The complexity of prognosis communication in heart failure: Patient and cardiologists’ preferences in the outpatient clinical setting

Patricia H. Strachan, Heather M. Arthur, Catherine Demers, Robert J. Robson

Department Medicine, Division of Cardiology, McMaster University, Hamilton, Canada.
Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, Canada.
Faculty of Health Sciences, McMaster University, Hamilton, Canada..
Heart and Stroke Foundation of Ontario, Ottawa, Canada.

DOI: 10.4236/wjcd.2013.31A017                

Abstract

Background: The determination of prognosis in heart failure (HF) has focused primarily on the identification of potential biological and physiological markers and not on communication. High morbidity and mortality rates suggest that patients require prognostic information to assist in life planning. This study examined the preferences of both patients with HF and cardiologists for prognosis communication in the outpatient clinical setting, with the aim of guiding practitioners in undertaking prognosis conversations. Methods: Using qualitative descriptive techniques informed by a grounded theory approach, 32 patients with HF and 9 cardiologists from outpatient settings in Ontario, Canada were interviewed to identify convergent preferences for prognosis communication. Strategies to enhance methodological rigor were employed. Results: Individualized, context-specific prognosis communication between patients and cardiologists was preferred. Two main themes and ten related attributes were identified to describe convergent preferences; 1) Set the Stage for Prognosis Communication, and 2) Map the HF route. Attributes reflected the complex, dynamic, interactive and iterative nature of prognosis communication preferences. Conclusions: Prognosis communication occurs within a complex, adaptive healthcare system. While specific preferences exist, changing contextual elements within and outside of the system create conditions that require cardiologists to adjust their approach to individual patients. Patients with HF and cardiologists each have preferences that affect their willingness and ability to engage in dyadic HF-specific prognosis communication. Findings have relevance for the implementation of any efforts, including HF guidelines, aimed at improving prognosis communication. Our findings, informed by a complexity science approach, offer an innovative and robust alternative to traditional linear approaches to prognosis communication.

Keywords

Heart Failure; Prognosis; Communication; Complex Adaptive Systems

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Goldberg, R.J., Ciampa, J., Lessard, D., et al. (2007) Long-term survival after heart failure: A contemporary population-based perspective. Archives Internal Medicine, 167, 490-496. doi:10.1001/archinte.167.5.490
[2]	Lee, D.S., Austin, P.C., Rouleau, J.L., et al. (2003) Predicting mortality among patients hospitalized for heart failure. JAMA, 290, 2581-2587. doi:10.1001/jama.290.19.2581
[3]	Arnold, J.M.O., Liu, P., Demers, C., et al. (2006) Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: Diagnosis and management. Canadian Journal of Cardiology, 22, 23-45. doi:10.1016/S0828-282X(06)70237-9
[4]	Huynh, B.C., Rovner, D. and Rich, M.W. (2006) Long-term survival in elderly patients hospitalized for heart failure. Archives of Internal Medicine, 166, 1892-1898. doi:10.1001/archinte.166.17.1892
[5]	Murray, S.A., Kendall, M., Benton, T.F. and Clausen, H. (2002) Dying of lung cancer or cardiac failure: Prospective qualitative interview study of patients and their carers in the community. BMJ, 325, 929-932. doi:10.1136/bmj.325.7370.929
[6]	Goodlin, S.J., Haupton, P.J., Arnold, R., et al. (2004) Consensus statement: palliative and supportive care in advanced heart failure. Journal of Cardiac Failure, 10, 200-209. doi:10.1016/j.cardfail.2003.09.006
[7]	Zapka, J.G., Hennesey, W., Lin, Y., et al. (2006) An interdisciplinary workshop to improve palliative care: Advanced heart failure—Clinical guidelines and healing words. Palliative and Supportive Care, 4, 37-46. doi:10.1017/S1478951506060056
[8]	The SUPPORT Principal Investigators (1995) A controlled study to improve care for seriously ill hospitalized patients. JAMA, 274, 1591-1598.
[9]	Strachan, P.H., Ross, H., Rocker, G.M., et al. (2009) Mind the gap: Opportunities for improving end-of-life care for patients with advanced heart failure. The Canadian Journal of Cardiology, 25, 635-640. doi:10.1016/S0828-282X(09)70160-6
[10]	Horne, G. and Payne, S. (2004) Removing the boundaries: Palliative care for patients with heart failure. Palliative Medicine, 18, 291-296. doi:10.1191/0269216304pm893oa
[11]	Califf, R.M., Vidaillet, H. and Goldman, L. (1998) Advanced congestive heart failure: What do patients want? American Heart Journal, 135, S320-S326.
[12]	Mulley, A.G. and Trimble, C. (2012) Stop the silent misdiagnosis: patients preferences matter. BMJ, 345, e6572,
[13]	Jaarsma, T., Beattie, J.M., Ryder, M., et al. (2009) Palliative care in heart failure. European Journal of Heart Failure, 11, 433-443. doi:10.1093/eurjhf/hfp041
[14]	Krumholz, H.M., Phillips, R.S., Hamel, M.B., et al. (1998) Resuscitation preferences among patients with severe congestive heart failure. Circulation, 98, 648-655. doi:10.1161/01.CIR.98.7.648
[15]	Cowie, M.R. (2002) The fine art of procrastination. European Heart Journal, 23, 1804-1806. doi:10.1053/euhj.2002.3380
[16]	Caldwell, P.H., Arthur, H.M. and Demers, C. (2007) Preferences of patients with heart failure for prognosis communication. Canadian Journal of Cardiology, 23, 791-796. doi:10.1016/S0828-282X(07)70829-2
[17]	Cilliers, P. (1998) Complexity and postmodernism. Routledge, London and New York.
[18]	Lanham, H.J., McDaniel, R.R., Crabtree, B.F., et al. (2009) How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. The Joint Commission Journal on Quality and Patient Safety, 35, 457-466.
[19]	Zimmerman, B., Lindberg, C. and Plsek, P. (1998) Edge-ware: Lessons from complexity. Plexus Institute, Sante Fe.
[20]	Sandelowski, M. (2000) Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340. doi:10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G
[21]	Cresswell, J.W. (1998) Qualitative inquiry and research design. Sage Publications, Thousand Oaks.
[22]	Denzin, N.K. and Lincoln, Y.S. (2005) The Sage handbook of qualitative research. 3rd Edition, Sage Publications, Thousand Oaks.
[23]	Hanratty, B., Hibbert, D., Mair, F., et al. (2005) Doctors’ perspectives of palliative care for heart failure: Focus group study. BMJ, 325, 581-585. doi:10.1136/bmj.325.7364.581
[24]	Buetow, S., Cantrill, J. and Sibbald, B. (1998) Risk communication in the patient-health professional relationship. Health Care Analysis, 6, 261-270.
[25]	MacIver, J., Vivek, R., Delgado, D.H., et al. (2009) Choices: A study of preferences for end-of-life treatments in patients with advanced heart failure. The Journal of Heart and Lung Transplantation, 27, 1002-1007. doi:10.1016/j.healun.2008.06.002
[26]	Bennett, S.J. and Sauve, M.J. (2003) Cognitive deficits in patients with heart failure. Journal of Cardiovascular Nursing, 18, 219-242.
[27]	McLellan, S.N., Pearson, S.A., Cameron, J., et al. (2006) Prognostic importance of cognitive impairment in chronic heart failure patients: Does specialist management make a difference? European Journal of Heart Failure, 8, 494-501. doi:10.1016/j.ejheart.2005.11.013
[28]	Pullicino, P.M., Wadley, V.G., McClure, L.A., et al. (2008) Factors contributing to global cognitive impairment in heart failue: Results from a population-based cohort. Journal of Cardiac Failure, 14, 290-295. doi:10.1016/j.cardfail.2008.01.003
[29]	Vogels, R.L., Scheltens, P., Schroeder-Tanka, J.M., et al. (2004) Cognitive impairment in heart failure: A systematic review of the literature. Palliative Medicine, 18, 564-572.
[30]	Goodlin, S.J., Quill, T.E. and Arnold, R.M. (2008) Communication and decision-making about prognosis in heart failure care. Journal of Cardiac Failure, 14, 106-113. doi:10.1016/j.cardfail.2007.10.022
[31]	Willems, D.L., Hak, A., Visser, F., et al. (2004) Thoughts of patients with advanced heart failure on dying. Palliative Medicine, 18, 564-572. doi:10.1191/0269216304pm919oa
[32]	O’Leary, N., Murphy, N.F., O’Loughlin, C., et al. (2009) A comparative study of the palliative care needs of heart failure and cancer patients. European Journal of Heart Failure, 11, 406-412. doi:10.1093/eurjhf/hfp007
[33]	Helft, P.R. (2005) Necessary collusion: Prognostic communicaiton with advanced cancer patients. Journal of Clinical Oncology, 23, 3146-3150. doi:10.1200/JCO.2005.07.003
[34]	Arnold, J.M., Howlett, J.G., Ducharme, A., et al. (2008) Canadian cardiovascular society consensus conference guidelines on heart failure-2008 update: Best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies. Canadian Journal of Cardiology, 24, 21-40. doi:10.1016/S0828-282X(08)70545-2
[35]	Davidson, P.M., Paull, G., Introna, K., et al. (2004) Integrated, collaborative palliative care in heart failure: The St. George heart failure service experience 1999-2002. Journal of Cardiovascular Nursing, 19, 69-75.
[36]	Zandbelt, L.C., Smets, E.M.A., Oort, F.J., et al. (2007) Medical specialists’ patient centered communication and patient-reported outcomes. Medical Care, 45, 330-339. doi:10.1097/01.mlr.0000250482.07970.5f
[37]	Kannampallil, T.G., Schauer, G.F., Cohen, T., et al. (2011) Considering complexity in healthcare systems. Journal of Biomedical Informatics, 44, 943-947. doi:10.1016/j.jbi.2011.06.006