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European Journal of Heart Failure 2004 6(5):585-591; doi:10.1016/j.ejheart.2003.11.018
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© 2004 European Society of Cardiology

Living with advanced heart failure: a prospective, community based study of patients and their carers

Kirsty J. Boyda,*, Scott A. Murrayb, Marilyn Kendallb, Allison Worthb,c, T. Frederick Bentond and Hans Clausene,1

a Royal Infirmary of Edinburgh and Honorary Senior Lecturer, Division of Community Health Sciences, General Practice Section, University of Edinburgh Edinburgh, UK
b Division of Community Health Sciences, General Practice Section, University of Edinburgh Edinburgh, UK
c Department of Nursing Studies, University of Edinburgh Edinburgh, UK
d St. Columba's Hospice Boswall Road, Edinburgh, UK
e Palliative Care Team Western General Hospital, Edinburgh, UK

* Corresponding author. Present address: Palliative Care Team, c/o Sanctuary, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK. Tel.: +44-0131-242-1998; Fax: +44-0131-242-1994. E-mail address: kirsty.boyd{at}ed.ac.uk


   Abstract
Top
 Notes
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Background: Services for people with heart failure are under-developed. The perspectives of patients, their informal and professional carers should inform development of service models.

Aim: To describes how patients and carers view health and social care in the last year of life.

Methods: Qualitative, serial interviews at three monthly intervals with 20 patients (New York Heart Association Grade IV heart failure), their main informal carer, general practitioner and other key professionals in an urban, community setting in SE Scotland. These were tape-recorded, and analysed with the aid of the qualitative data analysis package NVivo and techniques of narrative analysis.

Results: 112 interviews comprised; patients (50), informal carers (27), professionals (30), bereavement interviews (5). Patients with heart failure and their carers felt unsupported by services, and had little understanding of their condition, treatment aims or prognosis. Quality of life was severely compromised by physical limitations and psychological morbidity. Psychosocial care, patient and carer education, co-ordination of care between primary and secondary sectors and with social services was generally poor. Many patients had no access to a heart failure nurse specialist. A palliative care approach was rarely apparent.

Conclusions: Patients with advanced heart failure may benefit from specific models of care with strategic planning across primary and secondary care, and involvement of health and social care services and specialist palliative care providers. Models of care, which focus on quality of life, symptom control, and psychosocial support for patients and their families while continuing active treatment, should be developed.

Key Words: Heart failure • Quality of life • Community care • Patient views • Qualitative methods

Received June 2, 2003; Revised October 17, 2003; Accepted November 24, 2003


   1. Introduction
Top
 Notes
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Improved survival of patients with coronary heart disease is contributing to an increasing elderly population with considerable mortality and morbidity from chronic heart failure [1,2]. New York Heart Association Grade IV heart failure has a 50% annual mortality and a high risk of sudden death, a worse prognosis than many cancers [3].

Compared with other chronic conditions, heart failure patients have reported some of the worst physical and social problems [4]. A large, retrospective study of bereaved carers in the UK found that many patients experienced uncontrolled symptoms, low mood, and poor quality of life and had little understanding of their illness and its prognosis [5]. Many patients cope poorly with self-care and complex medication regimens [6]. Breathlessness, fatigue and poor mobility were common in patients attending a hospital heart failure clinic where physical problems were usually being addressed but only half of the patients’ social/functional problems and a third of their psychological issues [7]. Relatives of heart failure patients have said that severe uncontrolled symptoms were often present at the end of life [8].

The complexity of care, and the economic costs of hospitalisation for people with heart failure have led to the development and evaluation of various service models based in secondary care but primarily aimed at maintaining patients in the community. These multidisciplinary services have generally included patient and carer education, supervised medication titration, regular monitoring and some form of specialist nurse intervention [9–13]. Major end-points for all these services were reduced hospital admission rates, cost effectiveness and improved functional status.

The UK National Service Framework for coronary heart disease sets standards for the NHS in England and Wales. It advocates structured care through use of a general practice heart disease register and treatment protocols that are shared across the local care networks. There should be effective hospital discharge planning and referral to social services, and adoption of the WHO palliative care approach in end-stage disease [3]. In Scotland, the national guideline endorses a comprehensive education programme, exercise, closely monitored therapy and rapid access to professional help if symptoms deteriorate [14]. The European Task Force described a similar framework for heart failure care [15]. All have recommended further research to identify the most effective way of delivering the different components of heart failure care and the effectiveness of each of them.

The range of issues facing patients with advanced heart disease and their carers, during the last months of life, has not been evaluated prospectively in the UK. We have already reported the key differences we found between people dying of lung cancer and heart failure [16]. This paper provides a detailed patient/carer centred account of the changing and evolving physical, psychological, social, and spiritual and information needs of people with advanced heart failure, and explores patterns of service provision in relation to meeting those needs. A qualitative approach was used to gain access to people's perspectives about the issues that most concerned them. Qualitative research uses an in-depth approach that yields patient-centred, contextual data and allows an open exploration of potentially sensitive issues [17,18].


   2. Methods
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
A prospective, longitudinal design, using interviews at 3-monthly intervals for up to 1 year with patients, their informal carers, general practitioners and other key professional carers identified by the patient, was important in providing concurrent accounts from patients, carers and professionals. Once the interviews had been completed, a focus group was convened to allow key health and social care professionals, and lay representatives to discuss issues raised by the interviews and options for service improvements. The local research ethics committee and the primary care and hospital trusts approved the study. Written consent was obtained before the first interview and confirmed at subsequent interviews.

2.1. Participants and recruitment
Patients with New York Heart Association Grade IV heart failure were approached by their consultant cardiologist or geriatrician, and selected to reflect the demography of the condition in the local Health Board area using a sampling frame developed in consultation with local specialists. Purposive sampling ensured collection of data from a wide range of informants. Recruitment ceased when no new emergent themes were being generated from the interview data. If a patient agreed to allow their details to be passed to the research team, their general practitioner was asked to confirm suitability for inclusion. Suitable patients were telephoned by the researcher, and an interview arranged in the patient's home. Of the 35 patients identified, 26 wanted to participate. One died soon afterwards, 4 withdrew during recruitment and one was not recruited for sampling reasons.

Consequently, 20 patients were recruited; 11 men and nine women. Their mean age was 74 years (range 57–92). Eight lived alone, ischaemic heart disease was the commonest diagnosis, and 11 had significant co-morbidity. The 112 interviews comprised; 50 with patients, 27 with their informal carers, 30 with professionals, and 5 bereavement interviews; 8–12 weeks after the patient's death. Seven patients completed all four interviews. Six died (three suddenly) during the study. The remaining seven moved out of the area (2) became too ill (2) or wished to withdraw from the study after two interviews (3).

2.2. Interviews and focus group
An experienced social scientist (MK) conducted all the interviews over a 2-year period (1999–2001). Patients and carers were invited, in a non-directive manner, to talk about their main issues and concerns, to describe the care they were receiving from health and social services in primary and secondary care, and to consider whether their needs were being met. The general practitioners and other key professionals were interviewed by telephone or face to face, according to their preference, using a series of open questions.

The 16 participants who attended the focus group included key health professionals (from primary and secondary care), social care professionals, palliative care specialists, and representatives of patient and carer groups and from the non-statutory sector. A trained facilitator (TFB) presented the key findings from the analysis of the interviews, and chaired the discussion.

2.3. Data analysis
Data collection and analysis were concurrent to allow emergent themes to be fed back into the continuing data collection. The focus group and the majority of the interviews were tape-recorded and transcribed in full. Field notes were made after each interview, in more detail where a participant did not wish to be tape-recorded. All the data was entered into the qualitative data analysis package NVivo. Two qualitative researchers (MK and AW) took primary responsibility for analysis, coding the data independently, and using a narrative analysis framework [19]. The multidisciplinary steering group members read key sections of the transcripts and met regularly to review the data and discuss the evolving themes with them.


   3. Results
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
We found that people living with advanced heart failure described a pattern of progressive decline punctuated by episodes of acute deterioration and admission to hospital, growing dependence and an unpredictable terminal phase. We summarise the key themes in Table 1 and in the text below, concluding with a summary of the focus group discussion.


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  		Table 1 Key issues raised by patients with advanced heart failure and their carers

 
3.1. Physical problems
Health professionals tried to address these but many patients had severe breathlessness, persistent oedema, extreme fatigue, poor exercise tolerance, sleep disturbance and anorexia. Breathlessness caused particular anxiety, with patients commonly experiencing feelings of panic, worse when alone.
‘I slipped down the bed and oh the panic attacks I got, and I had to sit up. I could not get my breath. I felt, oh I cannot really, you cannot actually tell people.’—Patient 1.

There was considerable co-morbidity, from lung disease, arthritis, visual impairment and deafness, liver and renal problems and diabetes. Falls were common.

‘The heart problem does not seem to be the thing that bothers us. The other illnesses are so obvious that her heart did not enter the equation.’—Carer 2.

Complex, changing medication regimens and the side effects of treatment, including urinary frequency, gout, leg cramps and itching, presented further problems.

‘The sickness makes me feel lousy. I am taking that many tablets now and I do not know what is what reaction. You sort one thing out and it starts another.’—Patient 3.

The frustration felt by general practitioners that little could be done for these patients, apart from changing the medication, was often conveyed to patients and carers.

‘The main issues in her care... I suppose monitoring her renal function and trying to improve her shortness of breath and her exercise tolerance, although it would appear we're fighting a bit of a losing battle just now.’—General practitioner 4.

3.2. Psychosocial issues
Emotional and practical problems were just as pressing but less well recognised by professionals. Physical limitations led to considerable social restrictions for both patients and carers. Patients lacked confidence making them less likely to go out. They became experts in the logistics of their routine journeys, knowing the barriers such as hills they faced, where toilets were, and shops they could stop and pretend to look at. For some, the smallest household job required major planning. Satisfying roles and relationships were compromised, self-esteem declined and social isolation and dependency grew. Low mood and anxiety were prevalent among both patients and carers as they struggled with the daily grind of living with heart failure. A few were more able to cope, particularly if they had supportive family relationships or were able to hope that things would not get any worse. Humour, a determination not to be beaten, pragmatism and stoicism were all apparent, but often fragile, coping strategies. Feelings of uselessness or hopelessness were common. Some patients said their quality of life was so poor that they would welcome death. These feelings were often not admitted to close family for fear of causing distress.

‘I think he probably needs a gun if you were a horse, they would shoot you’—Carer 6.

Perceived ageism emerged, with many patients and carers feeling they had been written off.

‘I want to be treated like a human being, not a lump of flesh everyone is trying to get rid of’—Patient 3.

Few patients received social services, benefits advice or had contact with voluntary agencies. People described battling with a complex benefits system and being turned down. Some struggled with the loss of dignity they felt at having to accept assistance with bathing, a wheelchair or aids to daily living. Carers often said they did everything themselves and that their expertise was not recognised, particularly in hospital. They felt they had no choice about taking on the caring role and extra responsibilities in the relationship.

‘I felt we should have had more back up... really I was just left with it. I do not know what would have happened if I had been ill too’—Carer 6.

Many carers seemed to see the reality of the situation when patients wanted to maintain the pretence of managing well. Those patients who did not have an informal carer faced much greater difficulties and anxieties.

3.3. Organisation of care and patient involvement
Most patients and carers described a professionally-led model of care not a partnership approach. Some patients feared that professionals would take sanctions against them if they complained or were perceived as difficult.

‘She did not say anything about the tablets, and neither did I, because I would not like them to think that I was doing their job, because that can put them off you.’—Patient 7.

Having a poor understanding of heart failure, its management and prognosis compounded this. Some people did prefer to leave decision-making to the professionals and a few actively avoided information. Others adopted a more active role in seeking information or taking responsibility for decisions. Some would alter their diuretics to enable them to go out or actively question doctors about their treatment. Patients and carers often spoke of feeling responsible for ‘balancing and monitoring’ the situation, suggesting that these words were often used by professionals in explaining treatment. This was particularly in relation to medication, weight and activity level. Many thought that they had no choice about taking all the medication, believing it would prolong life.

‘You have got to look at it that that is what is keeping you alive, so you just swallow them’—Patient 8.

Some patients had built partnerships with key professionals. Those with good communication skills, who were able to convey a real interest in the wellbeing of patients and carers, were appreciated. The general practitioner was usually the main contact, and sometimes offered good practical and emotional support.

‘There is time to discuss the whole situation; she reviews the medication and our feelings.’—Carer 9.

However, if the patient and carer were unsure about raising emotional or spiritual issues and the general practitioner waited for cues, these areas remained neglected.

‘I do see emotional and spiritual needs as part of my job but we do not tend to talk about them’—General practitioner 10.

Others complained that their general practitioner did not act quickly enough to prevent hospital admission, or found them unapproachable, or unable to give helpful advice about managing their condition. Continuity of care was important. Seeing different doctors at each hospital appointment caused particular dissatisfaction.

‘Well the thing is that you wait all that time, and then do not always see Dr X, but one of his assistants, and they do not really know much about your case.’—Patient 11.

Patients often described negative experiences of hospital admission. Poorly co-ordinated care, lack of privacy and dignity, and noisy and hectic wards allowed little time for personalised care.

‘They are so busy on those wards. A nurse would say I shall be your nurse for the today, and then I would never see her again.’—Patient 12.

Few patients had contact with a heart failure nurse specialist. For those who did, home visits allowed more time than a clinic appointment, and the nurse was able to give comprehensive advice about managing medication, day-to-day care and accessing benefits and aids in addition to offering psychosocial support. However, some general practitioners were ambivalent, wanting the specialist nurse to act more as a resource for the primary care team.

3.4. End of life issues
Although many had experienced ‘brushes with death’, few patients had discussed their preferred place of death or wishes for end of life care with professionals. Most patients thought about dying in the context of ageing. Many had made plans with relatives for their funerals and arrangements about money and property. The uncertainty of the prognosis, and lack of an opportunity to discuss it, made it difficult for patients and carers to know how imminent death would be, although there was awareness of being ‘really ill’.

‘Sometimes I am afraid in the morning to go in... he is fading away before my eyes. It could be another year or two or it could be another week or two, it could be tomorrow. I do not know.’—Carer 6.

A final admission to hospital was as likely to be due to a non-cardiac condition or increasing care needs beyond the capacity of informal carers and community services to cope. Once admitted, insensitive communication caused much distress.

‘They just told us they had a plan. They said, we have a plan that if she arrests we will not be resuscitating her. Just as if it was nothing. It was terrible’—Daughter of Patient 7.

Community specialist palliative care services were not involved. One patient saw a hospital palliative care nurse specialist, but only the day before she died.

3.5. Focus group
The focus group discussed the key findings from the interviews. The participants agreed that the lack of good individualised information, written and verbal, was a key but complex issue. Professionals had difficulty finding the right language to explain heart failure and its prognosis.

‘If you use the words ‘heart failure’ people muddle it up with heart attack and there is a danger of immediately frightening them although you do want to explain the seriousness of it. If you say the heart muscle is weakened or damaged they say ‘ I expected to have a slightly weak heart’ and you have actually underplayed it.’—Consultant Geriatrician.

A range of models of care was seen as necessary to meet the different needs of individual patients and carers. Home visiting was considered an essential component, if information, psychosocial and spiritual needs is to be addressed effectively. Better co-ordinated services in hospital and community and improved communication between them would make a significant difference. Where heart failure nurse specialist services should be based was debated, although the needs and concerns they address were undisputed. Extending the role of specialist palliative care services, increasing people's choice about place of death, and adequate respite care were seen as important. Access to benefits could be improved through greater awareness of prognosis and clear eligibility criteria in advanced disease.


   4. Discussion
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
Until recently much of the focus for research and service development has been on medication to reduce mortality, and interventions to prevent frequent hospitalisation. Our study suggests that patients and carers want a more holistic approach to care with service providers taking account of psychosocial, spiritual, information and family needs. We confirmed that quality of life decreases as NYHA functional class worsens, but that it is not always directly related to the patient's physical status [20]. The psychosocial problems that dominated the life of many of these heart failure patients are common to those with other chronic diseases [21].

Our participants, like most people with heart failure were elderly and many had significant co-morbidity. A medical model targeting a single disease is unlikely to address the spectrum of needs they described [2,22]. Primary care can be the best setting for chronically ill people, provided that their management is proactive, co-ordinated and integrates health and social care [22]. Shared care protocols developed with general practitioners, and structured monitoring of medication, combined with rapid access to specialist advice in a heart failure clinic can help to optimise diagnosis and treatment [23]. Specialist heart failure nurses are seen as key professionals in a heart failure care network [24] but a shortage of specialist nurses in the area limited our ability to assess their impact.

Hospital care will continue to be essential and the reasons for admission complex [25]. Early involvement of appropriate specialists and either structured discharge planning or high quality endoflife care, using an integrated care pathway, should be available [26].

Participation in decision making, realistic goal setting and a sense of self worth contribute to maintenance of hope and involvement in life in those with advanced illnesses [27,28]. Improved quality of life, as defined by the patient and carer, is the goal as much as any reduction in mortality [29]. Our patients did not feel involved in decision making or goal-setting, and felt increasingly frustrated and worthless. That effective communication about diagnosis and prognosis is difficult was clear, and has many implications for end of life care planning. Judging prognosis is difficult but use of prognostic indicators in very advanced disease, and discussion about the patient's wishes can allow a shift in the goals of care [30,31]. It is interesting that most patients had planned their funerals, but not discussed their preferred place of care with any of the professionals. Professionals balance information giving with a desire to protect patients from losing hope [32]. Patient barriers to more open communication may include cognitive impairment or adoption of denial/disavowal as coping strategies, but it is clear that many patients and carers do want more information, provided it is given sensitively and in a way that addresses their individual concerns [33–35]. Communication skills training can equip professionals with the skills they need [32].

Palliative care specialists have expertise in communication skills, symptom control and management of the last days of life. Increased access to specialist palliative care advice in hospitals and the community should be available for patients with advanced cardiac disease but has resource implications and requires a cultural shift [36]. If the prognosis can be assessed as short, and a hospice/palliative care unit is acceptable to the patient and carer, inpatient care may also be appropriate. The Scottish Partnership for Palliative Care, a multi-professional organisation representing service providers from community, hospital and hospice sectors, is committed to widening access to specialist palliative care in Scotland [37].

Future research might usefully evaluate whether provision of psychosocial support for people with advanced cardiac failure improves their ability to cope and enhances quality of life. Rigorous assessment of heart failure services needs to include patient and carer centred outcomes and consider what types of specialist nurse interventions are most effective. End of life care in non-cancer patients merits much greater attention from service providers and researchers. The potential role of specialist palliative care services should be evaluated.


   Acknowledgements
 
We should like to thank the patients, their informal carers, and the professional participants for their contributions to the study. We are grateful to staff at the Royal Infirmary of Edinburgh, Liberton Hospital, Edinburgh and St Johns Hospital, Livingston for identifying patients. We thank Dr N Uren, Dr P Cantley, and Ms M Smith for help with developing the recruitment strategy. This study was funded by a grant from the Chief Scientist Office of the Scottish Executive.


   Notes
Top
 Notes
Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
{star} ‘I'm alive but it's no life...’ Back

1 Current addressMidlothian Young People's Advocacy Service, Tolbooth Hall, Dalkeith, Midlothian. Back


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

  1. Kelly D.T. Our future society: a global challenge. Circulation (1997) 95:2459–2464.[Free Full Text]
  2. Cowie M.R., Fox K.F., Wood D.A. Hospitalisation of patients with heart failure: a population based study. Eur Heart J (2002) 23:877–885.[Abstract/Free Full Text]
  3. Department of Health. National service framework for coronary heart disease (2000) London: DOH.
  4. Stewart A.L., Greenfield S., Hays R.D. Functional status and well-being of patients with chronic conditions. Results from the medical outcomes study. J Am Med Assoc (1989) Y262:907–913.[Abstract/Free Full Text]
  5. McCarthy M., Lay M., Addington-Hall J. Dying from heart disease. J Roy Coll Phys Lond (1996) 30:325–328.[Web of Science][Medline]
  6. Rogers A., Addington-Hall J., McCoy A.S.M., et al. A qualitative study of chronic heart failure patient' understanding of their symptoms and drug therapy. Eur J Heart Fail (2002) 4:283–287.[Abstract/Free Full Text]
  7. Anderson H., Ward C., Eardley A., et al. The concerns of patients under palliative care and a heart failure clinic are not being met. Palliative Med (2001) 15:279–286.[Abstract/Free Full Text]
  8. Levenson J.W., McCarthy E.P., Lynn J. The last 6 months of life for patients with congestive heart failure. J Am Geriatric Soc (2000) 48:S101–S109.[Medline]
  9. Rich M.W., Beckham V., Wittenberg C., et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New Engl J Med (2002) 333:1190–1195.[CrossRef]
  10. West J.A., Miller N.H., Parker K., et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilisation. Am J Cardiol (1997) 79:58–63.[CrossRef][Web of Science][Medline]
  11. Cline C.M.J., Israelsson B.Y.A., Willenheimer R.B., et al. Cost effective management programme for heart failure reduces hospitalisation. Heart (1998) 80:442–446.[Abstract/Free Full Text]
  12. Stewart S., Marley J.E., Horowitz J.D. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet (1999) 354:1077–1083.[CrossRef][Web of Science][Medline]
  13. Blue L., Langley-Evans A., McMurray J.J.V. Randomised control trial of a specialist nurse intervention in heart failure. Br Med J (2001) 323:715–718.[Abstract/Free Full Text]
  14. Scottish Intercollegiate Guidelines Network. Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction: a national clinical guideline (1999) Edinburgh: SIGN. 1.
  15. Renne WJ, Swedberg K, (co-chairman), Task force report: guidelines for the diagnosis and treatment of chronic heart failure. Eur J Gen Practice 2001; 22: 1527–1560.
  16. Murray S.A., Boyd K., Kendall M., et al. Dying of lung cancer or cardiac failure; prospective qualitative interview study of patients and their carers in the community. Br Med J (2002) 325:929–932.[Abstract/Free Full Text]
  17. Mays N., Pope C. Observational methods in health care settings. Br Med J (1995) 311:182–184.[Free Full Text]
  18. Mays N., Pope C. Rigour and qualitative research. Br Med J (1995) 311:109–112.[Free Full Text]
  19. Coffey A., Atkinson P. Making sense of qualitative data: complementary research strategies (1996) Thousand Oaks, London: Sage.
  20. Juenger J., Schellberg D., Kraemer S., et al. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart (2002) 87:235–241.[Abstract/Free Full Text]
  21. Skilbeck J., Mott L., Smith D., et al. Nursing care for people dying from chronic obstructive airways disease. Int J Palliative Nurs (1997) 3(2):100–106.
  22. Wagner E.H. Meeting the needs of chronically ill people: socioeconomic factors, disabilities, and comorbid conditions are obstacles. Br Med J (2001) 323:945–946.[Free Full Text]
  23. Hardman S.M.C. Heart failure: across the interface and beyond. Heart (2002) 88(Suppl. II):ii-28–ii-32.
  24. Hanratty B., Hibbert D., Mair F., et al. Doctors’ perceptions of palliative care for heart failure. Br Med J (2002) 325:581–585.[Abstract/Free Full Text]
  25. Deronzier C., Gilletti J. Heart failure and palliative care. Eur J Palliative Care (2001) 8(1):14–16.
  26. Ellershaw J.E., Ward C. Care of the dying patient: the last hours or days of life. Br Med J (2003) 326:30–34.[Free Full Text]
  27. Rideout E., Montemuro M. Hope, morale and adaptation in patients with chronic heart failure. J Adv Nurs (1986) 11:429–438.[Web of Science][Medline]
  28. Herth K. Fostering hope in terminally-ill people. J Adv Nurs (1990) 15:1250–1259.[Web of Science][Medline]
  29. Wolpert H.A., Anderson B.J. Management of diabetes: Are doctors framing the benefits from the wrong perspective? Br Med J (2001) 323:994–996.[Free Full Text]
  30. Ward C. The need for palliative care in the management of heart failure. Heart (2002) 87:294–298.[Free Full Text]
  31. Poole-Wilson P.A., Uretsky B.F., Thygensen K., et al. Mode of death in heart failure. Heart (2003) 89:42–48.[Abstract/Free Full Text]
  32. Maguire P., Pitceathley C. Key communication skills and how to acquire them. Br Med J (2002) 325:697–700.[Free Full Text]
  33. Rogers A.E., Addington-Hall J.M., Abery A.J., et al. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. Br Med J (2000) 321:605–607.[Abstract/Free Full Text]
  34. Buetow S., Goodyear-Smith F., Coster G. Coping strategies in the self-management of chronic heart failure. Fam Pract (2001) 18:117–122.[Abstract/Free Full Text]
  35. Gibbs J.S.R., McCoy A.S.M., Gibbs L.M.E. Living with and dying from heart failure: the role of palliative care. Heart (2002) 88(Suppl. II):ii-36–ii-39.
  36. Field D., Addington-Hall J. Extending specialist palliative care to all. Soc Sci Med (1999) 48:1271–1280.[CrossRef][Web of Science][Medline]
  37. Scottish Partnership for Palliative Care. www.palliativecarescotland.org.uk/news/update44.pdf (accessed 1/10/03).

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