Abstract

The problem of heart failure is increasing among people worldwide, but it’s common among those in developed countries. An estimated 5% of patients suffering from heart failure are usually in the end-stage which is refractory to any form of medical therapy.  As a result, such conditions require palliative care which helps relieve symptoms. Palliative care also increases the level of patient satisfaction and lowers the cost involved in taking care of the patient with advanced heart failure. According to the Australian government department for health, an approximate of 12 Australians die every minute from cardiovascular dieseases, and this has made the Australian government allocated $220 million to Medical research Future Fund for research to tackle heart diseases. The paper focuses on the relationship between palliative care and advanced heart failure using an 82-year-old with advanced heart failure with no treatment options left. It gives a literature review of palliative care and an analysis of how palliative care is used for a patient with advanced heart failure using the stress coping, adaptation, and appraisal framework concept.

Advanced Heart Failure and Palliative Care

Overview/introduction

Palliative care is specialized nursing, and medical care approach meant to help patients with life-limiting illnesses or the terminally ill. The interdisciplinary approach is intended to help the patients reduce pain, mental and physical stress and relieves them of the symptoms. There is an increase in the number of heart failure cases across the globe. Some advanced heart failure cases beyond a particular stage may not be treated, but the patients can get support for comfort while at this stage. The palliative care is meant to support the terminally ill patients such as the 82-year-old used in the case study. The patient has advanced heart failure, and there is no option for treatment but can only get support from palliative care to have comfort. The use of palliative care for patients with advanced heart failure helps in reducing the symptoms related to heart failure; the level of patient satisfaction also increases with palliative care and also helps in reducing the cost of taking care of the patients that are suffering from advanced heart failure problems (Adler, Goldfinger, Kalman, Park & Meier, 2009). Paper gives an analysis of the relationship between palliative care and advanced heart failure, the literature review on the use of palliative care in advanced heart failure and a framework on how the palliative care applies in the three major concepts: stress, appraisal, and coping for advanced heart failure patients.

Literature review

There is growing concern over the increase in the cases of heart failure across the world. Studies indicate that more than five million Americans have the problem of advanced heart failure. The number of advanced heart failure incidence is also estimated to be more than 500, 000 in a year across the world (Sidebottom, Jorgenson, Richards, Kirven&Sillah, 2015). In a study conducted by the department for health the year 2017, it indicated that the number of people dying out of heart failure is estimated to be more than 43,000 every year while more than 100,000 are diagnosed with cardiovascular diseases. During the year 2004, the number of people that died from heart failure was more than the amount that died from other conditions such as prostate cancer, HIV/AIDS, lung cancer and many other chronic diseases accoding to the Australian department for health. The high level of deaths out of heart failure complications made it necessary for the healthcare sector to devise better ways of dealing with the condition to reduce the number of deaths as a result of heart failure. This brought together different stakeholders from the united states, and across the world to devise measures to deal with the problem that was proving to be too costly for the people, and many people lost lives because of the condition.

The cost of heart failure treatment has also recorded high levels of time resulting in concerns from members of the public and stakeholders. In the year 2006, the cost involved in the treatment and taking care of patients with heart failure was estimated to be thirty billion dollars. Patients with heart failure problems stayed in the hospital for an average of 6 days (Dumanovsky et al., 2016). A majority of those that visited hospitals for heart failure problems stayed for not less than five days. In many cases of hospitalizations, the cost incurred by patients with heart failure conditions is more than the reimbursement from Medicare. The patients with heart failure have to use their resource further to pay the medical bill because the cost is high for some reasons.

One of the reasons why heart failure patients have to pay the high cost for hospital bills then other patients it’s because they have to have many physicians’ visits. Heart failure is a delicate condition, and the patients need to have frequent visits to physicians, and this is one of the reasons why heart failure patients have to incur high medical costs. The other reason why advanced heart failure patients have to incur high medical costs is because of the many hospital admissions that such patients have to go through (Dumanovsky et al., 2016). Heart failure patients are more likely to be admitted in the hospital than any other patient because once the heart develops complications, the person needs to be supported through medical and other specialized interventions to ensure that their comfort is restored and can cope with the condition. The heart failure patients spend more days in intensive care units because their state requires specialized attention. The number of times spent in intensive care units increases the cost that the heart failure patients are required to pay in their medical bill.

End-Stage heart failure is one of the biggest challenges to the patients and the healthcare providers because it has diverse effects on the quality of life of the patient. It also makes patients vulnerable to other advanced diseases. One of the top priority when it comes to advanced heart failure patients, it is the symptom and pain management which helps them to live a relatively comfortable life. At the state of advanced heart failure, there are no curative measures that can be taken to correct the condition but only steps that are meant to make the patient comfortable. The patients with advanced heart failure seek measures to prolong their lives and ensure that there is some sense of control from the medical and palliative care received. The advanced heart failure patients in many cases are seeking to have less burden for their loved ones and instead strengthening the relationship with friends, families, and relatives. Heart failure patients are believed to suffer from high cases of dyspnea and fatigue; many of them also suffer from pain (Dumanovsky et al., 2016). Depression is a common condition among heart failure patients. Other conditions are common among heart failure patients which include insomnia. Many heart patients lack sleep because they are disturbed by their condition. Heart failure patients also experience cases of anxiety, confusion, and anorexia. There are also many cases of constipation that are experienced by heart failure patients. Many other conditions are associated with heart failure that makes the life of the patients miserable, and these conditions cannot all be addressed through medical treatment. Some of the conditions can only be handled through other professional support services such as palliative care.

Overview of palliative care in advanced heart failure

The palliative care services began in 1970 where it was meant to help patients suffering from cases of cancer. The palliative movement began as a community movement offering hospice services for critically cancer patients from their homes (Sidebottom et al., 2015). The move made the Medicare plan to add hospice services to the benefits that can be paid for by insurance cover for the patients. Many patients enrolled for the hospice services, and a majority of the patients had cancer. The other category of the patients that enrolled for hospice services is those with cardiac diseases. The use of non-hospice palliative care in medical treatment is meant to ensure the quality of life is improved, and patients are supported. The care is meant to ensure that the families of the people who are terminally ill and uncertain prognosis get the necessary support.

The hospice approaches are provided for different reasons meant to ensure full support of both the terminally ill patient and their family and palliative hospice care is provided depending on the prognosis of the patient. Independent prognosis also determines whether non-hospice palliative care is given to a heart failure patient. Palliative care is essential for patients with heart failure because it seeks to ensure that the patients’ emotional, physical, spiritual and longitudinal needs are met through a multidisciplinary approach that gives holistic care to the patient. The prognosis for heart failure is usually variable, and in many cases, there is no timely referral for hospices care for the patients. It is essential for heart failure patients to have access to non-hospice palliative care to ensure that their quality of life and comfort are improved.

The relationship between hospice palliative care and non-hospice palliative care in advanced heart failure

Palliative care consultations are believed to increase the number of referrals to hospice care. Studies indicate the families of the terminally ill are usually not satisfied when the referral to hospice for the patients is done late. Palliative care has a focus on ensuring that both the patients and their families are satisfied with the kind of services they are receiving (Kavalieratos et al., 2014). In such cases where there is a late referral to hospice care, it results in a low level of satisfaction among the family members of the heart failure patient. Late referral to hospice results to reduced time for hospice services and this significantly contributes to the low levels of family and patient satisfaction. The hospice referrals should, therefore, be timely to ensure that there is satisfaction and restore confidence in the hospice system. There are more unmet needs for the patients and the family when there is a late referral to hospice care. There is also a lack of awareness about what to expect at the time of the death of the patient when there is a late referral to hospice care. The family loses confidence to help the patient back at home when there is a late referral to hospice care. Timely referral to hospice care helps in building the confidence of the family members resolve to help the heart failure patient back at home. The coordination of care is compromised or affected when there is a late referral of patients to hospice care. There have to be enough palliative consultations on the needs of the family and the patient which influence the outcome of the patient care given.

In a majority of the late hospice referrals, the family members have complained that the major challenge was the physician. Many families have complained of physicians being barriers to ensuring timely referral of advanced heart failure patients to hospice care (Gries, Curtis, Wall &Engelberg, 2008). It is usually a difficult decision to make for both the family and the healthcare providers on the right time to transition from non-hospice palliative care to hospice palliative care for advanced heart failure patients.  The transition from non-hospice palliative care to hospice palliative care is supposed to be made in a group and consultation with all parties involved in the care of the patient. The patient, their family, and the healthcare providers are supposed to be involved in deciding to transition from non-hospice palliative care to hospice palliative care. There is the need for ongoing assessment by a physician to make sure that the prognosis models are effectively used to give an accurate prediction on the date that death is likely to happen in a period of fewer than six months. One sign that can also be used to decide on the transition to hospice is the increase hospitalization of the patient. The high the frequency of hospitalization is a sign that transition to hospice for the patient is appropriate. Hospice is only an option when the benefits of therapy are less than the harm that comes with the therapies. The traditional medical models suggest that providing comfort for the patient and curative measures are two different things. As a result, an integrated model which recognizes the need to have palliation and life-prolonging therapies is necessary for patients with advanced heart failure. A hospice approach is an option that is sought when the patient wishes that there should be the transition from the non-palliative care and this has to be done in consultation with all those involved in the patient care process.

Palliative care effects on clinical outcomes

Many benefits come with palliative care in advanced heart failure. The use of palliative care helps in improving the results for both the patient and the families of the patients. The satisfaction of care is also increased through the use of palliative care (Gries et al., 2008). The symptoms management is believed to be relatively more comfortable when palliative care is involved in the management of the patients with advanced heart failure as compared to when there is no palliative care offered. Most patients that get the in-house palliative care are likely to die at home. Some patients prefer the in-house palliative care to reduce the cost of having the service in a health facility which may be expensive. Most of those that prefer to get the service from their homes are granted their wishes in line with the patient satisfaction guideline. The use of palliative care for advanced heart failure helps in the promotion of the wellbeing of the patient and their dignity as well. The patients can communicate with the healthcare providers in palliative care which helps them to get the emotional and spiritual support they need for their comfort and wellbeing. The palliative care also helps in ensuring that the patients’families get the necessary support needed for their emotional and psychological wellbeing. It is through palliative care that the patient and their family get to access community support which is essential for their wellbeing and comfort. Patients who get hospice care increase their chances of survival for approximately 81 days longer as compared to those that do not get hospice care. The increase in survival days is believed to be as a result of skipping some procedures and adverse events that contribute to infections.

The impact of palliative care on the costs and utilization of healthcare

When there is an inpatient approach to palliative care, the number of interventions sought for the patient reduces significantly as compared to when there are outpatient palliative care consultations during the end of life. The length of stay in inpatient wards and intensive care units increases the cost paid by the patient and their families on advanced failure care. The overall direct costs involved in imaging and pharmacy also increases the cost of healthcare in advanced heart failure. The use of palliative care helps in reducing the costs associated with the processes and interventions used in providing curative measures for patients with advanced heart failure. A study in 8 American hospitals indicated that the patients who are in palliative care could save about $5000 per admission and about $400 per day in direct costs. This is a sign that palliative care contributes to reduced healthcare costs for the patients that have advanced heart failure because they can save a significant amount of money in direct costs. The utilization of palliative care is also increasing because people appreciate the importance of the process. The utilization of healthcare has also improved with the use of palliative care because it has helped those with terminally ill patients to have increased confidence in the healthcare system. The use of hospice has also demonstrated an effective way of cost saving for those with patients with advanced heart failure. Studies indicate that hospice care helps the patients and their families to save up to 40% in healthcare costs during the last month of life. Hospice is also believed to help the patient to save up to about 20% on healthcare cost within the last six months to the end of life. Hospice users can save more than $3,000 per person using hospice. The enrolment in the hospice program helps reduce the general healthcare cost for advanced heart failure patients.

The guidelines for palliation in end of life heart failure

Several essential guidelines are needed in end-stage heart failure for patients and the family. Some of the guidelines for palliation in advanced heart failure include having ongoing discussions with the patient and their families on the prognosis. There is also the need to talk with the patient and the family on survival rate, the functional capacities, advance directives that the patient should give before they die (Connor, Teno, Spence& Smith, 2005).  An ongoing discussion around palliative care and hospice care should be enhanced during the end-stage heart failure. The patient and the family members should be informed about the option to deactivate the implanted cardiac defibrillators. There should also be a discussion around the provision of symptoms management care for the patient and the use of opiates. The guidelines for end-stage heart failure provide that the patient should not be taken through an aggressive process that is no longer resulting in the improvement in the quality of life or recovery. Some of the processes that should not be used in consultation with the patient include intubation and cardiac defibrillators. The end-stage heart failure guidelines do not provide for the right time to refer the patient to hospice because improvements and unpredictable decompensations characterize heart failure.

The prognostication in heart failure

Prognostic models and tools are used in advanced heart failure to understand the right time when the patient should be sent to hospice. Some of the prognostic models involve the use of body evidence such as the six-minutes-walk test that helps the healthcare team to understand whether the patient should be referred to hospice. The maximum oxygen consumption and other sophisticated approaches are used to help predict the time that an advanced heart failure patient should be taken to hospice. Some of the signs that help the healthcare providers understand the likelihood of death include frequent visits to emergency units, high dependency on activities of daily living, more than 10% weight loss and prior cardiopulmonary resuscitation among other signs.

Communication in advanced heart failure

Communication is critical in end-stage heart failure. Many families and relatives have complained about poor communication from the physician and the healthcare team. It is always good for the patient and their family to receive good communication regarding the prognosis and other essential information concerning the health of the patient. One of the most critical aspects of communication in advanced heart failure is advanced care planning for the patient(Doorenbos, Levy, Curtis & Dougherty, 2016). It is essential for the healthcare team to share information with the patient and their family on advance care plans. Some decisions such as the appointment of a healthcare proxy that should be making decisions on behalf of the patient should be subjected to a discussion between the patient, their family, and the healthcare providers. This helps to avoid cases of unethical practices in healthcare where proper consultation is not made on the healthcare decisions about a patient. Early in the course of the disease, it is necessary for the healthcare team to ensure that the discussion on the appointment of a healthcare decision maker takes place. The healthcare team should clarify to the patient and the family that the person picked as the proxy healthcare decision maker for the patient can as well be changed if the patient wishes or the family in consultation with the patient. The healthcare team should ensure that the families understand that the use of resuscitation only take place when there is pulmonary or cardiac arrest. One of the essential aspects in palliative care communication around advanced heart failure is ensuring that there is central decision making where the patient, the families, and the healthcare team are all consulted before a particular decision is made. The healthcare team should communicate with the patient on their preferred healthcare decisions whether comfort or live prolonging approaches. Patients should be allowed to express their fears and a condition they fear most than death such as the inability to communicate with their loved ones. Such information can help in picking the best intervention measures to help the patient during advance heart failure. Patients should be allowed to chose between measures meant to prolong life and comfort which helps in making the future decisions about a patient’s health (Doorenbos et al., 2016). The responses from such communication should be recorded so that there is evidence on the choice that a patient made before they went into a coma or have total cognitive impairment. The team taking care of the patient should make sure that they consult with a physician before making critical decisions such as cardiopulmonary resuscitation for the patient. The healthcare team should ask the patient about what they know regarding their health condition, to ensure there is effective communication. Prognostic uncertainty should not be a reason for failing to communicate with the advanced heart failure patient on the possible implications of the condition. The healthcare providers should prepare the patient on what is likely to happen and what to expect before communication about the condition and possible implications. The communication guidelines for advanced heart failure also direct that the approximate time is provided in months or years so that the patient is certain of their duration of life. The patient should be informed of the likely scenarios or outcomes of advanced heart failure treatment and the transition to hospice care. The healthcare team should discuss preferences with the advanced heart failure patient such as the goals when there is permanent brain damage, the healthcare proxy, the ventilators, cardiopulmonary resuscitation and their choice on the location of care. Other aspects that should be considered in advanced heart failure communication include the deactivation of ICD and cardiac resynchronization if it is applicable (Doorenbos et al., 2016). The healthcare team should help the patient plan for the worse such as the financial and the emotional implications. Helping the patient and the family in advanced heart care mobilize for community support is an essential aspect of advanced heart care communication. Community support is necessary for advanced heart failure patients to get services such as hospice referrals, home care, and palliative care.

Theoretical framework

Stress coping is essential in advanced heart failure and palliative care. The reduction of stress for the patients helps them in prolonging their life while high stress makes the patient’s days to live to reduce. The family members are also affected by psychologically and emotionally because of stress. Stress endangers the wellbeing of the patients in advanced heart failure. Communication is an essential tool in reducing stress in advanced heart failure.

The cognitive appraisals of the main stressing factors help the care providers devise ways of handling the challenge of stress. One of the apparent causes is the realization that one is not going to live for more than a certain period based on the prognosis prediction. The care provider needs to have skills on how to effectively communicate this to the patient and their family and helping them to come in reality with the fact that the patient cannot be assisted with curative measures. The realization that there is no money to sustain the treatment process for a prolonged life is significant stress causing factor in advanced heart failure.

The care provider is supposed to help the patient and their family cope with the stress through effective communication and involving them in the decision making the process that affect the wellbeing of the patient and the family. Coping with the stress of financial difficulties can be addressed through referring the patient to hospice while the stress of accepting that the patient may not live beyond a certain period should be addressed through destructions with other activities and counseling.

Other possible causes of stress during end-stage heart failure include fatigue, pain, depression, edema, and dyspnea. The challenges can be addressed through the use of evidence-based palliative care approaches to help the 82-year-old with advanced heart failure to cope with the condition as one way of ensuring comfort during the end of life.  At this stage, there is a need for the right end of life communication needed from the healthcare providers. Most family members and patients complain that the physician does not communicate on the exact number of days remaining many of the prognosis from physicians are not accurate. The patient should be told that the time they have to live is short and end of live conversation should be ongoing taking into account the stressors and other things that may contribute to increased discomfort instead of comfort for the patient.

Discussion and conclusion

There is an increase in heart failure complications across the world. The number of people with advanced heart failure which cannot be addressed with curative measures is also increasing. At the end-of-life heart failure, palliative care is essential to help in improving the quality of life of the terminally ill. Non-hospice and hospice palliative care vary, and a patient is transferred to hospice when no other curative approach can be used to prolong their life. Consultation is required between the patient, family and the healthcare providers before the patient is referred to hospice. Studies indicate that palliative care and hospice help in reducing the cost but the challenge comes to getting accurate prognosis which helps in making the referral to hospice decision. The patient and the family need to be helped to cope with stressors such as the end of life within a particular duration, pain, dyspnea, and insomnia. Counseling to accept reality, using destructive activities to divert the attention from stressors is some of the approaches that can be used to help the 82-year-old with advanced heart failure. Evidence-based approached can be used to support the patient to cope up with pain dyspnea, insomnia, and all the other stressors to make the patient comfortable as they await their end of life.

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