The Importance of Cultural Awareness in the Management of Heart Failure: A Narrative Review.

Heart failure is a commonly encountered clinical syndrome arising from a range of etiologic cardiovascular diseases and manifests in a phenotypic spectrum of varying degrees of systolic and diastolic ventricular dysfunction. Those affected by this life-limiting illness are subject to an array of burdensome symptoms, poor quality of life, prognostic uncertainty, and a relatively onerous and increasingly complex treatment regimen. This condition occurs in epidemic proportions worldwide, and given the demographic trend in societal ageing, the prevalence of heart failure is only likely to increase. The marked upturn in international migration has generated other demographic changes in recent years, and it is evident that we are living and working in ever more ethnically and culturally diverse communities. Professionals treating those with heart failure are now dealing with a much more culturally disparate clinical cohort. Given that the heart failure disease trajectory is unique to each individual, these clinicians need to ensure that their proposed treatment options and responses to the inevitable crises intrinsic to this condition are in keeping with the culturally determined values, preferences, and worldviews of these patients and their families. In this narrative review, we describe the importance of cultural awareness across a range of themes relevant to heart failure management and emphasize the centrality of cultural competence as the basis of appropriate care provision.

Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care.

The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.

Implementation of the Mental Capacity Act: a national observational study comparing resultant trends in place of death for older heart failure decedents with or without comorbid dementia.

BACKGROUND: Heart failure (HF) is increasingly prevalent in the growing elderly population and commonly associated with cognitive impairment. We compared trends in place of death (PoD) of HF patients with/without comorbid dementia around the implementation period of the Mental Capacity Act (MCA) in October 2007, this legislation supporting patient-centred decision making for those with reduced agency. METHODS: Analyses of death certification data for England between January 2001 and December 2018, describing the PoD and sociodemographic characteristics of all people ≥ 65 years registered with HF as the underlying cause of death, with/without a mention of comorbid dementia. We used modified Poisson regression with robust error variance to determine the prevalence ratio (PR) of the outcome in dying at home, in care homes or hospices compared to dying in hospital. Covariates included year of death, age, gender, marital status, comorbidity burden, index of multiple deprivation and urban/rural settings. RESULTS: One hundred twenty thousand sixty-eight HF-related death records were included of which 8199 mentioned dementia as a contributory cause. The overall prevalence proportion of dementia was 6.8%, the trend significantly increasing from 5.6 to 8.0% pre- and post-MCA (Cochran-Armitage trend test p < 0.0001). Dementia was coded as unspecified (78.2%), Alzheimer's disease (13.5%) and vascular (8.3%). Demented decedents were commonly older, female, and with more comorbidities. Pre-MCA, PoD for non-demented HF patients was hospital 68.2%, care homes 20.2% and 10.7% dying at home. Corresponding figures for those with comorbid dementia were 47.6%, 48.0% and 4.2%, respectively. Following MCA enforcement, PoD for those without dementia shifted from hospital to home, 62.5% and 17.2%, respectively; PR: 1.026 [95%CI: 1.024-1.029]. While home deaths also rose to 10.0% for those with dementia, with hospital deaths increasing to 50.4%, this trend was insignificant, PR: 1.001 [0.988-1.015]. Care home deaths reduced for all, with/without dementia, PR: 0.959 [0.949-0.969] and PR: 0.996 [0.993-0.998], respectively. Hospice as PoD was rare for both groups with no appreciable change over the study period. CONCLUSIONS: Our analyses suggest the MCA did not materially affect the PoD of HF decedents with comorbid dementia, likely reflecting difficulties implementing this legislation in real-life clinical practice.

The COVID-19 pandemic: challenges in providing supportive care to those with cardiovascular disease in a time of plague.

PURPOSE OF REVIEW: COVID-19 has permeated the very essence of human existence and society and disrupted healthcare systems. The attrition stemming from this highly contagious disease particularly affects those rendered vulnerable by age and infirmity, including those with underlying cardiovascular disease. This article critically reviews how best to integrate supportive care into the management of those affected. RECENT FINDINGS: Numerous studies have described the pathophysiology of COVID-19, including that specifically arising in those with cardiovascular disease. Potential treatment strategies have emerged but there is limited guidance on the provision of palliative care. A framework for implementation of this service needs to be developed, perhaps involving the training of non-specialists to deliver primary palliative care in the community, bolstered by the use of telemedicine. The appropriate use of limited clinical resources has engendered many challenging discussions and complex ethical decisions. Prospective implementation of future policies requires the incorporation of measures to assuage moral distress, burnout and compassion fatigue in healthcare staff who are psychologically and physically exhausted. SUMMARY: Further research based on patient-centred decision making and advance care planning is required to ensure the supportive needs of COVID-19 patients with cardiovascular disease are adequately met. This research should focus on interventions applicable to daily healthcare practice and include strategies to safeguard staff well-being.

Palliative Care in Acute Heart Failure.

PURPOSE OF REVIEW: Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. RECENT FINDINGS: The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research. Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients' preferences and values.

Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper.

The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for those affected by this burdensome condition. Integrating palliative care into evidence-based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a 'good death'. This new position paper aims to provide day-to-day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline-directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure.

Iron deficiency in 78 805 people admitted with heart failure across England: a retrospective cohort study.

Objectives: Iron deficiency (ID), with or without anaemia (IDA), is an important comorbidity in people with chronic heart failure (HF), but the prevalence and significance in those admitted with HF is uncertain. We assessed the prevalence of ID or IDA in adults (age ≥21 years) hospitalised with a primary diagnosis of HF, and examined key metrics associated with these secondary diagnoses. Methods: A retrospective cohort study of Hospital Episode Statistics describing all adults admitted to National Health Service (NHS) hospitals across England from April 2015 through March 2016 with primary diagnostic discharge coding as HF, with or without subsidiary coding for ID/IDA. Results: 78 805 adults were admitted to 177 NHS hospitals with primary coding as HF: 26 530 (33.7%) with secondary coding for ID/IDA, and 52 275 (66.3%) without. Proportionately more patients coded ID/IDA were admitted as emergencies (94.8% vs 87.6%; p<0.0001). Tending to be older and female, they required a longer length of stay (15.8 vs 12.2 days; p<0.0001), with higher per capita costs (£3623 vs £2918; p<0.0001), the cumulative excess expenditure being £21.5 million. HF-related (8.2% vs 5.2%; p<0.0001) and all-cause readmission rates (25.8% vs 17.7%; p<0.05) at ≤30 days were greater in those with ID/IDA against those without, and they manifested a small but statistically significant increased inpatient mortality (13.5% v 12.9%; p=0.009). Conclusions: For adults admitted to hospitals in England, principally with acute HF, ID/IDA are significant comorbidities and associated with adverse outcomes, both for affected individuals, and the health economy.

Putting the "Informed" in the informed consent process for implantable cardioverter-defibrillators: Addressing the needs of the elderly patient.

Implantable cardioverter defibrillator (ICD) management complexities challenge the ethos of fully informed consent, particularly for the typically multimorbid elderly patient considering the device for primary prevention. The Heart Rhythm Society recommends providers include discussion on the potential need for later device deactivation or nonreplacement at the time of first implant, and to revisit this at appropriate intervals. The initial consent procedure could meet this standard by incorporating the future need to discuss further such issues when the recipient's clinical condition changes to such an extent that defibrillation would no longer be beneficial. At the time of obtaining consent, some patients may lack the will or capacity to make medically complex decisions when it would be necessary for healthcare surrogate decision-makers to contribute to this process. Ensuring an appropriate level of understanding and response may be enhanced by the use of information and decision aids. With improved communication regarding the nuances of ICD therapy, device eligible patients, and those close to them, will be empowered with a better understanding of the nature, benefits, and risks of ICD implantation, allowing them to make treatment decisions consistent with their values.

Palliative care in heart failure: facts and numbers.

Millions of people worldwide have heart failure. Despite enormous advances in care that have improved outcome, heart failure remains associated with a poor prognosis. Worldwide, there is poor short-term and long-term survival. The 1 year survival following a heart failure admission is in the range of 20-40% with between-country variation. For those living with heart failure, the symptom burden is high. Studies report that 55 to 95% of patients experience shortness of breath and 63 to 93% experience tiredness. These symptoms are associated with a high level of distress (43-89%). Fewer patients experience symptoms such as constipation (25-30%) or dry mouth (35-74%). However, when they do, such symptoms are associated with high levels of distress (constipation: 15-39%; dry mouth: 14-33%). Psychological symptoms also predominate with possibly as many as 50% experiencing depression. Palliative care services in heart failure are not widely available. Even in countries with well-developed services, only around 4% of patients are referred for specialist palliative care. Many patients and their families would benefit from receiving specialist palliative care support.

Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death: guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care.

The Resuscitation Council (UK), the British Cardiovascular Society (including the British Heart Rhythm Society and the British Society for Heart Failure) and the National Council for Palliative Care recognise the importance of providing clear and consistent guidance on management of cardiovascular implanted electronic devices (CIEDs) towards the end of life, during cardiorespiratory arrest and after death. This document has been developed to provide guidance for the full range of healthcare professionals who may encounter people with CIEDs in the situations described and for healthcare managers and commissioners. The authors recognise that some patients and people close to patients may also wish to refer to this document. It is intended as an initial step to help to ensure that people who have CIEDs, or are considering implantation of one, receive explanation of and understand the practical implications and decisions that this entails; to promote a good standard of care and service provision for people in the UK with CIEDs in the circumstances described; to offer relevant ethical and legal guidance on this topic; to offer guidance on the delivery of services in relation to deactivation of CIEDs where appropriate; to offer guidance on whether any special measures are needed when a person with a CIED receives cardiopulmonary resuscitation; and to offer guidance on the actions needed when a person with a CIED dies.