Skip Navigation

European Journal of Heart Failure 2008 10(6):608-613; doi:10.1016/j.ejheart.2008.04.011
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Strömberg, A.
Right arrow Articles by Jaarsma, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Strömberg, A.
Right arrow Articles by Jaarsma, T.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© 2008 European Society of Cardiology

Thoughts about death and perceived health status in elderly patients with heart failure

Anna Strömberga,b,* and Tiny Jaarsmac

a Department of Medicine and Health Sciences, Division of Nursing, Linköping University Sweden
b Department of Cardiology, Linköping University Hospital Sweden
c Department of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen The Netherlands

* Corresponding author. Department of Cardiology, University Hospital, S-581 85 Linköping, Sweden. Tel.: +46 13 227762; fax: +46 13 222224. E-mail address: annst{at}imv.liu.se


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Aim: To explore thoughts about death and perceived health status in elderly patients with heart failure during a 6month period after a deterioration needing hospitalisation.

Methods: A descriptive, mixed methods design was used. Health was measured with EuroQol-5D, thoughts about death with multiple choice and open questions. A total of 145 patients with New York Heart Association class II–IV heart failure, mean age 70 years, 70% males, were included.

Results: During deterioration, 16% of the patients were afraid of dying and 4% had this fear very often. Fear of death did not change significantly during the 6 months after deterioration. Both during deterioration (r=0.26, P<0.01) and 6months later (r=0.40, P<0.001), fear of death and anxiety/depression were correlated. Content analysis of the open question produced 5 categories: (1) Death as a natural part of life; (2) Death as a relief from symptoms and disability (3) Death as fearful (4) Arrangements for time after death (5) A wish for an extended life.

Conclusion: Elderly patients with heart failure had a lot of thoughts about death. Higher levels of anxiety/depression were correlated to fear of death. Many expressed death as a natural relief from suffering, others were afraid of pain, loss of independence and dignity.

Key Words: Heart failure • Mixed method • Quality of life • Prognosis • Anxiety • Palliative care

Received July 31, 2007; Revised April 2, 2008; Accepted April 24, 2008


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Heart failure is a public health problem affecting approximately 10-14 million individuals in Europe and 5-6 million in North America [1-3]. It has a poor prognosis, 30-40% of patients with moderate to severe heart failure die within one year after the diagnosis and 60-70% die within 5 years. The cause of death is equal between worsening pump failure and sudden death caused by ventricular arrhythmias [4,5] leaving the patients in uncertainty not only about when, but also about how they will die. Heart failure is more malignant than most common forms of cancer [6], but surveys have shown that it is not clear to the public nor to all health care professionals how serious the condition is [7,8]. Further, little is known about how patients with heart failure perceive and reason about their prognosis and health status. A recent position paper on advanced heart failure highlights "thoughts about death and dying when having advanced heart failure" as a priority for clinical research [9]. There are a few qualitative studies [10-12] exploring thoughts about death, but to our knowledge there are no quantitative studies estimating how common thoughts and fear of death are in the heart failure population and how perceived health and other demographic and clinical factors are related to thoughts about death. The aim of the present study was therefore to explore thoughts about death and perceived health status in elderly patients with heart failure over a 6 month period after deterioration needing hospitalisation.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
2.1. Design and setting
A descriptive, mixed method design was used, integrating both quantitative and qualitative approaches. The study was performed at four outpatient heart failure clinics in southern and central Sweden, situated at 2 university hospitals and 2 county hospitals. Heart failure clinics in Sweden are mostly nurse-led and include similar components (patient education, psychosocial support, assessment of symptoms/signs, uptitration of heart failure treatment, increased access to care through telephone consultations) as described previously [13,14]. The four clinics in the study were representative in this respect. The study had a 6 month follow up. Inclusion criteria were: previous diagnosis of heart failure according to the European Society of Cardiology guidelines [2], in New York Heart Association Classification (NYHA class) II-IV, hospitalised due to deterioration of heart failure symptoms with a follow up at an outpatient heart failure clinic after discharge. Exclusion criteria were: dementia or severe psychiatric illness, inability to speak, read or write Swedish or refusal to participate.

The study was performed in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Regional Ethics Committees for Human Research at the University of Linköping, Sweden. The patients received both written and verbal information about the study before they agreed to participate.

2.2. Data collection
EuroQol-5D, a generic single index defining health in 5 dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression), was used to measure perceived health [15,16]. For each dimension the patients rated their health on one of three levels, no problem (coded as 1), some or moderate problems (coded as 2) and unable or extreme problems (coded as 3). Theoretically, 243 different health states can be generated by this classification. The ratings can be converted to health-state utility scores. These scores range from –0.594 to 1, with scores ≤0 being regarded as worse than death and 1 representing full health [15,16].

In addition, one global health question, asking whether the patient's general health status was improved, unchanged or worse over the past 12 months, was also asked.

There were two questions on thoughts about death. The first question was a closed question from the Cardiac Health Profile [17] addressing if the patient had a fear of dying. The answers could be rated as: [1] very seldom having a fear of dying, [2] having a fear of dying from time to time or [3] very often having a fear of dying. The second question was an open question, where the patients were invited to freely write down their thoughts about death.

All patients completed the EuroQol-5D, the global health question, the question about their fear of dying and the open-ended question regarding thoughts about death, at baseline. The baseline visit took place during a follow up visit to an outpatient heart failure clinic, 2-3 weeks after discharge from hospital following an admission due to heart failure deterioration. The same questionnaires, except for the open question, were sent to each patient by post 6 months after the baseline visit. Non-responders were sent two reminders over a period of 5 weeks. The rationale for repeating the questions after 6 months was to evaluate whether fear of dying changed when the majority of the patients were in a more stable phase.

2.3. Analysis
The comparison between and within groups was performed using the chi-square test for discrete variables, student's t-test was used for normally distributed continuous variables, and if the distributions were not approximately normal or ordinal the Mann-Whitney U test and Wilcoxon signed rank test were used. Correlations were analysed with Spearman rank correlation coefficient. A multiple binary logistic regression (Enter method) was used to determine the relationship between socio-demographic factors, dimensions of perceived health and fear of death. The model was constructed by using the logistic regression procedure available in SPSS 15.0. Factors included in the regression analysis were those which had significantly correlated to fear of death in univariate analysis (sex and anxiety), age was forced into the model despite a non-significant correlation. The first category: [1] very seldom having a fear of dying, we dichotomised as no/little fear of dying. The other two categories: [2] having a fear of dying from time to time and [3] very often having a fear of dying, were merged and dichotomised as having a fear of dying. A P-value of less than 0.05 was considered significant.

The open question was analysed by manifest content analysis [18]. All patients gave an answer to the open-ended question. The statements varied in length from 99 to 1653 characters. All statements were included in the analysis since they were focused in relation to the aim. Meaning units were extracted from the written answers, condensed, abstracted and labelled with a code. The codes were compared based on differences and similarities and sorted into categories that were internally homogenous and externally heterogeneous. The whole context was reread several times in order to preserve the original meaning of the codes during the categorisation. When the categorisation was finalised the distribution of meaning units in each category were was calculated and presented as percentages.

Credibility in the data collection was achieved by including patients with different experiences of heart failure in terms of disease severity, time since diagnosis, age, sex, civil status and education. This also influenced transferability of the findings. Credibility in the analysis was achieved by discussions between the two researchers during the process of sorting codes and naming categories.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
A total of 145 consecutive patients with systolic heart failure, verified by echocardiography, gave informed consent and were enrolled in the study. Eight patients died during follow up, the remaining 137 patients completed the 6 month follow up after two reminders. Patient characteristics are shown in Table 1. Demographic data and baseline anxiety scores for the eight patients who died did not significantly differ from the baseline scores of the patients who completed the 6 month follow up. Thirty percent of the patients included in the study were women, the only gender difference in socio-demographic variables was that significantly fewer women were living with someone (P<0.001).


View this table:
[in this window]
[in a new window]

  		Table 1 Demographic and clinical characteristics of the study patients (N=145)

 
3.1. Perceived health
The health-state utility score (median, inter quartile range) calculated from the five dimensions in the EuroQol-5D at baseline was 0.73 (0.62-0.85). Utility scores were significantly improved after 6 months 0.80 (0.66-0.94) (P=0.01). The ability to perform daily activities (e.g. work, household chores and social activities) increased after 6 months (P=0.01). Pain decreased after 6 months (P=0.001). Very few patients had problems with performing self-care, such as washing and dressing themselves, both at baseline and 6 months follow up. The psychological dimension measuring anxiety and depression did not change significantly over time. Table 2 summarises the results on perceived health. General health status improved significantly during the 6 month follow up (P=0.004), with fewer patients rating their health as worse or unchanged and more patients perceiving their health to be improved compared to the previous year.


View this table:
[in this window]
[in a new window]

  		Table 2 Perceived health status measured by EuroQol-5D in the elderly heart failure patients (n=137) at baseline and 6 months after deterioration

 
3.2. Thoughts about death
At baseline 16% of the elderly heart failure patients were afraid of dying compared with 13% of patients at the 6 month follow up. Few patients were severely afraid of dying and fear of death did not change significantly over time, see Table 3. There was a strong correlation between fear of death at baseline and after 6 months (r=0.50, P=0.001). Further, fear of death and anxiety/depression were significantly correlated at baseline (r=0.26, P=0.003) and 6 months (r=0.40, P=0.001). Women were more afraid of death at 6 months follow up (P=0.04). No other correlation to fear of death, except sex and anxiety/depression, was found among the dimensions of the EuroQol-5D, utility scores and demographic variables. In the logistic regression, only anxiety and depression were significantly correlated to fear of death at both baseline (odds ratio 2.49, P<0.03) and 6 months (odds ratio 6.46, P<0.001).


View this table:
[in this window]
[in a new window]

  		Table 3 Responses to the question about fear of dying at baseline and 6 months after deterioration in patients with heart failure (n=137)

 
The analysis of the answers from the open-ended question on thoughts about death showed that almost two thirds of the patients (64%) expressed in various ways that they often thought about death. The content analysis produced 5 categories: [1] Death as a natural part of life (38% of the meaning units); [2] Death as a relief from symptoms and disability (13% of the meaning units); [3] Death as fearful (22% of the meaning units) [4]; Arrangements for time after death (7% of the meaning units); [5] A wish for an extended life (20% of the meaning units).

3.2.1. Death as a natural part of life
This category described death as a natural part of life. Death was described as a certainty, the only sure thing that would happen; the uncertainty was not knowing how and when death would occur. Death was something that everyone had to accept and learn how to deal with. The patients realised that with increasing age death became more of a reality. Many of their friends and family members had already died and they had dealt with life and death issues during periods of grief several times. Some spoke openly about death and their prognosis. Nowadays, when I have become so old I often think about death. I am not afraid of death, but I think about it and I joke about it. You are always aware of death, it is natural.

3.2.2. Death as a relief from symptoms
This category described death as relief from pain, shortness of breath and lost functions. Some expressed a wish to die quickly and painlessly. I hope death will be peaceful and quick, that I will die during my sleep. Just go to bed at night in your own home and never wake up again. That is much better than ending your days in a nursing home....

Individuals that believed in God or had had a near death experience perceived death as something positive. I have seen the light in the tunnel and that made me realise that death is something good.

3.2.3. Death as fearful
This category described the fear of death. Some patients had always been afraid of dying. From a very young age they had feared the death of their own and other loved ones and had had to deal a lot with this fear. To some, death was so emotionally difficult to deal with that they always tried to repress these thoughts. I just cannot handle to think about death. To others the fear of death had come in connection to the heart failure diagnosis and in periods of deterioration. After I got this heart disease I am often afraid at night, I am afraid to go to sleep, I fear that I will not wake up again.

Many patients were afraid of deterioration and a painful and difficult time before death. That they would lose their independence and that they would not receive good care. I am afraid of becoming helpless, and lose my dignity. Limited health care resources for the elderly and in palliative care were described as a threatening cloud by some patients. I do not think that I am afraid of dying, but I am afraid of what might happen before death like severe pain and shortness of breath or that I will not get good care at the end of my life.

3.2.4. Arrangements for time after death
This category described that for many patients there were practical aspects connected to the thoughts about death. Many patients had made a testimony (Will) and planned their funeral. Some were occupied with trying to throw away old things and organise their possessions and financial issues. They did not want to leave all these practical things for their partners and children to deal with after their death. One woman described how she always made the house ready in case she died during the night. Death can come quickly when you are in my age; I do not leave anything to the next day.

3.2.5. A wish for an extended life
Some patients had no expectations for the future, since they were so old and sick and they just waited to die. Others were very motivated to try to do everything to live longer. They expressed how, despite physical limitations and symptoms, they enjoyed life and hoped that they would have an extended life. The patients described how they tried to improve their health through lifestyle changes, adherence to treatment and other self-care activities. The reasons given for the wish for a longer life was that they wanted to support their family, wanted to see their grandchildren grow up or finalise tasks they were dedicated to. I want to live longer. I like life and I have just started to write my memoirs, so right now is not a good time to die.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
This study underlines that it is important to start addressing existential and end of life care issues before heart failure becomes too advanced. At advanced stages of disease, the patient may be unable to participate in decision making or to receive counselling and support, to help them accept deterioration and death. The patients in our study, who had a poor prognosis due to moderate to severe heart failure with deterioration needing hospitalisation, described that they had a lot of thoughts about death and dying making this an area that clinicians should not neglect. The 5 categories from the content analysis, gave a more in-depth view of the different aspects of what heart failure patients think about their prognosis and how this relates to their thoughts about death. Only a few patients in our study stated that they were severely afraid of dying. A study by Willems et al. [11] also reported, that despite a poor prognosis, very few patients with heart failure feared death. This might be explained by a lack of knowledge and awareness about the poor prognosis of heart failure among both health care professionals and patients and their families [7,8]. Another explanation found in our qualitative analysis was that the patients with heart failure had accepted that they were in the process of dying and had adapted to this condition. Adaptation to illness provides a probable explanation for the occurrence of response shift, meaning that death is not fearful anymore. It is also known that patients adapt their rating of quality of life over time as the illness progresses [19,20]. Levenson et al. [20] found that when death came closer, disability and symptoms increased. However, there was no significant decrease in quality of life as death approached. During the last month of life, many patients described a good to excellent quality of life.

Only anxiety and depression correlated to fear of death in the present study, no correlation to general health or specific dimensions of health were found. Willems et al. [11] stated that very few patients thought about death, except during deterioration. Our data revealed that the patients often thought about death, but they were no more afraid of dying during the time of deterioration at baseline. This suggests that fear of death might be more influenced by personality and mental health than severity of symptoms and perceived health.

Our patients described that they were more afraid of the process of dying, with suffering and pain, than the fact that their life would end. Some wished for a pain free and quick death during sleep, while others were reluctant to go to sleep since they might not wake up again. Limited health care resources were mentioned as a threat to receiving palliation and dignity at the end of life. Fitzsimons et al. [21] also found that patients dying from chronic disease had many concerns and unmet needs. Aiken et al. [22] showed that provision of intensive home-based palliative care to patients with severe chronic heart failure can effectively decrease symptom distress and improve self management of illness, vitality, physical functioning and perceived health in the last years of life [22]. Brännström et al. [12] also highlighted the important role of advanced home care facilities. Rabow et al. [23] showed that consultations by a palliative team improved patient outcomes for dyspnoea, anxiety, and spiritual well-being, but failed to improve pain or depression, highlighting an area in need of improvement.

Most of the patients in the present study suffered from moderate to severe heart failure and the majority had problems in at least one of the five dimensions of health measured by EuroQol. Almost half of the patients had problems with mobility. Previous studies have shown that many patients with heart failure have limitations within the physical dimension [24,25]. In the present study, the patients described that they were very limited in their daily life and that death could be a relief from always being tired, having pain and being short of breath.

The mixed method used in this study integrated quantitative and qualitative approaches to collect and analyse data. By combining the methods their complementary strengths can be utilized and the analytic power improved. The mixed method made it possible for us to use both numbers and narratives in order to provide a more complete view of the phenomenon under study [26,27].

Although clinically relevant, this study was restricted by its small sample size and the descriptive design. Since all patients were enrolled in a disease management programme at a heart failure clinic the results may reflect a rather stable and well controlled sample with access to specialised care; therefore it may not be appropriate to generalise these findings to heart failure patients with mild to moderate heart failure in primary care or those in need of palliative or advanced heart failure care. The study population had a lower mean age and consisted of more men than in the general heart failure population. This was not unexpected, since the patient population receiving follow up at heart failure clinics tend to be younger and more often male. Some of the most elderly patients are not referred to heart failure clinics due to problems with communication, cognition or mobility. The aetiology was representative for a hospitalised heart failure population.

Further, when measuring fear of death we found the combination of one open and one closed question relevant. However, only these two questions were used and for future research a more extensive instrument, covering the different aspects of death and dying, would be relevant.

We are aware that asking questions about thoughts on death could be upsetting for severely ill heart failure patients. However, the study received ethical approval, and patients had the opportunity to withdraw from the study and to call a heart failure nurse if they wanted counselling or support.

Care and support for heart failure patients at the end of life is an area that needs to be addressed in research and clinical practice. Future research should further explore how patients with heart failure and their partners reason about death and dying, through interviews and larger quantitative studies comparing heart failure patients with age and sex matched controls.

Elderly patients with heart failure have a lot of thoughts about death and this needs to be recognised in clinical practice. Higher levels of depression and anxiety were correlated to a fear of death, but no other relation was found among the dimensions of the EuroQol-5D, utility scores and demographic variables. Many patients regarded death as natural and as a relief from suffering, others were afraid of pain and loss of independence and dignity.


   Acknowledgements
 
Anna Strömberg has a research position grant from the Swedish Research Council and additional funding from the Vardal Foundation. She is a member of the Vardal Institute. Tiny Jaarsma has been a guest researcher funded by Östergötland County council and has also a research position funded by the Netherlands Heart Foundation and the department of Cardiology of the University Medical Centre, Groningen.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. McMurray J., Pfeffer M. Heart failure. Lancet (2005) 365:1877–1889.[CrossRef][Web of Science][Medline]
  2. Swedberg K., Cleland J., Dargie H., et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): the Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J (2005) 26:1115–1140.[Free Full Text]
  3. Hunt S., Abraham W., Chin M., et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation (2005) 112:e154–e235.[Free Full Text]
  4. Ho K.K., Pinsky J.L., Kannel W.B., Levy D. The epidemiology of heart failure: the Framingham study. J Am Coll Cardiol (1993) 22:6A–13A.[Medline]
  5. Bleumink G., Knetsch A., Sturkenboom M., et al. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure The Rotterdam study. Eur Heart J (2004) 25:1614–1619.[Abstract/Free Full Text]
  6. Stewart S., MacIntyre K., Hole D.J., Capewell S., McMurray J.J.V. More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail (2001) 3:315–322.[Abstract/Free Full Text]
  7. Remme W., McMurray J., Rauch B., et al. Public awareness of heart failure in Europe: first results from SHAPE. Eur Heart J (2005) 22:2413–2421.
  8. Cleland J., Cohen-Solal A., Cosin Aguilar J., et al. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet (2002) 360:1631–1639.[CrossRef][Web of Science][Medline]
  9. Metra M., Ponikowski P., Dickstein K., et al. Advanced chronic heart failure: a position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail (2007) 9:684–694.[Abstract/Free Full Text]
  10. Vig E., Pearlman R. Quality of life while dying: a qualitative study of terminally ill older men. J Am Geriatr Soc (2003) 51:1595–1601.[CrossRef][Web of Science][Medline]
  11. Willems D., Hak A., Visser F., van der Wal G. Thoughts of patients with advanced heart failure on dying. Palliat Med (2004) 18:564–572.[Abstract/Free Full Text]
  12. Brännström M., Ekman I., Norberg A., Boman K., Strandberg G. Living with severe heart failure in palliative advanced home care. Eur J Cardiovasc Nurs (2006) 5:295–302.[CrossRef][Medline]
  13. Strömberg A., Mårtensson J., Fridlund B., Dahlström U. Nurse-led heart failure clinics in Sweden. Eur J Heart Fail (2001) 3(1):139–144.[Abstract/Free Full Text]
  14. Jaarsma T., Strömberg A., De Geest S., et al. Heart failure management programmes in Europe. Eur J Cardiovasc Nurs (2006) 5:197–205.[CrossRef][Medline]
  15. Brooks R. with the EuroQol Group. EuroQol: the current state of play. Health Policy (1996) 37:53–72.[CrossRef][Web of Science][Medline]
  16. EuroQolGroup. EuroQolGroup. Measure of health-related quality of life developed by the EuroQol Group. (2006) User Guide.
  17. Mannheimer B., Andersson B., Carlsson L., Währborg P. The validation of a new quality of life questionnaire for patients with congestive heart failure—an extension of the Cardiac health Profile. Scand Cardiovasc J (2007) 41:235–241.[CrossRef][Web of Science][Medline]
  18. Graneheim U., Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today (2004) 24:105–112.[CrossRef][Web of Science][Medline]
  19. Adang E., Kootstra G., Baeten C., Engel G. Quality of life ratings in patients with chronic illnesses. JAMA (1997) 277:1038.[Abstract/Free Full Text]
  20. Levenson J., McCarthy E., Lynn J., Davis R., Phillips R. The last six months of life for patients with congestive heart failure. J Am Geriatr Soc (2000) (48):S101–S109.
  21. Fitzsimons D., Mullan D., Wilson J., et al. The challenge of patients' unmet palliative care needs in the final stages of chronic illness. Palliat Med (2007) 4:313–322.
  22. Aiken L., Butner J., Lockhart C., Volk-Craft B., Hamilton G., William F. Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill. J Palliat Med (2006) 9:111–126.[CrossRef][Web of Science][Medline]
  23. Rabow M., Dibble S., Pantilat S., McPhee S. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med (2004) 164:83–91.[Abstract/Free Full Text]
  24. Alonso J., Ferrer M., Gandek B., et al. Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project. Qual Life Res (2004) 13:283–298.[CrossRef][Web of Science][Medline]
  25. Pihl E., Jacobsson A., Fridlund B., Strömberg A., Mårtensson J. Depression and quality of life in older patients suffering from heart failure and their spouses; a comparative study. Eur J Heart Fail (2005) 7:583–589.[Abstract/Free Full Text]
  26. Stange K., Crabtree B., Miller W. Publishing multimethod research. Ann Fam Med (2006) 4:292–294.[Free Full Text]
  27. Sandelowski M. Combining qualitative and quantitative sampling, data collection and analysis techniques in mixed-method studies. Res Nurs Health (2000) 23:246–255.[CrossRef][Web of Science][Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Eur J Heart FailHome page
T. Jaarsma, J. M. Beattie, M. Ryder, F. H. Rutten, T. McDonagh, P. Mohacsi, S. A. Murray, T. Grodzicki, I. Bergh, M. Metra, et al.
Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology
Eur J Heart Fail, May 1, 2009; 11(5): 433 - 443.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Strömberg, A.
Right arrow Articles by Jaarsma, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Strömberg, A.
Right arrow Articles by Jaarsma, T.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?