Please select the eligibility criteria that correspond to the clinical trial below.
Title: A Patient-Centered Approach to Advance Care Planning of Patients With End Stage Heart Failure and Renal Disease
Brief Summary: Based on theories regarding decision-making and patient education the investigators have developed Patient-Centered Advance Care Planning (PC-ACP). This intervention is designed to improve patient and surrogate knowledge of ACP, increase the congruence between patient and surrogate in treatment decisions, decrease the patient's and surrogate's conflict in making such decisions, and increase the consistency between patient preferences and the actual care they receive. The ACP intervention is conducted with the patient in the presence of the surrogate.


Options:
A: Inclusion Criteria:

* Veterans enrolled in VA Eastern Colorado Health Care System or VA Puget - Sound Health Care System
* Diagnosis of CHF, pulmonary fibrosis, or COPD in 2 years prior to enrollment
* High risk for hospitalization and death
* Poor quality of life
* Symptomatic
* Primary care or other provider who is willing to facilitate intervention medical recommendations
* Able to read and understand English
* Consistent access to and able to use a standard telephone

Exclusion Criteria:

* Previous diagnosis of dementia
* Active substance abuse
* Comorbid metastatic cancer
* Nursing home resident
* Heart or lung transplant or left ventricular assist device (LVAD)
* Currently receiving hospice, palliative or home-based primary care
* Currently pregnant
* Currently a prisoner
B: Inclusion Criteria:

* Duke University Hospital inpatient adults
* Hospitalization for acute decompensated heart failure
* Dyspnea (shortness of breath) at rest or minimal exertion plus at least 1 sign of volume overload
* Previous heart failure hospitalization within the past 1 year
* At significant risk of dying from heart failure in the next 6 months
* Anticipated discharge from hospital with anticipated ability to return to outpatient follow-up appointments

Exclusion Criteria:

* Are not an inpatient at Duke University Hospital
* Acute coronary syndrome within 30 days
* Cardiac resynchronization therapy (CRT) within the past 3 months or current plan to implant CRT device
* Active myocarditis, constrictive pericarditis
* Severe stenotic valvular disease amenable to surgical intervention
* Anticipated heart transplant or ventricular assist device within 6 months
* Renal replacement therapy
* Non-cardiac terminal illness
* Women who are pregnant or planning to become pregnant
* Inability to comply with study protocol
* Are not proficient in the English language
C: Inclusion criteria:

1. Diagnosis of HF from either systolic or diastolic dysfunction, with an ejection fraction of ≤ 40%
2. Completion of an outpatient HF visit within the past 6 months
3. Ability to read, write, and speak in English

Exclusion criteria:

1. Short BLESSED cognitive score \> 10 to rule out significant cognitive impairment;82
2. Diagnosis of any additional terminal illness with life expectancy of ≤ 1 year not related to heart disease
3. Psychiatric illness that required hospitalization in the past year; and (4) age less than 18 years
D: Inclusion Criteria:

* At high risk for impending death in the next 12 months

Exclusion Criteria:

* Patient not having decision-making capacity

Answer: D