Heart Failure Palliative Care Intervention

Palliative Care Intervention for Heart Failure

By Katie Van Marter

Faculty Member Marie Bakitas

Gap

Practice and Status

Problem

Guidelines

Patients with HF and cancer have similar palliative care needs. Can ENABLE be adapted to HF?

Data

ENABLE

-Heart failure

-6 million Americans over 65yrs

-Median post diagnosis survival rate 2 years

-Roughly 30% develop depression

-Quality of Life decreases

Palliative care improves quality of life "through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems..."

-Palliative care increases quality of life

-Works best soon after diagnosis

-Palliative care important just as in cancer

(Spulveda, 2002)

-Educate Nurture Advise Before Life Ends

-Nurse administered phone based intervention

-Cancer

Bekelman et al.,2009

ENABLE I: Efficacy data

ENABLE II: Preliminary effectiveness data

-QOL increase

-Mood increase

-No symptom change

ENABLE III: Current study

-Implementation feasibility

-Effectiveness in diverse population

(Bakitas et al.,2009)

Gap

Physician Side

Patient Side

Current Status

-Patients "caught off-guard"

-View of PC as peripheral

-Reject if viewed as hospice

-Distance to PC too far

-not worth it

-too sick

-67% HF specialists ever refer patients to PC

-Refer late in disease course

-Lack of training in rural areas

-Lack of research

-History

Metzger, Noton, Quinn, and Gramling, 2013

Bekelman et al., 2009

Bakitas et al., 2013

Berry, 2010

Conclusion

Leaving Behind

-Materials adapted for HF patients

-ENABLE team and HF specialists

-consult physicians

-Pilot study

-5 patients

-similar results to ENABLE

Adapt ENABLE to work for rural patients with HF. Use Type 1 Hybrid to demonstrate effectiveness of the adaptation and identify implementation barriers for future randomization.

People in rural areas...

-lack resources

-no care early in diagnosis

-no care when very sick

Help!

Research Design

-Given efficacy of ENABLE and and pilot study, Hybrid 1 appropriate

Effectiveness

Implementation

-Chat room incentives

-Questions for Nurses

Next Steps

Semi-structured interviews

-Nurses

-Difficulty of intervention

-Necessity of intervention

-Palliative Care Team Leader

-Resources to sustain and implement

-Organizational levels

-RCT randomized at patient level

-Based on ENABLE II trial

-Measure:

1) Functional status (KPS)

2) Symptom intensity (ESAS)

3) Mood status (CES-D)

4) QOL (FACIT-Pal)

-Caregiver

-Hospital usage

Hybrid Type 3

1) Karnofsky and Burchenal, 1949

2) Bruera, 1996

3) Randolf, 1977

4) Cella et al., 1993

Bakitas et al, 2009

-Increase effectiveness data

-Roughly 25 sites

-Collect various implementation strategies

Randomization of

Implementation Strategies

-Implementation strategies from Hybrid 3

-Identify best strategies

Website to increase reach

-Possible Implementation strategy

-Conferences too, reach those reachable by diffusion

-Early, eager adopters

-Chat rooms for support, sustainability independent of researchers

Scale up Partners

-Works best with partners already invested

-National Board for Certification of Hospice and Palliative Nurses

-Joint Association for Advanced Certification for Palliative Care

-American Heart Association

References