Cheryl H. Zambroski

Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure

Background: Heart failure is an escalating health problem around the world. Despite significant scientific advances, heart failure patients experience multiple physical and psychological symptoms that can impact the quality of life. Aims: To determine the (1) symptom prevalence, severity, distress and symptom burden in patients with heart failure; (2) impact of age and gender on symptom prevalence, severity, distress and symptom burden; and (3) impact of symptom prevalence and symptom burden on health-related quality of life (HRQOL) in patients with heart failure. Methods: A convenience sample of 53 heart failure patients participated in this descriptive, cross-sectional design. Symptoms and HRQOL were measured using the Memorial Symptom Assessment Scale—Heart Failure and the Minnesota Living with Heart Failure Questionnaire. Results: Patients experienced a mean of 15.1 ± 8.0 symptoms. Shortness of breath and lack of energy were the most prevalent. Difficulty sleeping was the most burdensome symptom. Lower age, worse functional status, total symptom prevalence and total symptom burden predicted 67% of the variance in HRQOL. Conclusion: Patients with heart failure experience a high level of symptoms and symptom burden. Nurses should target interventions to decrease frequency, severity, distress and overall symptom burden and improve HRQOL.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft.

OBJECTIVE This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders. METHODS This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist. RESULTS The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms. CONCLUSIONS The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

Factors influencing food intake in patients with heart failure: a comparison with healthy elders.

Background and research objective: Promoting adequate nutritional intake of patients with heart failure (HF) is an essential component of comprehensive management. This goal can be hampered by decreased appetite, as well as psychological, social, and HF-related factors that can affect food intake. Factors related to aging may also affect food intake in older patients. The purpose of this study was to compare patients with HF to healthy elders regarding the extent to which they perceived how appetite and hunger, emotional and social, and illness factors affected the amount of food they ate in the previous week. Subjects and methods: Sixty-seven patients with HF were recruited from 3 Midwestern HF clinics. As part of a larger study examining nutrition in HF, patients filled out the Food Eating Experiences and Diet (FEED) questionnaire, an instrument designed to assess factors affecting appetite and hunger. Patients were asked to rate their hunger and appetite on a visual analog scale. On Likert-type scales, they rated the extent to which appetite/hunger, emotional/social, and illness factors affected the amount of food intake. Sixty-eight healthy elders were recruited from 2 Midwestern senior citizen centers. As part of a study collecting a large data set for comparison with HF patients, healthy elders provided demographic and health information and filled out the FEED questionnaire. Results and conclusions: Factors rated as affecting food intake most often by patients with HF were decreased hunger sensations, diet restrictions, fatigue, shortness of breath, nausea, anxiety, and sadness. Factors rated most often by healthy elders as affecting food intake were diminished hunger sensations, early satiety, eating alone, and decreased senses of taste and smell. Among patients with HF, many factors unique from those present due to age were reported to affect food intake.

Hospice as an alternative model of care for older patients with end-stage heart failure.

The end of life for patients with end-stage heart failure is often characterized by pain, shortness of breath, and diminished quality of life, indicating a lack of adequate care necessary for patients to experience a good death. The vast majority of those who die from heart failure are 65 or older and potentially eligible for the Medicare Hospice Benefit. Yet, only about 10% of patients with end-stage heart failure actually enroll in hospice programs. Lack of enrollment into hospice has been attributed to a variety of factors including a lack of understanding of the availability of hospice as an option for those with heart failure. While improving models of care for patients with heart failure has been of great interest during the last two decades, little is known about the benefits of hospice as a model for care in patients with end-stage heart failure. Nursing must participate in research that explores options of either improving current models of care or developing new and improved models of care for patients with heart failure.

The COPE Intervention for Caregivers of Patients with Heart Failure: An Adapted Intervention.

The purpose of this 2-group comparative experimental study was to pilot test the heart failure–COPE (creativity, optimism, planning, and expert information) intervention for caregivers of heart failure patients in hospice care in a small randomized trial focusing on caregiver burden, quality of life, depression and anxiety, caregiver knowledge, patient quality of life, and emergency room visits and hospitalizations. Forty patient-caregiver dyads participated with the treatment group receiving the COPE–heart failure intervention in 21 days, and both groups provided data at baseline and at weeks 4 and 5. Results showed no effect of the intervention, but the sample was small, and patients had been diagnosed for a mean of more than 10 years. The most commonly reported symptoms by patients were dry mouth and fatigue. Self-care was less than adequate, but depression and distress among patients were low, whereas quality-of-life scores were relatively high. Caregivers reported low distress from patient symptoms and from caregiving burden and low mean anxiety and depression scores. We concluded that caregivers had been managing heart failure symptoms for a long time and that our intervention near the end of the disease trajectory was not needed; caregivers already felt competent to manage the care of these patients.

Upstreaming Palliative Care for Patients With Heart Failure

Upstreaming palliative care, practicing and advocating for palliative care earlier in the heart failure (HF) trajectory, is an idea whose time has come. In this article, we explore the meaning of palliative care for HF and then discuss its relationships with both chronic care and end-of-life care. A case study is used to envision the practical implementation of palliative care into existing systems of care. We conclude by discussing the clinician’s role in implementing palliative care earlier for individuals with HF by practice and advocacy.

Assessing the response of patients and spousal/partner caregivers to a new instrument measuring dyadic heart failure care types

Background: Nurse researchers are exploring new ways of understanding heart failure (HF), spousal/partner dyad’s self care. Aims: To assess the response to a new instrument developed to measure dyadic HF care type in HF patients and spousal/partner caregivers and explore relationships between type and other variables. Methods: Dyads answered a written criterion referenced question related to dyadic HF care type. The relationships between the dyadic care type and sociodemographic and clinical variables were explored using χ 2, φ coefficient. Degree of agreement within the dyad on particular type was assessed by kappa statistic. Results: A total of 19 dyads were accrued. Patients were aged 71.7±9.7 years (mean±SD), male (n=15), and NYHA Class IIIB/IV (79%). Caregivers were aged 69.2±11.7 years, female (n=15), married for 45.2±14.1 years. HF patient and caregiver dyads were easily able to self select a dyadic type given specific criteria. Agreements ranged from 21% to 5%, by type, resulting in a kappa of 0.28 (p = 0.025) when patient self reported type was compared to their caregiver’s type. Conclusions: Now that we are able to measure types of dyadic HF care, understanding how dyadic care type relates to self care outcomes is needed to advance the science.

Palliative symptom management in patients with heart failure

Abstract Effective symptom management is a critical component of quality palliative care. For those with heart failure, poorly managed symptoms contribute to frequent rehospitalization and significantly increase the overall burden to patients and families as well as the healthcare system. The purpose of this paper is to review assessment and management strategies for patients with heart failure who remain symptomatic despite guideline-indicated heart failure treatment. Initially, we focus on the Symptom Management Model as a guiding framework consistent with palliative care. Then, we address several specific symptoms commonly reported by heart failure patients, including dyspnea, fatigue, difficulty sleeping, depression and anxiety. Comprehensive, on-going assessment of symptoms and the symptom experience is critical to guide planning, intervention, and evaluation of patients with heart failure. Through targeted assessment and interventions, the burden of symptoms may be reduced to improve quality of life for patients and their families as they face this life-limiting, chronic illness.

“Everything They Were Discussing, We Were Already Doing”: Hospice Heart Failure Caregivers Reflect on a Palliative Caregiving Intervention

There is little to no evidence concerning the efficacy of heart failure caregiver interventions in hospice populations. The objective of this study was to examine heart failure caregivers’ responses to a hospice caregiving intervention and elicit recommendations for future interventions. A qualitative descriptive design was used with a one-time semistructured interview conducted within 2 weeks of completing the intervention. The interview began with general questions related to the helpfulness of the intervention and continued with probes regarding the particular parts of the intervention used to explore more deeply the caregivers’ perceptions. Analysis involved constant comparison of the interview transcriptions according to established approaches with codes generated through a line-by-line reading of the interviews by two investigators. A sample (n = 7) made up of spouses, adult children, and sibling caregivers responded to the intervention based on their length of caregiving (with early caregivers embracing the intervention, experienced caregivers ignoring it) and experience with hospice. They were able to give detailed feedback and make recommendations for future studies—targeting less experienced caregivers, discussing multimorbid symptom management, and streamlining the information and contact with help. Heart failure caregivers recommend providing interventions earlier (or upstream) in the disease trajectory.

Lessons from the field: challenges in accruing hospice heart failure patients to intervention research.

Recent clinical practice guidelines suggest that hospice can be a valuable alternative for patients with advanced heart failure (HF). Unfortunately, there are very few evidence-based nursing interventions to guide symptom management for HF patients in hospice and their caregivers. Nevertheless, conducting clinical research in hospice populations remains fraught with methodological and ethical challenges. Our research team was not naive to the fact that hospice research is difficult. We believed that we had prepared well for a number of contingencies before the beginning of our clinical trial testing the feasibility of delivering a psychosocial intervention to caregivers of patients with HF. Despite the team expertise and well-defined recruitment strategies, the recruitment, both accrual and attrition, remained daunting in this population. The purpose of this article was to report the challenges of recruiting hospice patients with HF and caregivers for our randomized clinical trial, those we anticipated and those we did not.