A systematic review of the evidence in support of palliative care in people with persistently symptomatic heart failure

Background: Heart failure is common. People with advanced stages of the disease are symptomatic and have poor quality of life. Despite recommendations, this population have little access to palliative care. A barrier for people with heart failure accessing palliative care is clinicians' perceptions that there is little or no evidence to show that palliative care is beneficial in this patient group.Aim: The thesis aims is to identify the evidence in support of palliative care in heart failure management.Methods: A systematic review was conducted of the current evidence in support of palliative care in people with persistently symptomatic heart failure. Medline, Cochrane database, CINAHL, PsycINFO, HMIC, Care Search Grey Literature, reference lists, and citations were searched and experts were emailed for studies about 'persistently symptomatic heart failure' and 'palliative care'.Results: Two researchers screened 7,005 titles and abstracts independently. Seven phase III trials, one phase II trial, one non-randomised quasi-experimental trial, five cohort studies, and one case-control study were included. Studies were heterogeneous in terms of population, intervention, comparator, and outcomes. However, study designs with adequate power and a multi-disciplinary palliative care intervention showed benefit for a variety of patient-reported outcomes such as symptom burden, depression, functional status, and quality of life, as well as, administrative outcomes such as resource use and costs of care.Discussion: Overall, the results support the use of palliative care in managing patients with heart failure; however, findings were not consistent across all studies. Various methodological issues may contribute to discrepant results, and effect may have been under-estimated in several studies due to risk of contamination of controls. Further research is needed to understand which patients would benefit most from general and specialist palliative care

Multi-disciplinary palliative care is effective in people with symptomatic heart failure: A systematic review and narrative synthesis

Background: Despite recommendations, people with heart failure have poor access to palliative care. Aim: To identify the evidence in relation to palliative care for people with symptomatic heart failure. Design: Systematic review and narrative synthesis. (PROSPERO CRD42016029911) Data sources: Databases (Medline, Cochrane database, CINAHL, PsycINFO, HMIC, CareSearch Grey Literature), reference lists and citations were searched and experts contacted. Two independent reviewers screened titles and abstracts and retrieved papers against inclusion criteria. Data were extracted from included papers and studies were critically assessed using a risk of bias tool according to design. Results: Thirteen interventional and 10 observational studies were included. Studies were heterogeneous in terms of population, intervention, comparator, outcomes and design rendering combination inappropriate. The evaluation phase studies, with lower risk of bias, using a multi-disciplinary specialist palliative care intervention showed statistically significant benefit for patient-reported outcomes (symptom burden, depression, functional status, quality of life), resource use and costs of care. Benefit was not seen in studies with a single component/discipline intervention or with higher risk of bias. Possible contamination in some studies may have caused under-estimation of effect and missing data may have introduced bias. There was no apparent effect on survival. Conclusion: Overall, the results support the use of multi-disciplinary palliative care in people with advanced heart failure but trials do not identify who would benefit most from specialist palliative referral. There are no sufficiently robust multi-centre evaluation phase trials to provide generalisable findings. Use of common population, intervention and outcomes in future research would allow meta-analysis

Barriers and facilitators for cardiopulmonary resuscitation discussions with people with heart failure

Background Care planning with people with advanced heart failure enables appropriate care, and prevents futile interventions, such as cardio-pulmonary resuscitation (CPR). Aim To explore what motivates clinicians to conduct, and people with heart failure and their carers, to engage in well-conducted CPR discussions. Methods In-depth remote interviews with i) people with heart failure and self-reported daily symptoms (≥ 3 months), ii) informal carers and, iii) clinicians recruited through social media and professional groups, team contacts and snowballing. Interviews were audio-recorded, transcribed, anonymised and subjected to framework analysis. Findings were mapped to the Capabilities, Opportunities, Motivation-Behaviour change model. Results Two themes were generated from 23 interviews: a) the cardio-pulmonary resuscitation discussion: preparation; who should conduct discussions; what should happen during discussions; impact on future discussions; b) Understanding of the: patient’s health status; and purpose and likely outcome of cardio-pulmonary resuscitation. For clinicians, ensuring preparation time, education, and support provided physical and psychological capability. For all, constructive experiences and a realistic understanding of health status and likely cardio-pulmonary resuscitation outcome motivated engagement in cardio-pulmonary resuscitation discussions providing opportunity for patient involvement in decision-making.Conclusions For all, constructive past experiences of important conversations motivates engagement with CPR discussions. A realistic understanding of health status and likely cardio-pulmonary resuscitation outcome (all stakeholders), and training, skills, preparation and multidisciplinary support (clinicians) provide physical and psychological capability. Findings should inform organisational structures and training to ensure opportunity for this important clinical practice to take place

Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis

Background: Previous studies have shown that opioids can reduce chronic breathlessness in advanced disease. However, physicians remain reluctant to prescribe opioids for these patients, commonly due to fear of respiratory adverse effects. Aim: To systematically review reported respiratory adverse effects of opioids in patients with advanced disease and chronic breathlessness. Methods: Pubmed, Embase, Cochrane central register of controlled trials, CINAHL, ClinicalTrials.gov and the reference lists of relevant systematic reviews were searched. Two independent researchers screened against predefined inclusion criteria and extracted data. Meta-analysis was conducted where possible. Results: We included 63 out of 1990 articles, describing 67 studies. Meta-analysis showed an increase in partial pressure of carbon dioxide (0.27 kPa; 95% CI 0.08 to 0.45) and no significant change in partial pressure of oxygen and oxygen saturation (both p>0.05). Non-serious respiratory depression (definition variable/not stated) was described in 4/1064 patients. One cancer patient pre-treated with morphine for pain needed temporary respiratory support following nebulized morphine for breathlessness (single case study). Conclusions: We found no evidence of significant or clinically relevant respiratory adverse effects of opioids for chronic breathlessness. Heterogeneity of design and study population, and low study quality are limitations. Larger studies designed to detect respiratory adverse effects are needed

859148_supp_mat – Supplemental material for Multi-disciplinary palliative care is effective in people with symptomatic heart failure: A systematic review and narrative synthesis

Supplemental material, 859148_supp_mat for Multi-disciplinary palliative care is effective in people with symptomatic heart failure: A systematic review and narrative synthesis by Sushma Datla, Cornelia Antonia Verberkt, Angela Hoye, Daisy J.A. Janssen and Miriam J Johnson in Palliative Medicine</p