Please select the eligibility criteria that correspond to the clinical trial below.
Title: Effects of a Transitional Palliative Care Model on Patients With End-stage Heart Failure
Brief Summary: Palliative care for end-stage organ failure patients has been included as one of the key programs to be implemented in 2011-2012 in the Hospital Authority, Hong Kong. Among all the disease groups, end-stage heart failure patients have the highest mortality rate. Patients at the end stage of heart failure have health concerns shared by other end-stage patients including cancer patients. Many guidelines, local and world-wide, have advocated a palliative approach of care for those heart failure patients who are at end stage. Studies have shown that end-stage heart failure patients tend to have frequent emergency room visits and repeated hospital admissions. Also, these patients suffer from a number of health problems that adversely affect their Quality Of Life.

There is scarcity of experimental studies informing practitioners which models work best for palliative patients in Hong Kong. There were randomized controlled trials conducted outside Hong Kong which suggest multidisciplinary approach of palliative care is possible to reduce readmissions but evidence is not present for other outcomes such as symptom control and carer burden.

In an attempt to fill knowledge gap and inform practice using evidence, this study is launched to compare the effects of a customary hospital-based palliative heart failure care and an interventional Home-based Palliative heart failure Program.

Hypothesis

* there is no difference in health care utilization for end-stage heart failure patients between the customary hospital-based group and the Home based palliative heart failure program group
* there is no difference in evaluated health outcomes (functional status, symptom intensity, and satisfaction with care) between the customary hospital-based group and the Home based palliative heart failure program group
* there is no difference in perceived health outcomes (quality of life, caregiver burden) between the customary hospital-based group and the Home based palliative heart failure program group
* there is no difference in cost effectiveness between the customary hospital-based group and the Home based palliative heart failure program group
* there is no difference In patients' lived experiences between the customary hospital-based group and the Home based palliative heart failure program group


Options:
A: Inclusion Criteria

* Symptomatic Heart Failure (NYHA II-IV)
* Hospitalized or recently for acute decompensation with at least one of the following high-risk features

  * Prior hospitalization for Heart Failure (HF) within 1 year
  * Age \> 80 years
  * Chronic Kidney Disease (estimated Glomerular Filtration Rate (eGFR) \< 45 mL/min/m2)
  * Systolic Blood Pressure \< 100 mm Hg
  * Serum sodium \< 130 meq/L
  * Cardiogenic Shock (Cardiac Index \< 2.0)
  * Serious Non-Cardiovascular Illness (e.g. advanced stage cancer, Chronic Obstructive Pulmonary Disease (COPD) , or the like.
* Ability to Provide Informed Consent
* Permission of attending physician

Exclusion Criteria

* Anticipated major cardiac surgery, including Ventricular Assist Device (VAD) or transplant, within 3 months of enrollment
* Already enrolled in hospice or receiving outpatient palliative care
B: Inclusion Criteria:

1. A diagnosis of advanced heart failure as defined by ALL THREE of the following:

   • New York Heart Association Class III or IV (NYHA III or IV) (III: marked limitation in activity due to symptoms, even during less-than-ordinary activity; IV: severe limitations, experiences symptoms while at rest).

   AND
   * Hospitalization for heart failure within the last six months. AND
   * Age greater than or equal to 65.
2. Additionally ONE of the following must be met:

   * According to the attending physician's best judgment the patient's survival is limited to 2 years but may very well be less than 1 year (i.e. the physician would not be surprised if the patient died within one year from any cause) OR
   * Three heart failure hospitalizations in the last year OR
   * One of the following:

     * Two Systolic Blood Pressures \< 90 within the last 6 months in the ambulatory setting
     * Na \< 130 within the last 6 months
     * NTproBNP \> 3,000
     * EGFR \< 35
     * High diuretic use (160 mg po Lasix or 100 mg po torsemide or equivalent total daily dose)

Exclusion Criteria:

* New patient
* A transplant or mechanical circulatory support candidate
* Major psychiatric illness as determined by the attending that would make this study inappropriate.
* Any patient that has been excluded for transplant or mechanical circulatory support due to psychological or psychiatric co-morbidities.
C: Inclusion Criteria:

* Ability to speak Cantonese
* Living within the hospital service area
* Ability to be contacted by phone
* Identified as end-stage heart failure eligible for palliative care, guided by Prognostic Indicator Guidance, National Gold Standards Framework,to fulfill at least two of the indicators below:

  (i) Congestive heart failure New York Heart Association stage III or IV (ii) Patient thought to be in the last year of life by the care team (iii) Repeated hospital admissions with symptoms of heart failure (3 hospital admissions within one year) (iv) Existence of physical or psychological symptoms despite optimal tolerated therapy

Exclusion Criteria:

* Discharged to nursing home or other institution
* Inability to communicate
* Diagnosed with severe psychiatric disorders such as schizophrenia, bipolar disorder
D: 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

Answer: C