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Rapid Responses: Rapid Responses published:
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Who is the judge?
- Dr R Pal (15 September 2002)
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Successfull PTCA and Stent, but really sick!
- Friedrich Flachsbart (15 September 2002)
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Patients Should Be The Judge
- Frances S Mair (16 September 2002)
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Heart Failure and palliative management
- Renzo Rozzini, Tony Sabatini and Marco Trabucchi (23 September 2002)
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Palliative Care Needs of In-Patients with Advanced Heart Failure
- Josie Clare, Maelie Swanwick, Palliative Care Consultant, Nightingale MacMillan Unit, Derby, DE1 2QS (10 October 2002)
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Dr R Pal
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Pallative care for heart failure may be applicable in those with end stage problems. Advocating pallative care for heart failure by general practitioners will only bring the subjective view of the doctor into play. Doctors are people governed by their background and training. There are times when doctors feel that a person should have pallative care as opposed to active management. Merely to elucidate the problems of subjective judgement, we should consider DNR as an issue in heart failure. As a junior doctor and having attended some cardiac arrests with DNR notices, we have brought the patient back to life and they have gone on to lead relatively well maintained lives. Heart failure is an unpredictable condition. An objective test should be used for pallative care involving patient, patient relatives, consultant and general practitioner. Different doctors percieve patients differently. I for example may feel that a person who watched Dad's army and happily listens to music has a good quality of life. Another doctor may feel that the patient requires pallative care and perceive him to be " dying". Subjective judgements are dangerous. A standardised objective measurement based on a number of criteria involving the patient is required to avoid mistakes in management. Kind Regards Dr Rita Pal |
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Friedrich Flachsbart, Praxis of general medicin 37085 Göttingen
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Dear Sir, June 2002 I sent a patient to the hospital. The suspected deep-vein-thrombosis was diagnosed. Then multiple restenosis in the ACVB-operated heart was diagnosed. But the PTCA and the stent did not change the terminal coronary artery disease. The patient came home September 2002, felt really sick. I tried to organize palliative care. This was rejected by the insurance: "He is successfully treated by stent." So I think, we have to face terminal heart-insufficency on an international basis: Help the sick if cure is not possible any more. Sincerily Yours Friedrich Flachsbart |
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Frances S Mair, Senior Lecturer (Clinical) Dept of Primary Care, University of Liverpool, Whelan Bldg, Quadrangle, Brownlow Hill, L69 3GB
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Editor, I read Dr R Pal's letter with interest. However, I believe Dr Pal may have somewhat misconstrued our views relating to palliative care and heart failure. We know that patients with heart failure have unmet needs for health care at the end of life. Our interest and aims are to improve quality of care for this patient group by highlighting this as a subject worthy of debate and consideration. Box 1 in our paper highlights aspects of palliative care that heart failure patients may be missing out on. These include: improved symptom control and attention to co-morbidities (1); emphasis on quality of life; discussion of prognosis early in the course of disease (2); seeking patients' views (3); and adequate information for patients (4). We believe patients are central to this discussion and we are definitely not advocating that doctors should make unilateral decisions about their future care. We would, on the contrary, advocate empowering patients so that they are in a position to help direct their care and thereby hopefully improve their quality of life. The present paper aimed to get doctors' views on these issues and how best to move forward from the present, rather unsatisfactory situation. 1. Gibbs LME, Addington-Hall J, Gibbs JSR. Dying from heart failure: lessons from palliative care. BMJ 1998; 317:961-962. 2. Rogers AE, Addington-Hall JM, Abery AJ et al. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. BMJ 2000; 321: 605-607. 3. Ward C. The need for palliative care in the management of heart failure. Heart 2002; 87: 294-298. 4. Anon. Palliative care of heart failure. Factfile 5/2001. London: British Heart Foundation, 2001. |
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Renzo Rozzini, Poliambulanza Hospital&GRG Via Bissolati 57, 25124 Brescia (Italy), Tony Sabatini and Marco Trabucchi
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To the editor: We read with interest the paper by Hanratty et al., on doctor’s perception of palliative care for heart failure HF) and we would like to make some comments. The first concerns the definition of terminal care itself: when patients have to switch from ordinary clinical to palliative care? Isn’t there a risk of precocious withdrawal of useful treatments due to the unpredictable course of heart failure? What about patients’ wishes and preferences? Secondarily, while in palliative care for cancer patients we follow precise guidelines, what about pharmacological and non pharmacological interventions when a HF patient enters a palliative care program? Even the enhanced role for nurses could be ambiguous, if it is not clear the role of physicians (hospital doctors and family practitioners), since they could be induced to delegate the decisions for important treatment choices. In contrast with the model proposed by the focus group study we think that continuity of care is the best answer to the need of patients. In this light we would like to discuss our model of guiding the long term care of patients through a careful information of family practitioners and a continuos contact with patients and their caregivers, without a palliative care program. In a group of 149 HF patients (NYHA classes III-IV) we observed a 33.6% mortality at 6-months; of these 10 patients died in-hospital (6.7%). Blindly reviewing the discharge charts of the 139 discharged patients we were unable to predict a short term risk of death and the consequent need for palliation. In conclusion we think that in the Italian NHS a compromise could be the best answer to HF patients needs, i.e. an informal follow-up by hospital doctors in strict relationship with general practitioners and the family for the entire natural history. |
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Josie Clare, Specialist Registrar in General and Elderly Medicine Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, Maelie Swanwick, Palliative Care Consultant, Nightingale MacMillan Unit, Derby, DE1 2QS
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Hanratty et al(1) highlight the concerns of health professionals and the organisational problems involved in providing palliative care services for patients with heart failure. The need for palliative care services for heart failure patients is now well documented with McCarthy et al’s (2) retrospective study of carers describing a wide range of symptoms experienced by patients in the last year of life and Anderson et al demonstrating the similarity in many of the symptoms experienced by patients with cancer and heart failure in an out-patient setting. Many of the symptoms experienced by patients with heart failure were inadequately addressed. We interviewed 24 hospital in-patients with NYHA Class III-IV heart failure, median age 69 (30-89), and enquired about their symptoms, perceived limitation of activity, concerns about their health, support and quality of life. Dyspnoea was reported by all participants, with a median numerical rating scale (NRS) of 8 (0 = not breathless, 10=extremely breathless) and the median score for limitation due to breathlessness was 9 (0 = no limitation 10 = totally prevents me from doing what I would like to do). Comments included “I can’t get my breath… can’t catch up on myself, just walking to the toilet it’s as if I’m being squashed by a weight”. 23 out of 24 patients complained of fatigue with a median score of 9 (0 = not tired at all 10 = totally exhausted). Comments included “I’m falling asleep all the time, I’ve got no control…I’m listless, even chewing food is very tiring, I have to choose easy food”. “I’ve got no energy, I couldn’t get out of the bath the other day my legs felt too weak”. 15 participants complained of at least one pain. 6 patients attributed their pain to angina and were taking anti-anginal medication. Others had pain in their legs or abdomen related to their oedema, none of these were on regular analgesics. Other symptoms reported were anorexia (67%), nausea/vomiting (33%), thirst (33%), faecal incontinence (12%), sleep disturbance (79%), disturbed body image (37%) and dyspepsia (33%). Ten patients (42%) scored 10 or greater on either (or both) of the anxiety or depression sub-scales of the Hospital Anxiety and Depression Score. Quality of life (QOL) was generally rated poorly and there was a significant correlation between QOL and the perceived limitation caused by the symptoms. When asked of their understanding of their illness, only a minority appeared to be aware of the severity of the illness. “It’s going to take time to get better, not this week, possibly next.” 15 patients mentioned concerns about their deteriorating health and increasing debility “In two years I’ve got from being a fit person to someone who can do nothing”. “All I’m able to do now is sit in my flat, I’m confined to four walls”. Only 3 patients were receiving either attendance or disability living allowance, although undoubtedly more would have been eligible. This study emphasises that patients with heart failure experience a wide variety of symptoms and psychosocial needs in addition to the problems conventionally associated with heart failure. Unfortunately these wider issues had not been dealt with during their hospital stay. We would endorse the view that heart failure can take an unpredictable course and therefore it is often appropriate to continue active management, even in patients who would appear to have a very limited prognosis. Certain aspects of patient care are still being overlooked; advice from the specialist palliative care team, either as a one off or continued support, should be sought for patients with difficult symptoms, recurrent hospital admissions or psychosocial problems within the hospital or community setting. Pooling of resources and experience can only improve patient care and should not be seen as a barrier to palliative care. (1) Hanratty B, Hibbert D, Mair F, May C, Ward C, Capewell S, Litva A, Corcoran G. Doctors’ perceptions of palliative care for heart failure; focus group study. BMJ 2002; 325:581-585 (2)McCarthy M, Lay M, Addington-Hall JM. Dying from heart disease: syptoms and hospital care in the last year of life reported by informal carers.J R Coll Physicians 1996;30;325-328 (3)Anderson H, Ward C, Eardley A, Gomm SA, Connolly M, Coppinger T, et al. The concerns of patients under palliative care and a heart failure clinic are not being met. Palliative Med 2001; 15;279-286 |
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