded in recent decades to include more intensive care for increasingly precarious patients with HF-tasks that would previously have been undertaken by healthcare professionals in clinical settings. The specific tasks of caregivers of patients with HF vary widely based on the patient's symptoms and comorbidities, the relationship between patient and caregiver, and the complexity of the treatment regimen. Effects of caregiving on the caregiver and patient range from physical and psychological to financial. Therefore, it is critically important to understand the needs of caregivers to support the increasingly complex medical care they provide to patients living with HF. This scientific statement synthesizes the evidence pertaining to caregiving of adult individuals with HF in order to (1) characterize the HF caregiving role and how it changes with illness trajectory; (2) describe the financial, health, and well-being implications of caregiving in HF; (3) evaluate HF caregiving interventions to support caregiver and patient outcomes; (4) summarize existing policies and resources that support HF caregivers; and (5) identify knowledge gaps and future directions for providers, investigators, health systems, and policymakers.

Excellence in Postlicensure Interprofessional Palliative Care Education: Consensus Through a Delphi Survey.

An increasing number of palliative care educational programs strive to meet the workforce need for palliative care clinicians. This growth necessitates development of robust quality standards. The purpose of this Delphi consensus process was to describe high-quality postlicensure interprofessional palliative care education programs. The steering committee, composed of 6 faculty with experience implementing interprofessional palliative care educational programs, developed initial characteristics, definitions, and subcategories, which were refined through a series of 3 iterative Delphi surveys and a public presentation at a national palliative care meeting. More than 50 palliative care clinicians and educators representing multiple professions were invited to participate in the Delphi surveys; 20 completed round 1, 23 completed round 2, and 15 participants completed round 3. The final consensus included 6 characteristics with definitions, and both required and recommended subcategories for each characteristic. Identified characteristics include competencies, content, educational strategies, interprofessional focus, evaluation, and systems integration. This initial description of quality for postlicensure interprofessional palliative care education programs may be used by learners to guide program selection, new or existing program faculty for course development or quality improvement, or professional organizations to evaluate program quality in a program certification or quality award initiative.

Adverse-Event Free Survival, Hospitalizations, and Mortality in Left Ventricular Assist Device Recipients: A Rural-Urban Cohort Comparison.

BACKGROUND: The number of individuals with advanced heart failure (HF) receiving left ventricular assist devices (LVADs) is growing. Postimplantation LVAD recipients return home to both rural and urban locations. The impact of rural or urban living on postimplantation outcomes has not been adequately explored. OBJECTIVE: This cohort study examined adverse event-free survival, hospitalization-free survival, and all-cause mortality between rural and urban LVAD recipients in the first 2 years after implantation. METHODS: Data from LVAD recipients (N = 141) implanted at a single center in the northeastern United States were analyzed. Recipients of LVAD were designated as rural or urban by county of residence. Adverse events, hospitalizations, and survival time were examined using multivariate Cox proportional hazards models. RESULTS: Thirty-seven percent of LVAD recipients in the cohort were rural. Two-thirds of all LVAD recipients experienced at least 1 adverse event (96/141, 68.1%). Although more urban recipients experienced adverse events, including death, rural versus urban models of both adverse events and survival were nonsignificant (adverse events: log-rank = 1.18, P = .28; hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.57-1.63; P = .89; survival: log-rank =2.81, P = .09; HR, 0.45; 95% CI, 0.17-1.23; P = .12). Rural LVAD recipients experienced significantly more hospitalizations and shorter hospitalization-free survival (log-rank = 6.67, P = .009). However, the HR for survival was nonsignificant (HR, 1.5; 95% CI, 0.94-2.39; P = .08). CONCLUSIONS: Frequent adverse events and hospitalizations are of ongoing concern for LVAD recipients. More data are necessary to understand why urban LVAD recipients may experience shorter survival time compared with rural counterparts. Hospitalization may serve as a protective factor for rural LVAD recipients.

Family caregiver-reported outcomes regarding decision-making for left ventricular assist device implantation.

BACKGROUND: Family caregivers (FCGs) often participate in the decision for their loved one to receive a left ventricular assist device (LVAD). Little is known about the contribution of FCGs to this complex decision. OBJECTIVES: To investigate family caregiver-reported outcomes related to decision-making for LVAD implantation and their experiences post-implantation. METHODS: Descriptive thematic analysis was used to analyze longitudinal data. Thematic saturation was achieved. RESULTS: Three key themes emerged from the data. The main theme in the pre-implantation period was: Not a decision. The two themes in the post-implantation period were: More satisfaction than regret and Unanticipated situational change. CONCLUSIONS: Family caregiver-reported outcomes inform clinical practice and future research. FCGs of LVAD recipients did not see viable alternatives to LVAD implantation, were generally satisfied with post-implantation outcomes, and experienced unexpected life changes in the post-implantation period despite feeling prepared preoperatively. Education of both LVAD recipients and their FCGs must be optimized.

Intergenerational Caregivers of Parents With End-Stage Heart Failure.

Purpose: The purpose of this study was to longitudinally explore the experiences of young adult, adult, and older adult intergenerational caregivers caring for a parent with end-stage heart failure (HF). Design: This study was a secondary analysis of qualitative data collected during a longitudinal study that sought to determine the palliative care needs of individuals with end-stage HF and their family caregivers. Methods: Longitudinal interviews from 23 young adult, adult, and older adult children who were caring for a parent with end-stage HF were selected for thematic analysis. Researchers individually analyzed the interviews and then, as a group, came to a consensus about themes. Findings: Five major themes were identified: caregiver resources, role management, caregiver-parent relationships, filial responsibility, and personal benefits and challengesConclusions: These intergenerational caregivers struggled to balance their busy lives and caregiving roles. However, most felt supported by other family members or external resources. Longitudinal findings support a need for improved employer-based support for intergenerational caregivers and special attention to young carers in research and practice. Recognition of and advocacy for intergenerational caregivers providing care for a chronically ill parent is needed.

The Experiences of Younger Individuals Living With Heart Failure.

BACKGROUND: Heart failure (HF) impacts 1.7 million Americans between the ages of 20 and 59 years, but limited research exists addressing the issues unique to this age group. OBJECTIVE: The aim of this study was to investigate the experiences of younger persons living with HF. METHODS: Semistructured interviews (n = 18) were analyzed using a qualitative thematic analysis. RESULTS: Six themes emerged: (1) role fulfillment: participants who perceived their roles as a parent, caregiver, spouse, employee, and friend have been negatively affected by HF; (2) autonomy: participants frequently linked their well-being to a sense of independence, productivity, and purpose; (3) financial impact: most of the sample expressed financial instability further complicated by existing disability policies; (4) perception of self: recurrent statements revealed participants feeling judged because of their HF diagnosis and younger age; (5) retrospective life changes: participants reflected on past decisions and often blamed themselves for their current health; and (6) symptom burden: participants reported higher levels of psychosocial symptoms, such as depression, anxiety, and fatigue. CONCLUSIONS: Younger individuals living with HF reported overwhelmingly poor health-related quality of life that was linked to the 6 themes identified previously. The effect of HF was seen on numerous life events that traditionally occur earlier in the life course such as establishing a career, meaningful relationships, family, and financial security. This directly impacted health-related quality of life by disrupting what each individual perceived as important to them, which took a toll on their overall mental health. To provide holistic care to younger patients living with HF, interventions that address the heavy burden of psychosocial symptoms and policy changes associated with financial burden and disability laws must be developed.

Naive Expectations to Resignation: A Comparison of Life Descriptions of Newly Diagnosed Versus Chronic Persons Living With Stage D HF.

PURPOSE: This study examined life descriptions of persons with stage D heart failure (HF) comparing those newly diagnosed to those with chronic HF. METHODS: A secondary analysis of interviews from 75 participants followed in a longitudinal study of persons with stage D HF was thematically analyzed. There were 24 participants who were recently diagnosed with stage D HF (less than 2 years) and 51 participants with HF longer than 2 years. RESULTS: Both groups shared life descriptions along a continuum, where recently diagnosed participants described naive expectations with hope for improvement, while the chronic group appeared resigned to their fate and the reality of the limitations of living with HF. Four themes illustrated differences between the groups: outlook on life, activity adjustments, understanding of HF, and mood. CONCLUSIONS: Although persons with stage D HF share the same life descriptions, they have differing perspectives of life with HF. Findings from this study can help health-care providers tailor interventions based on the length of time from diagnosis.