Provision of palliative care for chronic heart failure inpatients: how much do we need?

BACKGROUND: Clinical guidance recommends early CHF palliative care intervention, but the magnitude of need is unknown and evidence-based referral criteria absent.This study aimed to: 1) Measure point prevalence of inpatients appropriate for palliative care. 2) Identify patient characteristics associated with palliative care appropriateness. 3) Propose evidence-based clinical referral criteria. METHODS: Census: all adult medical inpatient files in a UK tertiary teaching hospital were reviewed, identifying patients with CHF as a reason for current admission, using NYHA stage 3/4 classification, cross referenced with existing ECHO data. Each CHF patient was classified according to appropriateness for palliative care against a definition of unresolved pain and/or symptoms and/or psychosocial problems 7 days post admission. RESULTS: Three hundred and sixty-five patient files were reviewed, and 28 clinically identified as having CHF. Of these, 11 had confirmed unpreserved ejection fraction,16 of the 28 patients were appropriate for palliative care. Of the total inpatient population reviewed, 10 (2.7%) had both confirmed ejection fraction 45% also require palliative care. Our conservative criteria suggest a point prevalence of 2.7% of patients having both ejection fraction

Managing patients with non-ST-segment elevation acute coronary syndrome.

Acute coronary syndromes (ACSs) can be described as ST-segment elevation or non-ST-segment elevation, including unstable angina. Traditionally, ST-segment elevation ACS has been considered to be more serious, but non-ST-segment elevation ACS has higher mortality rates in the longer term. This article discusses diagnosis, including history taking, clinical examination, electrocardiogram and biochemical markers that help to differentiate between types of non-ST-segment elevation ACSs. Risk stratification and treatment strategies are examined, as well as pharmacological treatments. The nurse's role in assessment, treatment, ongoing management and discharge practice is discussed.

B-type natriuretic peptide testing in a nurse-led heart failure clinic.

Heart failure has a significant impact on health and its prevalence increases with age (Cowie et al, 1997). Coronary heart disease (CHD) and hypertension are the most common causes (Cowie et al, 1999). The National Service Framework for Coronary Heart Disease identifies that people with suspected heart failure should be offered appropriate investigations to confirm the diagnosis and identify the cause (DoH, 2000). Also, those with confirmed heart failure should be offered treatment to relieve symptoms and reduce the risk of death. The National Institute for Clinical Excellence will publish guidelines this summer, which will aim to improve the management of heart failure.

Meeting the communication and information needs of chronic heart failure patients.

There is a lack of evidence on how best to meet policy guidance in fulfilling the information needs of patients with chronic heart failure (CHF) and their families. We aimed to generate guidance for appropriate information provision to CHF patients and their families through a cross-sectional qualitative methodology with constant comparison of emergent themes. Participants were 20 CHF patients (New York Heart Association Functional Classification III, III-IV, and IV); 11 family carers; six palliative care staff; and six cardiology staff. Patients and carers severely lacked understanding of CHF and its symptoms. None had discussed disease progression or advanced care planning with staff. Although patients expected honest discussion of disease implications, data from clinicians described an unwillingness to disclose poor prognosis. We identified four types of barriers to the discussion of disease progression: disease-specific; patient-specific; specialism-specific; and staff time and resources. This is the first study to integrate cardiology, palliative care, and patient and family views to develop feasible recommendations on meeting information needs. Three recommendations for hospital-based clinical practice were generated from the data: (1) improved methods of providing information; (2) introduction of mutual education and joint working; and (3) development of care pathways and referral criteria.

Modelling services to meet the palliative care needs of chronic heart failure patients and their families: current practice in the UK.

OBJECTIVE: To describe current provision of specialist palliative care for chronic heart failure (CHF) patients, and explore challenges, referral criteria and recommendations to inform service development. METHOD: Semi-structured qualitative telephone survey of key professionals involved in CHF palliative care in the UK. RESULTS: Twenty telephone interviews were conducted with staff from 17 services comprising three main types: hospital-based (n = 7), community-based (n = 6) and hospice-based (n = 4). The main recommendations made were to establish mechanisms for joint working between palliative care and cardiology; to ensure that stakeholders are involved from the outset of service planning; and to involve community heart failure nurses in service provision. Referral guidelines were collected from four services, covering diagnostic, symptomatological, psychosocial and team-related criteria. CONCLUSIONS: Information regarding existing services' challenges, recommendations and referral systems is essential when designing a new service, maximising feasibility and acceptability. This study design is of particular value when descriptions and evaluations of service models are lacking in the literature. The survey gives much-needed depth and detail to the types of services currently providing palliative care to CHF patients across the UK.

Improving end-of-life care for patients with chronic heart failure: "Let's hope it'll get better, when I know in my heart of hearts it won't".

BACKGROUND: Although chronic heart failure (CHF) has a high mortality rate and symptom burden, and clinical guidance stipulates palliative care intervention, there is a lack of evidence to guide clinical practice for patients approaching the end of life. AIMS: (1) To formulate guidance and recommendations for improving end-of-life care in CHF; (2) to generate data on patients' and carers' preferences regarding future treatment modalities, and to investigate communication between staff, patients and carers on end-of-life issues. DESIGN: Semistructured qualitative interviews were conducted with 20 patients with CHF (New York Heart Association functional classification III-IV), 11 family carers, 6 palliative care clinicians and 6 cardiology clinicians. SETTING: A tertiary hospital in London, UK. RESULTS: Patients and families reported a wide range of end-of-life care preferences. None had discussed these with their clinicians, and none was aware of choices or alternatives in future care modalities, such as adopting a palliative approach. Patients and carers live with fear and anxiety, and are uninformed about the implications of their diagnosis. Cardiac staff confirmed that they rarely raise such issues with patients. Disease- and specialism-specific barriers to improving end-of-life care were identified. CONCLUSIONS: The novel, integrated data presented here provide three recommendations for improving care in line with policy directives: sensitive provision of information and discussion of end-of-life issues with patients and families; mutual education of cardiology and palliative care staff; and mutually agreed palliative care referral criteria and care pathways for patients with CHF.