Integrated heart failure care and palliative care at home

Patients with severe heart failure suffer from a high symptom burden and high mortality | BMJ Supportive & Palliative Care

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Image source: Rick&Brenda Beerhorst – Flickr // CC BY 2.0

Objectives: European and Swedish guidelines for HF care recommend palliative care for these patients. Different models for integrated palliative care and HF care have been described in the literature. No studies were found that qualitatively evaluated these models. The purpose of this study is to describe patients’ experiences of a new model of person-centred integrated HF and palliative care at home.

Method: Interviews were conducted with 12 patients with severe HF (New York Heart Association class III–IV) and included in the research project of Palliative advanced home caRE and heart FailurE caRe (PREFER). Qualitative content analysis was used for data analysis.

Results: Two themes and a total of five categories were identified. The first theme was feeling secure and safe through receiving care at home with the categories: having access to readily available care at home, being followed up continuously and having trust in the team members’ ability to help. The second theme was being acknowledged as both a person and a patient, with the following two categories: being met as a person, participating in decisions about one’s care and receiving help for symptoms of both HF and comorbidities.

Conclusions: Person-centred integrated HF and palliative care provides a secure environment and holistic care for patients with severe HF. This approach is a way to improve the care management in this population.

Full reference: Talabani, N. et al. (2017) Patients’ experiences of person-centred integrated heart failure care and palliative care at home: an interview study. BMJ Supportive & Palliative Care. Published Online First: 7th July 2017.

Patient values informing medical treatment: a pilot community and advance care planning survey

Milnes, S. et al. BMJ Supportive & Palliative Care | Published Online: 2 March 2017

Objectives: We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life.

Conclusions: ‘Living as long as possible’ was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

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Treatment targeted at underlying disease versus palliative care in terminally ill patients

Reljic, T. et al. BMJ Open. 7:e014661

Objective: To assess the efficacy of active treatment targeted at underlying disease (TTD)/potentially curative treatments versus palliative care (PC) in improving overall survival (OS) in terminally ill patients.

Results: Initial search identified 8252 citations of which 10 RCTs (15 comparisons, 1549 patients) met inclusion criteria. All RCTs included patients with cancer. OS was reported in 7 RCTs (8 comparisons, 1158 patients). The pooled results showed no statistically significant difference in OS between TTD and PC (HR (95% CI) 0.85 (0.71 to 1.02)). The heterogeneity between pooled studies was high (I2=62.1%). Overall rates of adverse events were higher in the TTD arm.

Conclusions: Our systematic review of available RCTs in patients with terminal illness due to cancer shows that TTD compared with PC did not demonstrably impact OS and is associated with increased toxicity. The results provide assurance to physicians, patients and family that the patients’ survival will not be compromised by referral to hospice with focus on PC.

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Stated values and treatment preferences for end-of-life care: results of a multicentre survey

Heyland, D.K. et al. BMJ Supportive & Palliative Care. Published Online: 6 October 2016

Background: Medical orders for the use of life-supports should be informed by patients’ values and treatment preferences. The purpose of this study was to explore the internal consistency of patients’ (or their family members’) stated values, and the relationship between these values and expressed preferences.

Methods: We conducted a prospective study in 12 acute care hospitals in Canada. We administered a questionnaire to elderly patients and their family members about their values related to end-of-life (EOL) care, treatment preferences and decisional conflict.

Results: Of 513 patients and 366 family members approached, 278 patients (54%) and 225 family members (61%) consented to participate. Participants’ most important stated values were to be comfortable and suffer as little as possible, to have more time with family, to avoid being attached to machines and tubes and that death not be prolonged. The least important stated value was that life be preserved. Based on prespecified expected associations between the various values measured, there were inconsistencies in participants’ expressed value statements. With few exceptions, participants’ expressed values were not associated with expected corresponding treatment preferences. Of the 109 (40%) patients and 95 (42%) family members who had made decisions about use of life-supports, 68 (56%) patients and 60 (59%) family members had decisional conflict.

Conclusions: Decision-making regarding medical treatments at the EOL is inadequate. To reduce decisional conflict, patients and their families need more support to clarify their values and ensure that their preferences are grounded in adequate understanding of their illness and treatment options.

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Palliative care in the trauma ICU

O’Connell, K. & Maier, R. Current Opinion in Critical Care. Published online: September 21 2016

Purpose of review: The benefits of palliative care for critically ill patients are well recognized, yet acceptance into surgical culture is lagging. With the increasing proportion of geriatric trauma patients, integration of palliative medicine within daily intensive care services to facilitate goal-concordant care is imperative.

Recent findings: Misconceptions of palliative medicine as it applies to trauma patients linger among trauma surgeons and many continue to practice without routine consultation of a palliative care service. Aggressive end-of-life care does not correlate with an improved family perception of medical care received near death. Additionally, elderly patients near the end of life often prefer palliative treatments over life-extending therapy, and their treatment preferences are often not achieved. A new geriatric-specific prognosis calculator estimates the risk of mortality after trauma, which is useful in starting goals of care discussions with older patients and their families.

Summary: Shifting our quality focus from 30-day mortality rates to measurements of symptom control and achievement of patient treatment preferences will prioritize patient beneficence and autonomy. Ownership of surgical palliative care as a service provided by acute care surgeons will ensure that our patients with incurable injury and illness will receive optimal patient-centered care.

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Appreciating the autonomy of cancer patients on deciding whether they want to be informed about interventional studies for fatigue

Poort, H. et al. (2016) Palliative Medicine. 30(9) pp. 897-898

Background: Fatigue is a prevalent and burdensome symptom for patients with advanced cancer. The long-term use of pharmacological interventions for fatigue is not supported by evidence, although non pharmacological and behavioral interventions are promising approaches to reducing fatigue based on their effectiveness in early-stage cancer patients. Behavioral factors, like sleeping problems and being less physically active, can also contribute to fatigue in advanced cancer patients. Interventional studies for the management of fatigue in advanced cancer patients are needed.

However, it is a notorious challenge to identify patients for interventional studies aimed at fatigue or symptom control while patients are undergoing cancer treatment with palliative intent. One of the barriers to successful identification of these patients is professional gatekeeping, due to the care professionals’ perception that study participation might be too burdensome for the patient. Although gatekeeping is done in order to prevent additional burden for patients who are seriously ill, it also limits access for patients to potentially effective interventions for fatigue and makes it difficult to develop evidence-based interventions for fatigue in advanced cancer patients.

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