Spiritual needs and spiritual support preferences of people with end-stage heart failure and their carers: implications for nurse managers.

BACKGROUND: Spiritual care is an important element of holistic care but has received little attention within palliative care in end-stage heart failure. AIMS: To identify the spiritual needs and spiritual support preferences of end-stage heart failure patients/carers and to develop spiritual support guidelines locally. METHOD: Semi-structured interviews (totalling 47) at 3-monthly intervals up to 1 year with 16 end-stage heart failure patients/carers. Focus group/consultation with stakeholders. RESULTS: Participants were struggling with spiritual/existential concerns alongside the physical and emotional challenges of their illness. These related to: love/belonging; hope; coping; meaning/purpose; faith/belief; and the future. As a patient's condition deteriorated, the emphasis shifted from 'fighting' the illness to making the most of the time left. Spiritual concerns could have been addressed by: having someone to talk to; supporting carers; and staff showing sensitivity/taking care to foster hope. A spiritual support home visiting service would be valued. CONCLUSIONS: Our sample experienced significant spiritual needs and would have welcomed spiritual care within the palliative care package. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers could play a key role in developing this service and in leading further research to evaluate the provision of such a service in terms of its value to patients and other benefits including improved quality of life, spiritual wellbeing, reduced loneliness/isolation and a possible reduction in hospital admissions.

Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure.

BACKGROUND: Heart failure, a condition predominantly affecting the elderly, represents an ever-increasing clinical and financial burden for the NHS. Cardiac rehabilitation, a service that incorporates patient education, exercise training and lifestyle modification, requires further evaluation in heart failure management. AIM: The aim of this study was to determine whether a cardiac rehabilitation programme improved on the outcomes of an outpatient heart failure clinic (standard care) for patients, over 60 years of age, with chronic heart failure. METHODS: Two hundred patients (60-89 years, 66% male) with New York Heart Association (NYHA) II or III heart failure confirmed by echocardiography were randomised. Both standard care and experimental groups attended clinic with a cardiologist and specialist nurse every 8 weeks. Interventions included exercise prescription, education, dietetics, occupational therapy and psychosocial counselling. The main outcome measures were functional status (NYHA, 6-min walk), health-related quality of life (MLHF and EuroQol) and hospital admissions. RESULTS: There were significant improvements in MLHF and EuroQol scores, NYHA classification and 6-min walking distance (meters) at 24 weeks between the groups (p<0.001). The experimental group had fewer admissions (11 vs. 33, p<0.01) and spent fewer days in hospital (41 vs. 187, p<0.001). CONCLUSIONS: Cardiac rehabilitation, already widely established in the UK, offers an effective model of care for older patients with heart failure.

Patterns of fatigue in elderly heart failure patients measured by a quality of life scale (Minnesota living with heart failure).

BACKGROUND: Progression of fatigue in elderly heart failure patients is not well documented. AIM: To report on patterns and severity of fatigue in surviving patients (n = 112, mean age 75 years) of a 5 year heart failure programme (HFP). METHODS: Patients (n = 200 at baseline) participated in a 6 month trial of cardiac rehabilitation (CR versus standard care) followed by the same prescribed maintenance programme (Phase IV and/or independent exercise). Fatigue was rated by the MLHF questionnaire and compared to quality of life (QoL), physical and clinical measures. Patterns of fatigue are described in the whole sample. Data analysis is undertaken on sub-groups based on baseline randomisation, aetiology, gender, co-morbidity and survival. Heart failure patients (n = 29) newly diagnosed at the 5 year follow-up time point provided information on their experience of fatigue. RESULTS: At baseline and 5 years, 45% patients rated fatigue within the two highest categories of severity, whereas 10% reported no symptoms on assessment. Over 5 years, the fatigue patterns in the sample were unsustained improvement commensurate with the HFP (37%), an adverse pattern from baseline (37%), maintained improvement (18%) or no overall change (8%). Fatigue was higher in patients with joint problems and responded to the intervention. There was a significant increase (p < 0.05) in the proportion of patients with reduced haemoglobin level and severe fatigue at 5 years. Fatigue scores correlated significantly (p < 0.01) with QoL and physical measures. CONCLUSIONS: Severe fatigue progresses differently in elderly patients and is a modifiable symptom in the early phases of CR.

Multidisciplinary management of elderly patients with chronic heart failure: five year outcome measures in death and survivor groups.

BACKGROUND: The utility of multidisciplinary chronic disease evaluation measures, especially health related quality of life (HRQL), for long long-term prognostic use in elderly patients with heart failure is uncertain. AIM: To report on clinical, functional and HRQL values of deceased and surviving patients of a 6-month RCT of Cardiac Rehabilitation in addition to specialist nurse outpatient clinic at 5 years. METHODS: The original measures (walk test, Borg RPE, MLHF, EuroQol score and vas, biochemistry) were repeated for patients in a satisfactory condition. RESULTS: Five year survival was characterised by significantly better baseline values for LV dysfunction and NYHA class and 6-month values for MLHF, physical function and biochemistry measures. EuroQuol scores were worse than baseline for surviving patients at 5 years, in contrast to MLHF scores. The walk test gave the highest 5-year relative mortality risk, whereas the MLHF gave similar values to the Borg and uric acid measures. Deaths were more evident in normal weight older patients than in younger obese patients. CONCLUSION: Changes in patient measures were evident over 5 years and most differentiated between survivor and deceased groups. In comparison to the use of the MLHF and EuroQuol-vas, the EuroQuol score was limited by impairments of the ageing process.

Five-year follow-up findings from a randomized controlled trial of cardiac rehabilitation for heart failure.

BACKGROUND: A follow-up study was carried out on the 5-year status of the surviving patients (n=179 at 6 months) of a 24-week randomized controlled trial comparing cardiac rehabilitation (CR) with heart failure outpatient clinic care (standard care). METHODS: In the original randomized controlled trial, 200 patients (60-89 years, 132 men) with New York Heart Association II/III heart failure confirmed by echocardiography had been randomized (2000-2001). At the 5-year follow-up, the initial trial measures (6-min walk test, Minnesota living with heart failure, EuroQol health-related quality of life, and routine biochemistry) were repeated if the patient was in a satisfactory condition. Data on deaths and admissions were obtained from the medical records department. RESULTS: Over half of the original participants (n=119, 59.5%) were alive at 5 years (mean age 75.2 years), and most (94%) attended the clinic for assessment. A sustained improvement from baseline for both groups in Minnesota living with heart failure, but not in EuroQol was observed, and the majority of the other measures had deteriorated. In contrast to the CR group, the standard care group showed a significant deterioration in walking distance (5 versus 11%; P<0.05). More patients in the CR group were taking regular exercise (71 versus 51%; P<0.05). No significant differences between the groups in health care utilization or survival were observed. CONCLUSION: A 24-week CR programme for patients with stable heart failure showed some long-term benefit at 5 years. Differences in the mean values of most of the functional and quality of life measures were evidently to the advantage of the CR group, which also showed a better exercise profile.