Palliative Care in Heart Failure: A Public Health Emergency.

BACKGROUND: Palliative care (PC) is the holistic care of patients with life-limiting illnesses focused on relief of suffering and maximizing quality of life for patients and their families. Patients with heart failure (HF) are the largest group eligible for PC services, but only a small percentage of them receive PC. AREAS OF UNCERTAINTY: The optimal content and method of delivery of PC interventions to HF patients in resource-limited countries remain unknown. The integration of PC into existing HF disease management continues to be a challenge. DATA SOURCES: PUBMED was searched to identify articles on the topic published in the last 5 years (2014-April 2019). One hundred thirty-six articles were identified-14 articles out of were included in the revision. THERAPEUTIC ADVANCES: Research concerning PC in HF is still scarce and comes predominantly from developed countries. PC in HF improves patients' and caregivers' outcomes in terms of dyspnea, sleep, depression, communication, coping, and care-giving burden. Specialized home-based PC services have a positive impact on patients' physical and emotional wellbeing while decreasing utilization of medical services. Fatigue, dyspnea, and pain are frequent symptoms. Evidence concerning use of opioids for dyspnea is increasing. Family caregivers offer a considerable amount of care during the disease trajectory. There is often incongruence between the carer's and the patient's wishes in terms of treatment decisions and preferences. Carers should be assessed for risk and supported in their roles in care management and care coordination. CONCLUSIONS: Because of the unpredictability of the disease and difficulty in prognostication, PC should be introduced at the point of diagnosis of HF. Basic education in PC needs to be introduced early in the training of cardiology staff, focused on concept definition, differencing PC and terminal care, symptom management, communication, and decision-making.

Phase of Illness in palliative care: Cross-sectional analysis of clinical data from community, hospital and hospice patients.

BACKGROUND: Phase of Illness describes stages of advanced illness according to care needs of the individual, family and suitability of care plan. There is limited evidence on its association with other measures of symptoms, and health-related needs, in palliative care. AIMS: The aims of the study are as follows. (1) Describe function, pain, other physical problems, psycho-spiritual problems and family and carer support needs by Phase of Illness. (2) Consider strength of associations between these measures and Phase of Illness. DESIGN AND SETTING: Secondary analysis of patient-level data; a total of 1317 patients in three settings. Function measured using Australia-modified Karnofsky Performance Scale. Pain, other physical problems, psycho-spiritual problems and family and carer support needs measured using items on Palliative Care Problem Severity Scale. RESULTS: Australia-modified Karnofsky Performance Scale and Palliative Care Problem Severity Scale items varied significantly by Phase of Illness. Mean function was highest in stable phase (65.9, 95% confidence interval = 63.4-68.3) and lowest in dying phase (16.6, 95% confidence interval = 15.3-17.8). Mean pain was highest in unstable phase (1.43, 95% confidence interval = 1.36-1.51). Multinomial regression: psycho-spiritual problems were not associated with Phase of Illness ( χ2 = 2.940, df = 3, p = 0.401). Family and carer support needs were greater in deteriorating phase than unstable phase (odds ratio (deteriorating vs unstable) = 1.23, 95% confidence interval = 1.01-1.49). Forty-nine percent of the variance in Phase of Illness is explained by Australia-modified Karnofsky Performance Scale and Palliative Care Problem Severity Scale. CONCLUSION: Phase of Illness has value as a clinical measure of overall palliative need, capturing additional information beyond Australia-modified Karnofsky Performance Scale and Palliative Care Problem Severity Scale. Lack of significant association between psycho-spiritual problems and Phase of Illness warrants further investigation.

Romania: changing the regulatory environment.

Access to the necessary medications for palliative care, especially opioids, is an essential part in the development of a national palliative care program. In November 2005, Romania's Parliament adopted new legislation concerning the medical use of opioids and psychotropic substances to replace the old and restrictive legislation of 1969. The new law and regulations are the result of a four-year project in which governmental authorities collaborated with health care professionals and international experts. The World Health Organization "Achieving Balance in National Opioids Control Policy--Guidelines for Assessment" was used to propose balanced legislation that would facilitate modern pain management and provide adequate control of these substances with the potential for abuse. A national education program to facilitate the implementation of the new legislation has been organized. The training started in November 2006 and will continue throughout 2007. It is anticipated that at least 3,000 doctors and 500 pharmacists will attend these courses.