Does the type and frequency of palliative care services received by patients with advanced heart failure impact symptom burden?

JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 1, 2014 a Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013. 0231 Brief Reports Does the Type and Frequency of Palliative Care Services Received by Patients with Advanced Heart Failure Impact Symptom Burden? Lorraine S. Evangelista, PhD, RN, FAHA, FAAN, 1 Solomon Liao, MD, FAAHPM, 2 Marjan Motie, PhD, 3 Nathalie De Michelis, RN, BSN, 4 Jennifer Ballard-Hernandez, MSN, NP, AACC, 5 and Dawn Lombardo, MD 4 pies, organ and tissue donation, and medical device donation), and worked with participants to develop a treat- ment plan that listed the goals of care. The treatment plan was presented to the interdisciplinary PC team during their weekly meetings, in order to support a team-based approach to providing patient-family centered care that encouraged active involvement of patients and their families in decision making involving their care. Introduction P atients with heart failure (HF) experience a myriad of symptoms that are associated with marked distress and impaired quality of life. 1–3 In light of their high symptom burden and poor prognosis, patients with symptomatic HF are an appropriate population in whom to introduce pallia- tive care (PC). 4–6 However, PC referral early in the course of symptomatic HF is a relatively new practice and few data exist that describe the nature of these encounters. 7 The current study was conducted to describe the nature of outpatient PC services (i.e., type of services and care received, duration, and frequency of visits) used by patients discharged from the hospital with acute HF exacerbation, i.e., New York Heart Association (NYHA) Functional Class II–III, and to describe levels of symptom burden during the initial PC consultation and three months thereafter. Data collection methods The study was approved by the appropriate institutional review board. Participants provided informed consent prior to completing the modiﬁed Edmonton Symptom Assessment Scale (ESAS), 8 a nine-item, self-reported visual analog scale numerically rated from 0 (no symptom at all) to 10 (worst possible symptom) at baseline and three months, to assess ratings of each symptom at the time that the survey was completed. 9 The severity of each individual item was cate- gorized as none (0), mild (1–4), moderate (5–7), and severe (8– 10). The reliability (Cronbach’s a) of the ESAS for the current study was 0.86. Data on types of PC services received, the focus of care for each encounter, and medication use over three months were abstracted from the medical records. Methods Study design, setting, and participants This descriptive-exploratory study was conducted at a single university afﬁliated medical center. Participants were recruited from the inpatient setting through HF provider referrals. Data analyses Palliative care intervention Descriptive summaries of demographic and clinical data, symptom burden scores, and duration and frequency of PC encounters were computed using SPSS 18.0 (SPSS Inc., Chi- cago, IL). The paired Wilcoxon signed-rank test was used to compare symptom burden scores immediately after discharge and three months postdischarge. A symptom response rate (i.e., percentage of participants presenting a reduction of ‡ 2 points on an individual symptom of the ESAS) was computed to determine efﬁcacy of PC in reducing symptom burden; a two-point change in individual symptom scores has been Participants met within seven days of hospital discharge with a PC specialist (e.g., physician or advanced practice nurse) who retained primary responsibility for their PC needs over three months. The PC specialist performed a compre- hensive physical and psychosocial assessment, initiated dis- cussions about advance care planning (e.g., completion of advance directives, options to take in the event of worsening health, family involvement, pain management, hydration is- sues, artiﬁcial nutrition, blood transfusions, advanced thera- Program of Nursing Science, University of California Irvine, Irvine, California. Palliative Care Services and Department of Medicine, 4 Clinical Heart Failure Program, University of California Irvine Medical Center, Irvine, California. Pro-HEART, Program of Nursing Science, University of California Irvine, Irvine, California. Hoag Memorial Hospital Presbyterian, Newport Beach, California. Accepted August 30, 2013.