Complex Decision-Making in Heart Failure: A Systematic Review and Thematic Analysis.

BACKGROUND: Heart failure follows a highly variable and difficult course. Patients face complex decisions, including treatment with implantable cardiac defibrillators, mechanical circulatory support, and heart transplantation. The course of decision-making across multiple treatments is unclear yet integral to providing informed and shared decision-making. Recognizing commonalities across treatment decisions could help nurses and physicians to identify opportunities to introduce discussions and support shared decision-making. OBJECTIVE: The specific aims of this review are to examine complex treatment decision-making, specifically implantable cardiac defibrillators, ventricular assist device, and cardiac transplantation, and to recognize commonalities and key points in the decisional process. METHODS: MEDLINE, CINAHL, PsycINFO, and Web of Science were searched for English-language studies that included qualitative findings reflecting the complexity of heart failure decision-making. Using a 3-step process, findings were synthesized into themes and subthemes. RESULTS: Twelve articles met criteria for inclusion. Participants included patients, caregivers, and clinicians and included decisions to undergo and decline treatment. Emergent themes were "processing the decision," "timing and prognostication," and "considering the future." Subthemes described how participants received and understood information about the therapy, making and changing a treatment decision, timing their decision and gauging health status outcomes in the context of their decision, the influence of a life or death decision, and the future as a factor in their decisional process. CONCLUSIONS: Commonalities were present across therapies, which involved the timing of discussions, the delivery of information, and considerations of the future. Exploring this further could help support patient-centered care and optimize shared decision-making interventions.

Fear of falling among community-dwelling older adults: A scoping review to identify effective evidence-based interventions.

Fear of falling presents a significant problem for many older adults by reducing physical function and increasing the risk of future falls. Several different types of interventions have improved fear of falling and a summary of efficacious interventions will help clinicians recommend treatment options. Using the Arksey and O'Malley Framework for scoping reviews, the purpose of this review was to identify efficacious interventions for treating fear of falling among community-dwelling older adults in order to provide a list of potential treatment options for care providers. A total of 45 publications were identified for inclusion in this review.

Memory Matters: A Mixed-Methods Feasibility Study of a Mobile Aid to Stimulate Reminiscence in Individuals With Memory Loss.

Reminiscence interventions are potentially effective in improving well-being of persons with memory loss (PWMLs) and may also enhance relationships with family and professional caregivers. Using a parallel convergent mixed-methods design, the feasibility of "Memory Matters" (MM), a mobile device application developed to promote reminiscence, was evaluated. Eighteen PWMLs and eight family members were enrolled from a long-term care facility and asked to use MM for 4 weeks. Participants were observed using MM at enrollment and 2 weeks and completed 1-month interviews. Six staff participants also completed a system review checklist and/or focus group at 1 month. Three qualitative domains were identified: (a) context of use, (b) barriers to use, and (c) MM influences on outcomes. Participants reported real-time social engagement, ease of use, and other benefits. However, PWMLs were unlikely to overcome barriers without assistance. Empirical data indicated that family and staff perceived MM favorably. Participants agreed that MM could provide stimulating, reminiscence-based activity. [Journal of Gerontological Nursing, 42(7), 15-24.].

American Association of Heart failure nurses' knowledge, barriers and facilitators in conducting research.

BACKGROUND: To provide high-quality patient care, heart failure (HF) nurses must comprehend/use best evidence; however, HF nurses' ability to do so are unknown. OBJECTIVES: To describe HF nurses' research interest/involvement, confidence, facilitators/motivators, and barriers to lead/collaborate in research studies. METHODS: A descriptive design with convenience sampling and online data collection (Qualtrics) were used with American Association of HF Nurses members. Recruited/included nurses (n = 145) needed to be of any educational level and currently practicing in any practice setting in the United States. A 30-item, adapted instrument assessed research interest (one-question), involvement (two-questions), confidence (two-questions), facilitators (one-question), motivators (three-questions), and barriers (21-questions). RESULTS: Subjects (n = 145) were Caucasian (n = 124, 86.1 %) females (n = 137, 96.5 %) with an average age of 52.5 ± 10.38 years and 26.90±12.06 years of nursing experience. Nurses were interested in conducting nursing research (7.78/10±2.37) but involvement was low. Most frequently (n = 73, 50.3 %) nurses served as principal/co-investigators. Confidence with research participation was moderate (70.28/100±26.92) and in their ability to understand/apply research findings were low (21.68/100±80.07). The most frequently reported facilitator was the ability to control their own schedule/work (n = 30, 20.7 %) and the strongest motivator (n = 107, 73.8 %) was the perception presenting nursing research/EBP impacts HF care. The greatest reported barrier was the authority to seek research funding (2.39/5 ± 1.14). Nursing experience (p=.034), interest in participating in nursing research (p=.01), and how much presenting nursing research/EBP impacted one's performance review (p<.001) added to the prediction (R2=0.499, p<.001). CONCLUSIONS: The gained knowledge may promote development of innovative programs and educational opportunities to increase HF nurses' research activities.

Substance abuse at the time of left ventricular assist device implantation is associated with increased mortality.

BACKGROUND: Advanced heart failure teams are often faced with the decision of whether or not to offer a left ventricular assist device (LVAD) to patients who have end-stage heart failure and recent or ongoing substance abuse. The outcomes of these patients after LVAD implantation are unknown. METHODS: Baseline predictors and outcomes were collected and analyzed from patients with active substance abuse and a cohort of patients without active substance abuse matched for age, INTERMACS profile and year of implantation. The primary outcome was all-cause mortality. Secondary outcomes included rates of listing for cardiac transplantation, transplantation and chronic drive-line infection. RESULTS: The cohort consisted of 20 consecutive LVAD recipients with active substance abuse and 40 recipients without active substance abuse. During a median follow-up period of 2.3 years (IQR 1.4 to 3.6), the substance abuse group had 3.2 times the rate (hazard) of death compared with a matched cohort (HR 3.2, 95% CI 1.2 to 8.0, p < 0.05). Furthermore, the rate of listing for transplant was 69% lower (rate ratio 0.31, p < 0.0005), rate of cardiac transplant was 89% lower (rate ratio 0.11, p < 0.0005), and risk of chronic drive-line infection was 5.4 times higher (rate ratio 5.4, p < 0.0005) in the substance abuse group. CONCLUSIONS: Active substance abuse in patients who received an LVAD was associated with increased mortality and overall poor outcomes. Larger scale data will be needed to confirm these findings and to inform decision-making in this population.

Identification of differentially expressed transcripts and pathways in blood one week and six months following implant of left ventricular assist devices.

INTRODUCTION: Continuous-flow left ventricular assist devices (LVADs) are an established therapy for patients with end-stage heart failure. The short- and long-term impact of these devices on peripheral blood gene expression has not been characterized, and may provide insight into the molecular pathways mediated in response to left ventricular remodeling and an improvement in overall systemic circulation. We performed RNA sequencing to identify genes and pathways influenced by these devices. METHODS: RNA was extracted from blood of 9 heart failure patients (8 male) prior to LVAD implantation, and at 7 and 180 days postoperatively. Libraries were sequenced on an Illumina HiSeq2000 and sequences mapped to the human Ensembl GRCh37.67 genome assembly. RESULTS: A specific set of genes involved in regulating cellular immune response, antigen presentation, and T cell activation and survival were down-regulated 7 days after LVAD placement. 6 months following LVAD placement, the expression levels of these genes were significantly increased; yet importantly, remained significantly lower than age and sex-matched samples from healthy controls. CONCLUSIONS: In summary, this genomic analysis identified a significant decrease in the expression of genes that promote a healthy immune response in patients with heart failure that was partially restored 6 months following LVAD implant.