Outpatient Palliative Care for Chronic Heart Failure: A Case Series

Bekelman, David B.; Nowels, Carolyn T.; Allen, Larry A.; Shakar, Simon F.; Kutner, Jean S.; Matlock, Daniel D.

doi:10.1089/jpm.2010.0508

Cited by 61 publications

(45 citation statements)

References 42 publications

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“…There were some studies about burden of caregivers of terminally ill patients (Bekelman et al, 2011;Nelson et al, 2011;Rittenberger et al, 2011;Xian et al, 2011). However, to our knowledge, there had been few studies to compare burden of terminal cancer patients and their caregivers.…”

Section: Discussionmentioning

confidence: 99%

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Burdens, Needs and Satisfaction of Terminal Cancer Patients and their Caregivers

Chang

Kwon

Lee

et al. 2013

Asian Pacific Journal of Cancer Prevention

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Objectives: Terminal cancer patients and their caregivers often experience traumatic stress and need many types of assistance. In the present study we interviewed terminally ill cancer patients and caregivers to determine how much burden they experienced and to find out what factors are most important for satisfaction. Design: We constructed a questionnaire including overall care burden and needs experienced, and administered it to 659 terminal cancer patients and 659 important caregivers at 11 university hospitals and 1 national cancer center in Korea. Results: Finally, 481 terminal cancer patients and 381 caregivers completed the questionnaire. Care burden was not insubstantial in both and the caregiver group felt more burden than the patient group (P<0.001). While the patient group needed financial support most (39.0%), the caregiver group placed greatest emphasis on discussion about further treatment plans (44.8%). Stepwise multiple logistic regression analyses showed that in the patient group, patient's health status (OR, 2.03; 95%CI, 1.16-3.56) and burden (OR, 2.82; 95%CI, 1.76-4.50) influenced satisfaction about overall care, while in the caregiver group, high education level (OR, 1.84; 95%CI, 1.76-4.50), burden (OR, 2.94; 95%CI, 1.75-4.93) and good family function (OR, 1.94; 95%CI, 1.24-3.04) were important. Conclusions: Our study showed that burden was great in both terminal cancer patients and their caregivers and was perceived to be more severe by caregivers. Our study also showed that burden was the factor most predicting satisfaction about overall care in both groups.

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Section: Discussionmentioning

confidence: 99%

“…And there are few studies which compared burden the two groups had, too. In this study, we investigated burden and need of terminal cancer patients and their caregivers and those differences, which is important for caregivers have critical role in palliative care (Bekelman et al, 2011). …”

Section: Introductionmentioning

confidence: 99%

Burdens, Needs and Satisfaction of Terminal Cancer Patients and their Caregivers

Chang

Kwon

Lee

et al. 2013

Asian Pacific Journal of Cancer Prevention

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“…Aspects of ACP discussions include an explanation of HF trajectory and prognosis, 4,[15][16][17] an exploration and elicitation of treatment preferences and goals of care, 12,[18][19][20] and a discussion of concerns that transcend but are related to the biomedical, such as psychosocial, spiritual, and quality of life issues. 21,22 Provider attention to multiple areas of patients' concern may serve to facilitate more meaningful and productive discussions around future care. Nonetheless, physicians face several barriers to timely ACP discussions, particularly in the outpatient setting.…”

Section: Introductionmentioning

confidence: 99%

Missed Opportunities for Advance Care Planning Communication During Outpatient Clinic Visits

et al. 2011

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BACKGROUND: Early provider-patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease. OBJECTIVE: To identify opportunities for physicians to engage in ACP discussions and to characterize physicians' responses to these opportunities. DESIGN: Qualitative study of audio-recorded outpatient clinic visits. PARTICIPANTS: Fifty-two patients≥65 years recently hospitalized for HF with one or more post-discharge follow-up outpatient visits, and their physicians (n=44), at two Veterans Affairs Medical Centers. APPROACH: Using content analysis methods, we analyzed and coded transcripts of outpatient follow-up visits for 1) patient statements pertaining to their future health or their future physical, psychosocial and spiritual/existential care needs, and 2) subsequent physician responses to patient statements, using an iterative consensus-based coding process. RESULTS: In 13 of 71 consultations, patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient's expressed emotion, or inadequately acknowledging the sentiment underlying the patient's statement. CONCLUSIONS: Physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses; in order to successfully leverage opportunities to engage in ACP discussions.KEY WORDS: qualitative research; advance care planning; heart failure; physician-patient communication.

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“…1 People with HF suffer from numerous symptoms, such as breathlessness, fatigue, and pain that worsen quality of life. 2,3 These symptoms tend to persist despite optimal guidelinebased HF management, and a symptom-oriented approach offered by palliative care may be beneficial.…”

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confidence: 99%

“…To accomplish this, we developed a new intervention, Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA), with the ultimate goal of improving symptoms and quality of life in patients with HF. The CASA intervention was developed based on (1) evidence showing potentially modifiable contributors to quality of life 2 ; (2) patient and informal caregiver major concerns and needs and preferences for palliative care 7 ; and (3) a successful model of health care delivery: collaborative care. Symptoms and depression, or difficulty adjusting to illness, are important, potentially modifiable contributors to quality of life.…”

mentioning

confidence: 99%

Feasibility and Acceptability of a Collaborative Care Intervention To Improve Symptoms and Quality of Life in Chronic Heart Failure: Mixed Methods Pilot Trial

Bekelman

Hooker²,

Nowels

et al. 2014

Journal of Palliative Medicine

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Background: People with chronic heart failure (HF) suffer from numerous symptoms that worsen quality of life. The CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) intervention was designed to improve symptoms and quality of life by integrating palliative and psychosocial care into chronic care. Objective: Our aim was to determine the feasibility and acceptability of CASA and identify necessary improvements. Methods: We conducted a prospective mixed-methods pilot trial. The CASA intervention included (1) nurse phone visits involving structured symptom assessments and guidelines to alleviate breathlessness, fatigue, pain, or depression; (2) structured phone counseling targeting adjustment to illness and depression if present; and (3) weekly team meetings with a palliative care specialist, cardiologist, and primary care physician focused on medical recommendations to primary care providers (PCPs, physician or nurse practioners) to improve symptoms. Study subjects were outpatients with chronic HF from a Veteran's Affairs hospital (n = 15) and a university hospital (n = 2). Measurements included feasibility (cohort retention rate, medical recommendation implementation rate, missing data, quality of care) and acceptability (an end-of-study semi-structured participant interview). Results: Participants were male with a median age of 63 years. One withdrew early and there were < 5% missing data. Overall, 85% of 87 collaborative care team medical recommendations were implemented. All participants who screened positive for depression were either treated for depression or thought to not have a depressive disorder. In the qualitative interviews, patients reported a positive experience and provided several constructive critiques. Conclusions: The CASA intervention was feasible based on participant enrollment, cohort retention, implementation of medical recommendations, minimal missing data, and acceptability. Several intervention changes were made based on participant feedback.

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Outpatient Palliative Care for Chronic Heart Failure: A Case Series

Cited by 61 publications

References 42 publications

Burdens, Needs and Satisfaction of Terminal Cancer Patients and their Caregivers

Burdens, Needs and Satisfaction of Terminal Cancer Patients and their Caregivers

Missed Opportunities for Advance Care Planning Communication During Outpatient Clinic Visits

Feasibility and Acceptability of a Collaborative Care Intervention To Improve Symptoms and Quality of Life in Chronic Heart Failure: Mixed Methods Pilot Trial

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