Integrating Palliative Care and Heart Failure: the PalliatHeartSynthesis realist synthesis

Aim

To understand how integrated PC and HF interventions may work in different healthcare settings for example inpatient/outpatient, and for which groups of people, so we can recommend strategies to maximise the potential for widespread implementation, reduce healthcare costs, and improve QoL for patients and informal carers.

Objectives

1. To conduct a realist synthesis (RS) to build an understanding of which integrated PC and HF interventions work best together, in which contexts and for which patients who have HF and informal carers

2. To co-produce implications with an expert stakeholder group, to maximise potential for widespread implementation through a user guide for healthcare providers and user-friendly summaries for patients and the public

Refinement of the preliminary initial programme theory

Following the presentation of the preliminary initial programme theory at our first stakeholder group, we found that stakeholders focused on HCPs’ perspectives as providing key explanations for challenges around implementation of integrated PC in HF management. This indicated that we should narrow the scope of the synthesis to focus on HCPs’ perspectives on integrated PC. We still considered the importance of patient and informal caregiver perspectives; however, stakeholders emphasised the gatekeeping nature of HCPs to access integrated PC in HF.

Formal search

Our search strategies were designed, piloted and implemented by an information specialist with experience of carrying out iterative searches for RS ‒ Claire Duddy (CD), in collaboration with Clare Howie (CH) and TM.

For the main search, CH identified potential search terms using published search strategies from existing systematic reviews18,19,31–34 and by reading other relevant published research documents22–24,36,48–50 that were identified via earlier scoping searches and during protocol development. Other search terms were chosen based on suggestions of key documents and language used by our stakeholder group.

Claire Duddy used MEDLINE (via Ovid) to iteratively develop a search strategy, identifying a core set of free text and subject heading (MeSH) terms and then testing the effect of adding, removing and refining terms. We used existing sets of known relevant documents to benchmark the search strategy and assess the impact of making changes. These were documents that were cited in the protocol, and documents included in two recent systematic reviews. 18,34 Our overall aim was to reach an appropriate balance of sensitivity and specificity, such that the search strategy retrieved a range of relevant literature that was likely to contain data that could be used to refine and develop our initial programme theory, while minimising the retrieval of irrelevant literature. The final agreed strategy for the main search combined terms for HF with terms for PC and is outlined in full in Appendix 1.

In November 2021, CD conducted searches in the following databases: MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), AMED (The Allied and Complementary Medicine Database via Ovid), HMIC (The Healthcare Management Information Consortium via Ovid) and CINAHL (Cumulative Index to Nursing and Allied Health Literature via EBSCOhost) (see Appendix 1). We adapted the search strategy developed for MEDLINE for use in each database, adjusting the search syntax and subject heading terms as appropriate. All search results were exported to EndNote X9 (Clarivate Analytics, Philadelphia, PA, USA) reference management software and duplicates were removed using the ‘Find Duplicates’ function and additional manual checks by CD.

In addition to the database searches, we sought to identify additional academic and grey literature via several supplementary searching methods. We ran simplified versions of our search strategy in Google, OpenGrey and the NICE Evidence search website with the aim of identifying relevant grey literature. Results (up to the first 500 for Google and NICE Evidence) from these resources were screened ‘on screen’ to identify material that described PC for patients who have HF and new material was added to the EndNote library.

Although our protocol documented we may undertake forward citation searching, we judged the large volume of documents retrieved did not necessitate additional searching. We asked our stakeholder group and wider networks to suggest additional relevant literature that we should consider for inclusion.

Following the main search in November 2021, we set up an alert using Google Scholar to help us to identify any newly published relevant material. The alert used the terms ‘heart failure’, ‘palliative care’ and ‘end of life’. New results were collated by CD on a monthly basis until August 2022 and shared with CH, TM and Carolyn Blair (CB) who considered them for inclusion throughout the project.

Inclusion criteria

We kept the initial inclusion and exclusion criteria for the review deliberately broad as we aimed to identify all relevant quantitative, qualitative, mixed-methods and non-empirical documents relating to HF and PC.

The following inclusion criteria was applied:

The screening process was piloted by CH with a sample of 50 titles and abstracts to ensure the application of the inclusion criteria was suitable. Consistency checks were carried out by a second reviewer (TM) on a 10% random sample of the screening (title, abstract and full text) and the coding process for the main search. Very few inconsistencies were identified and, when identified, these were resolved through discussion.

We also included all documents from the stakeholders and the alerts that contributed to the evolving programme theory. Documents were screened initially by title and abstract, using the inclusion criteria detailed in Table 2. Following this process, 1066 documents met the initial inclusion criteria (January 2022). Selection was predominantly focused on whether documents were likely to contain data that would contribute to the refinement of the initial programme theory. Documents were organised according to perspective reported, that is whether they included data speaking to patient, informal caregiver, HCP perspectives related to PC in HF management (or no particular perspective). Discussions were held with Joanne Reid (JR), TM, CH, CD, Loreena Hill (LH) and GW to refine the inclusion criteria (25 January 2022). At this point, based on the initial programme theory and stakeholder discussions, it was decided to refine the inclusion criteria further to align with the focus of the review (see Chapter 2, Refinement of the preliminary initial programme theory).

Documents that described HCPs’ perspectives on PC in HF were included for full-text screening. With the refinement of the inclusion criteria, 140 documents from the main search were found to provide data relating to HCPs’ experiences of PC in HF. All documents containing data thought to contribute to programme theory refinement were included.

CMOc 1: understanding the impact of a biomedical culture

Overarching CMOc 1 highlights the ‘biomedical culture’ within cardiology, and the need and potential for this culture to be challenged before PC can be successfully integrated into HF management. 48,55–58 We deem this overarching CMOc to be one of the most important explanations of why certain HF physicians and HF nurses are less likely to work to support integration of PC. 48,55–58 The narrative below describes and explains the nuances of how this biomedical culture prevents timely access to PC. This includes the difficulties with terminology in HF and PC, covering common misunderstandings which impact perceptions of PC and hence when it is most appropriately integrated. 56,59–63 Due to the complexity of the HF, illness trajectory prognostication is evidently challenging, which can cause delays in timely PC integration. 29,61,63–66 Finally, we consider specific issues relating to life-prolonging devices, and the challenges these pose for HF physicians and HF nurses conducting PC conversations with patients and their caregivers. 62,67–70 The perspectives of key HCPs have been cited in the narrative that follows. It is however important to note that, despite differences in perspectives that are likely to occur within practice across the subspecialties in cardiology (i.e. electrophysiologists), the majority of sources do not necessarily distinguish between these different subspecialties, and therefore an accurate comparison of perspectives is not possible. Furthermore, given that international literature has been included in this synthesis, we are aware that the differences in medico-legal systems within countries may result in differing perspectives on care delivery.

CMOc 1.1: biomedical culture and fears of clinical failure

Cardiology is described as active and interventional,71 and as such, HF physicians are trained to treat patients’ cardiac conditions with urgent effect which has been very successful in terms of the marked reduction in deaths now following myocardial infarction (MI). However, the intense, fast-paced environment and expectations of cardiology do not naturally permit HF physicians time to reflect on palliative and/or EoL needs. 65,72 Rather the literature illustrates that HF physicians’ clinical focus is firmly set on the need for immediate medical action to prevent patients with HF illness progression or death. 57,67,73,74 Interpretation of the data shows that HF physicians are reluctant to engage with PC, as moving from a biomedical to more holistic PC focus is seen as medical failure. 48,55–58 The fear of medical failure is not restricted to physicians, it is also evident in a proportion of nurses (24%) when they are not able to change the natural progression of HF. 58 These feelings may be embedded with a reported discomfort with death, which is often incorrectly seen as synonymous with PC. 75 PC discussions are viewed as ‘taboo’ and perpetuated by moral discomfort and a biomedical approach. 56,59,60 Within the literature reviewed PC was predominantly aligned with EoL care29,76 and a determination to prolong life is perpetuated by the mindset that anything other than biomedical treatment means clinical failure. 55–57 Therefore, hospitalisation or aggressive treatment73 is considered less of a ‘defeat’ than ensuring PC is integrated earlier in the illness trajectory to improve QoL and relieve distressing symptoms. 77 There is a clear necessity to create more willingness and ease in discussing PC needs alongside medical care directed specifically at treating HF. Building skills which will help identify PC needs in patients with HF is also key, and this is addressed under CMOc 2.

CMOc 1.2a and 1.2b: terminology and misunderstandings of palliative care

Another barrier to integrating PC identified in the literature is around terminology. In the context of a biomedical culture where the focus is on saving lives, hearing the words ‘heart failure’ is described by HF physicians and HF nurses as a shock to most patients and informal caregivers. As a result, physicians and HF nurses sometimes adapt their terminology to, for example, a pumping problem to soften the diagnosis. 61–63 The justification for this approach is rooted in the physicians’ desire to prevent upset and discomfort with the emotional responses evoked by the word ‘failure’ (interpreted by patients as meaning their heart would stop abruptly). 61–63,79 As a result, the term ‘heart failure’ is avoided by some physicians, who feel it is too emotive or inappropriate for the patient to hear. 61–63,79 The issue with semantics is also present when discussing PC. 80 Findings consistently point towards the discomfort among HF physicians about discussing a term associated with EoL care with their patients. 64,80 The consequence is a lack of information being given to patients regarding HF severity and prognosis,81 hindering patient-centred, holistic care and hindering patient and family opportunities to make advance preparations, which impacts on the patient’s QoL. 62,80,82 As with the stigma around PC terminology, the diagnostic term ‘heart failure’ evidently incites difficulties in communication for HF physicians and HF nurses. Therefore, training in communication skills with patients and informal caregivers could help to more easily facilitate confident conversations which ensure that patients and informal caregivers are fully aware of the diagnosis and holistic care options.

CMOc 1.3: the problems associated with terminology and misunderstandings of palliative care

As alluded to earlier in CMOc 1, integration of PC for patients with HF may be suboptimal due to limited knowledge and misperceptions of PC as a service reserved for those near death and not suitable for patients with chronic conditions like HF. 58,74,75,83 The evidence suggests PC is being inaccurately synonymised with EoL care and this attitude evidently informs whether and how early HF physicians integrate PC into HF management. 58,74–76,83 Given HF physicians’ self-perceived identity as life-savers84 and considering that PC is synonymised with EoL care, this paradigm does not naturally nor easily merge with the role of conducting PC conversations. PC is described as a ‘grey area’ which evidently incites a fear for HF physicians and HF nurses that post-conversation patients will have the perception that they going to die imminently. 82,85–87 Although time issues to initiate PC conversations is often blamed on inadequate staffing67,85 (expanded on in CMOC 4), the widespread reference to lack of time may actually hide a lack of confidence in HF physicians and HF nurses to conduct PC conversations, as has been suggested in the literature – respondents working in the hospital mentioned that they do not feel comfortable to make time for conversations with patients about PC needs. 88 HF physicians report not having adequate knowledge and feeling under-skilled, thus lacking in confidence in a palliative approach, which then makes them reticent to discuss PC. 63,82,85–88 The term ‘supportive care’ as a service name was viewed by HF physicians and HF nurses to be less synonymous with EoL and hospice; less prognosis dependent compared to the term ‘palliative care’; and is deemed more suitable to adopt in HF care. 64 The issue of rebranding is part of a current, larger debate among PC specialists, which has not been studied among HF physicians and patients with HF. 64 However, changing the name to ‘supportive care’ without adequate education around what this type of care involves may raise the same problems as those found for the term ‘palliative care’. What is necessary is to ensure that there is adequate PC education to improve knowledge in the underlying ethos and components of PC and how this can be integrated at all stages of HF illness trajectory. 58,64,74,75,83 The literature also highlights communication difficulties between the clinician and the patient in relation to the core aspects of PC,58,74,75,83 so whether or not PC is rebranded64 HF physicians and HF nurses require training to improve communication skills in order to accurately convey what PC means.

CMOc 1.4: heart failure physicians and heart failure nurses’ fears in relation to giving up on patients

The presence of a biomedical culture within cardiology, combined with the stigma around the term PC as synonymous with EoL, also generates moral tension, as HF physicians feel that they have given up on patients with HF and their informal caregivers when they introduce PC. 57,88–90 As a primary care physician in an American qualitative study explains: ‘It’s that dance around giving up, the perception of giving up on them when you start talking about end‐of‐life in hospice and that sort of thing’. 67 The distress caused through fears of diminishing hope for patients when introducing PC is evidently closely linked to HF physicians’ misperception of PC and concerns of ‘walking away from’ or giving up on patients. 57,67,78,89 There is also dual pressure from HF physicians’ clinical perception of their role as ‘life-savers’84 and their possible (inadvertent) misconstruction of what patients and informal caregivers need and want that is holistic individualised care. 60,67 However, this attachment to their professional identity is in part understandable as evidence suggests that HF physicians are not the only group who view themselves as life savers. 90 Patients with HF and informal caregivers have an understandable confidence in cardiology teams’ competency to prolong life and many may have a resistance to PC through lack of understanding and misconceptions that it is EoL care only. Therefore, public health campaigns to help communicate a wider knowledge of the benefits of PC and regarding the integration of PC into HF management early in the illness trajectory may help provide more familiarisation and realistic expectations. Knowledge of PC and adequate time to provide continuity of care could also help to relieve undue pressure relating to HF physicians’ concerns about ‘walking away’ from patients and informal caregivers.

CMOc 1.5: the complexity of the illness trajectory: delays to palliative care

A further barrier to integrated PC for patients with HF relates to complexity of the illness trajectory, which can follow an extremely variable clinical course with periods of stability interrupted by exacerbations that may rapidly lead to instability and ultimately death. 61,62,76,92 HF physicians and HF nurses point towards the various barriers that delays a PC conversation with patients with HF. Firstly, given the alternating phases of acute HF and phases of prolonged relative stability, HF physicians and HF nurses emphasise that it is very difficult to make a definitive prognosis. 61,66,86 The complexity in formulating a short- to medium-term prognosis is further compounded by HF physicians’ and HF nurses’ perception of patients’ readiness, or lack of readiness for PC conversations. 65,66,85 When twinned with the biomedical culture, and misunderstandings of PC this creates barriers to shared decision-making93 (expanded in CMOc 4) and ultimately a delay in timely PC conversations. Some HF physicians and HF nurses acknowledged that this delay in having PC conversations was suboptimal, and primary care physicians in particular highlighted how this can lead to the inequity of PC provision for patients with HF compared to those with a cancer diagnosis, where they would routinely discuss ‘prognosis’ and PC needs at the same time. 61 The evidence suggests that HF physicians and HF nurses mistakenly intertwine PC needs with an EoL prognosis29 and therefore opportunities to have PC conversations based on a patient needs, rather than on solid evidence that nothing more can be done from a life-prolonging treatment-only perspective, are missed. 61,63–66 Some HF physicians and HF nurses highlighted an awareness that they should discuss prognosis early (which in the literature also generally means discuss PC), ideally at the point of diagnosis. 56,67,71 However, they rarely did, as this was perceived as inappropriate (or ‘cruel’) and generated fears around causing excessive distress for patients; or perhaps, as previously noted in the literature, this masked their lack of confidence in having PC conversations. 63 This feeling of being under-skilled in discussing prognosis and PC issues led to a ‘trickling down’ of prognostic information and indirect and abstract communication about the progressive and terminal nature of HF. 63 While it is evident that HF physicians and HF nurses want to ensure patients have the best care possible, they are constrained by underpinning barriers including a lack of PC knowledge and confidence in communication skills. 25,66,82,85,86 There is clearly a need for education and training for HF physicians and HF nurses so they understand that PC for patients with non-malignant chronic illness such as HF should be based on patient need and not on their prognosis, and that PC can be integrated into any point of their HF management plan when symptoms are more problematic, and stopped when patients are feeling better. 29,61,63–66

CMOc 1.6: the reluctance to accept the need for palliative care and distress in decision-making

Underlying the biomedical culture in cardiology are a wide range of therapeutic options which are used to ‘fix the problem’ including numerous interventional procedures and devices. 65,67,93 Cardiology is described as a discipline which is known to prolong treatment for as long as possible, referred to as ‘cracking on until the end’57 as the limits of modern medicine are difficult to accept. 57,67,73,74 The evidence suggests that this culture causes notable difficulties in merging with the principles and needs-based holistic approach of PC that focuses on relieving psychological, social, spiritual and physical suffering48,56,60,71,90,93,94 which leads to a certain cognitive dissonance. 71,77,86 Most patients who have HF reach an advanced stage in their illness without an advance care plan in place, which is recognised as important for all chronic, life-limiting conditions, to ensure patient-centred treatment goals, along with ensuring that EoL care needs and preferences are met. 72,95,96 When the disease has reached an advanced stage, HF physicians and HF nurses are evidently subject to distress when deciding whether to permit the continuation of unnecessary treatments to prolong life, or discuss EoL options with patients. 55–57,72 As one source suggests, incremental increases in PC as the HF progresses until life-prolonging care is discontinued causes incoherence and can be challenging for HF teams to navigate. 86 Therefore, the timing of PC conversations, which should include advance care plans, is often deferred to the point when all medical options are exhausted; it is only when HF physicians perceive themselves as no longer useful that PC is perceived as patients’ ‘only option’. 72,83,97 Clinical guidelines acknowledge that integrating PC into HF management is a complex task; however, they clearly state that initiating PC early is advised to relieve patient suffering and improve QoL from the point of a HF diagnosis if needed. 43,93 Despite high adherence to clinical practice guidelines on optimising active treatments, guidelines in relation to early integration of PC remain largely unpractised72,93,98 (expanded in CMOc 5). HF physicians and HF nurses’ reflections largely illustrate difficulties in acceptance that PC needs to be implemented. 48,57,67,74,93 Overall, both disciplines (PC and cardiology) report that HF physicians tend to focus on treatment and neglect the more holistic palliative approach until all medical options have been exhausted which evidently delays a timely integration of PC. 63,82,85–88 Further training on how PC can be, and why PC should be incrementally increased based on patients’ needs while active treatments are ongoing would aid in reducing distress in decision-making for HF physicians and HF nurses (see CMOc 2).

CMOc 1.7a and CMOc 1.7b: the complexity of life-prolonging devices and the associated palliative care-related issues

As already noted in previous sections, the continuous rapid advancements in life-prolonging treatments in cardiology generates a belief that technology will always continue to prolong patients’ lives, adding to the tension of integrating PC into active HF management. 62,68,99 Rapid developments and advancements in pharmaceutical management and devices such as mechanical circulatory support (MCS) devices, implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapies (CRT) can improve symptoms and prevent sudden cardiac death. 62,67–70 However, the use of advanced HF therapies such as MCS should not mean that PC is not discussed or integrated. 67,100 Recent randomised controlled trials (RCTs) have demonstrated that patients awaiting implantation of MCS, or cardiac transplantation should be offered the opportunity to have a PC consultation. 21,101 Indeed, this is recommended within the ESC HF position paper and is now mandatory in the USA. HF physicians openly admit their bias toward interventions, and when combined with communication issues, this helps explain why some patients with HF receive overly aggressive, non-beneficial care. 67 An important part of PC input would take into account the patient’s expectation of treatment and their preference regarding deactivation of their implantable device, when appropriate. 67 In regard to ICD insertion, a survey of HF physicians and trainees indicated that only 9.4% of respondents involved in the insertion of ICDs always explained the possibility of future deactivation of the device, with a significant proportion of trainees never raising this issue before implantation. 84 Many HF physicians and trainees reported a lack of knowledge and thus a need for education on how to discuss and include the patient and their informal caregivers in deactivation decisions. 62,77,87,99 Although HF physicians may realise that they should engage in these types of conversations with patients, they rarely do. This again illustrates the significant communication challenges which are evidently underpinned by a lack of confidence in how to respond to patients’ questions relating to PC needs62,70,77,100 and fear of ‘information overload’ for the patient and their informal caregivers prior to implantation. 26 HF physicians require knowledge and communication skills to discuss PC issues with patients who have HF referred not only for an implantable device or transplantation as well as during the course of the patient’s illness. 84 Given that this literature spans over a decade with the same questions occurring again and again, there is still a need to bridge the cultural divide between PC and cardiology as opportunities for PC conversations are still consistently missed. 62,77

Palliative care physicians and PC nurses working in hospice also note the clinical complexity and the need for expertise related to care of patients with HF with cardiac devices (i.e. ICDs) or advanced HF therapies (i.e. MCS). 69,70,102,103 The literature indicates that there is significant moral complexity surrounding the withdrawal of life-prolonging devices such as MCS, raising the question as to whether death would be deemed a natural outcome of HF or an act of assisted suicide for patients for whom a device was deactivated at the EoL (although this is more of an issue in the USA than in Europe). 102–104 Just over a quarter of HF physicians felt comfortable personally switching off the MCS,102,103 although this number was higher in PC physicians. 103 This points towards a difference in culture between consultants specialising in PC compared to cardiology around the acceptance of death and ease with being actively involved in the cessation of life-prolonging treatments. Bridging the gaps and engaging in dialogue and shared education between these two specialties is a critical first step in creating a more cohesive approach to care for patients with HF. 103 It is evident that PC physicians and PC nurses would benefit from HF-specific PC education which highlights the importance of joint education/working to harness shared learning between PC and HF disciplines (expanded in CMOc 2). There are also unique communication needs when considering relevant patients with HF PC needs including expectations of a cardiac device and how the technology impacts QoL and the dying process, which point towards the need for a joint education and shared decision-making approach. 77

CMOc 2: achieving culture change, using educational opportunities to change the culture for palliative care in heart failure

The overarching CMOc 2 highlights that educational strategies which teach and prioritise PC are essential to integrating PC into HF management. These are explained in more detail in sub CMOcs 2.1–2.7. In this section, we focus on the evidence which points towards the importance of shared learning across PC and HF and developing a learning collaborative across relevant settings. This includes formal training and education but also informal knowledge transfer between the various professional groups. 34,48,55,61,87,88,105–110 In CMOc 2.2, we report on the lack of confidence PC physicians and PC nurses have in their understanding of HF management, which highlights a need for experiential learning through informal and formal training. 62,65,85,107 CMOc 2.3 covers HF physicians and HF nurses, where we report on why more confidence and supportive communication skills in PC is needed through specialised training in PC. 87,108,109,111–114 In CMOc 2.4 we report why formal ongoing education is necessary for all professionals caring for patients with HF. Two aspects are discussed: integrating PC modules into the undergraduate (UG) and post graduate (PG) curriculum;23,75,83,88,115–117 and continuing professional development (CPD) for the wider care team. 85,87,112,117 CMOc 2.5 illustrates how the evidence suggests that it is clearly not enough to suggest formalised education as a solution to integrating PC into HF management; rather it is important to consider the specific techniques and strategies needed to best educate HF and PC physicians and nurses. 58,75,85,86,112,118 CMOc 2.6 report on why specific techniques and strategies that enhance supportive communication skills in PC can help HF physicians and HF nurses to increase their confidence and put learning into practice. 58,75,85,86,112,118 Finally, in CMOc 2.7 we report on why education for patients and their informal caregivers is important. Three aspects are discussed in this section: the importance of direct conversations, techniques which may make conversations easier and the need to prioritise a public health approach to education in relation to PC. 55,77,87,119,120

CMOc 2.1: the importance of shared education

The evidence suggests that shared education, that is learning from and with each other, between PC and HF health and social care (HSC) professionals, is an essential component towards the integration of PC into HF management. 34,48,55,61,87,88,105–110,121–123 The Caring Together (CT) programme is a useful example of a partnership developed to pioneer integrated models of HF and PC that was implemented across different care settings in Glasgow. 87,124 A core component of this model of care includes the provision of shared HF and PC training,87,124 with success of the programme hinging on both formal training and education, but also importantly through informal knowledge transfer and shared learning between the various specialist groups. 87,124 It should be noted, however, that this programme was supported by funding from two charitable organisations and local government. However, additional evidence suggests that a collaborative approach to educating HF and PC HF physicians and HF nurses would improve the competence of these specialists in providing patient information and facilitate agreement about care pathways and issues such as referral criteria to SPC. 55,87,124,125 Data highlight that through shared learning and knowledge transfer, a learning collaborative could develop which could take place during both formal events (i.e. dedicated study days), as well as through informal discussions on an opportunistic or ‘needs based’ approach. 87,88 Importantly, sources report that this flow of knowledge transfer must operate in multiple directions, from cardiology to PC, community/hospice to acute care and vice versa (see CMOc 4). 59,87,126 In particular, shared education is central to influence HF physicians’ and HF nurses’ perceptions of PC’s role and similarly to help PC physicians and PC nurses understand the uncertain disease trajectory of patients with HF (see CMOc 1).

Being mindful that PC and cardiology are two distinctly different specialties, as Graham et al. report ‘this mutual understanding allows the specialty-specific skills to be leveraged more effectively as they are grounded in the same core philosophy of care’. 85 The evidence suggests that shared education can also help to establish processes for joint working between PC and cardiology (see CMOc 4). Multidisciplinary working and improved team working are considered essential to ensure patients receive more joined up and consistent care (see CMOc 4). 61,87,110,121,127 Overall, shared education creates the opportunity for improved patient and informal caregiver care through a mutual understanding and increase in provider knowledge of PC for HF physicians and HF nurses (see CMOc 6) and of HF management for PC physicians, PC nurses and the wider MDT121,128 (see CMOc 4). 34,48,55,61,87,88,106–110,122,123

CMOc 2.2a and 2.2b: palliative care training is needed for all involved in the care of patients with heart failure across settings

The evidence points to three specific areas of importance in relation to training: (1) the need for PC physicians and PC nurses to understand that PC for patients with HF must be needs based due to the uncertainty of the HF illness trajectory;112 (2) similarly HF physicians and HF nurses also need to understand that PC must be needs-based; and (3) the importance of PC training for all those involved in the care of patients with HF across settings. Firstly, PC physicians and PC nurses may lack confidence in their understanding of HF management,62,65,85,107,123 with the literature indicating that experiential learning through informal and formal training is essential. 85,129 Secondly, the literature also indicated that training in HF is also needed across settings to include community PC nurses, GPs, unscheduled care staff, social workers, care home staff and care assistants involved in PC. 21,112,122 The quote which follows, from the CT programme, illustrates the importance of good communication and relationships between PC and HF physicians and nurses and the necessity for PC physicians to be open to guidance and advice from HF physicians and HF nurses when integrating PC into HF management:

P13: … (talking about key cardiologist & HF nurse) they are very good to go to for advice and they can bounce ideas off of us so that’s very important time, when they manage to come up (i.e. to MDTs) […] if there is anything outstanding about any medication or anything that we maybe need to go back to the GP about, or we need to go back to the heart failure specialist, then we would do that as well but it would be outlined. 87

It is evident that HF physicians and HF nurses also encounter covert and overt difficulties integrating PC into HF management when PC physicians incorrectly translate the guidelines for a malignant PC model with a predictable prognosis to patients with HF who have an unpredictable disease trajectory. 25,62,129 An example is given of a HF nurse who was unable to refer a patient to the local hospice: ‘ … they were actually reluctant to take him until the consultant had given us a prognosis, a predicted time of life’. 62 Further areas where PC physicians and PC nurses require training include HF specific medications,85 symptom management62,65,85 and interventions including medical devices. 106

CMOc 2.3: training for heart failure physicians and heart failure nurses in palliative care

The American Heart Association has endorsed integration of PC into the early care of all patients with HF,50 yet no explicit recommendations exist to guide the content and quality of PC education for cardiology trainees. The evidence suggests that more specialised education in the principles of PC is needed for trainees and continuing education is essential for HF physicians and HF nurses. 87,94,108,109,111–114,130 Millerick et al. 112 conducted a PC- and HF-specific training needs assessment in Scotland in 2015 involving GPs, community nurses, HF and PC nurses, care home staff, out-of-hours nursing staff, hospital-based nursing staff, care home liaison nurses, HF physicians, care-of-the-elderly physicians, care assistants and other professionals involved in care of patients with HF, such as pharmacists, allied health professionals, social care staff and chaplains working across all settings (acute and community care). This training needs assessment (which received 470 responses) highlights the in-depth knowledge and skill set of HF specialist nurses. 112 It also reveals that over 60% of HF-professional-specific respondents had not received any specific training in relation to PC in HF. 112 A later review of the international literature by Singh et al. 113 conducted in 2017, and published in 2019, which includes studies of HF providers, reports that 53% had received no formal education in PC. Furthermore, HF nurses directly reported needing further PC training to enable them to become more confident and skilled in communication, and in the integration of PC into patient management. 109 This indicates a major training and knowledge gap that is essential to the early identification, comprehensive assessment and anticipatory care management of PC needs in patients with HF. 94,109,112,113,130 As covered in CMOc 1, evidence suggests that the lack of integration of PC into HF management relates to a misconception that PC is synonymous with patients facing imminent death or close to EoL. 108,114 It is also important to note that this is not solely relating to HF physicians and HF nurses but rather many primary PC providers, including nurses, also have misconceptions of PC, which again points towards the need for education across settings and disciplines. 131 The sources reviewed identify specific training needs for HF physicians and HF nurses such as symptom identification/management and supportive communication skills. 65,117,130 The evidence suggests that it is imperative that HF physicians and HF nurses have access to, and allocated time to avail of, PC learning opportunities to raise awareness of PC benefits and how PC can be integrated alongside life-prolonging treatment. 87,108,109,111–114,130

CMOc 2.4: continuing professional development

Evidence suggests that increasing knowledge of PC requires integration of PC education into the existing curriculum for all prospective providers during UG and/or PG training23,75,83,88,115–117 as well as ongoing education for those in practice. 85,87,112,117 Shared education needs to be available for the broader care team across settings to help guard against siloed working and successfully integrate PC into HF management. 34,131 Therefore, evidence-based inter- and multidisciplinary education is advocated to improve PC knowledge while also increasing understanding of clinical roles for all who currently provide PC and will provide PC to patients with HF in the future. 34,131 Although the educational experiences proposed by the literature vary between medical specialties, the commonalities were clear and centre on clarifying misconceptions about PC and hospice, identifying PC needs, effective working with respective disciplines (HF or PC) and when to refer to SPC. 85,117 It is evident that training and education have resource implications and need to be ongoing rather than seen as a one-off expense. 87

CMOc 2.5a and 2.5b: educational techniques and strategies

Identifying the optimal techniques and strategies is important when considering how to best educate HF and PC physicians and nurses. This review identified some promising educational techniques for improving their understanding of PC for HF management, such as experiential learning and peer support. 58,75,85,86,112,118 It is evident that experiential learning opportunities present in everyday clinical practice, which can complement more formal knowledge, skills and expertise, and occurs naturally on a patient-by-patient basis during times of real clinical need. 75,85–87 As Millerick and Armstrong112 report, this ‘… encourages cross-fertilization of knowledge and skills that deepens our understanding of needs and the challenges that can often inhibit effective care across care settings’. This type of ‘on-the-job’ learning is reported to encourage mutual understanding and the recognition of the unique contribution of each individual’s clinical role, thus building relationships and care co-ordination. 75,85,112 Evidence suggests that experiential learning such as this helps to identify and manage comorbidities and patient needs collaboratively between HF and PC, guarding against siloed working. 75,85,112 HF physicians and HF nurses may also benefit from peer support, mentoring and supervision from PC physicians and PC nurses, and vice versa, to enhance experiential learning and provide a supportive culture which is receptive to learning. 58,75,85,86,118 In particular, HF physicians and HF nurses experiencing feelings of failure (see CMOc 1) may need peer support from other HF physicians and HF nurses combined with training in reflective practice which may also serve to improve the quality of PC delivered to patients. 58

The evidence overwhelmingly suggests that the preferred learning method was formal face-to-face activities, including conferences, seminars and discussions, with alternative modes of delivery, such as multimedia and full online platforms less favoured. 59,112 However, it must be noted that these findings are based on pre-COVID-19 data, so we cannot be sure that face-to-face learning is still the preferred learning mode post-COVID-19.

Regardless of the mode of delivery, in the context of increasing time constraints on busy HF and PC physicians and nurses, educational and learning opportunities must be accessible to encourage attendance. 59,87,112 Fitting educational programmes within existing programmes of work is deemed essential for sustainability, accessibility and attendance. As Schichtel et al. report, ‘Ideally, the training should take place at their local surgery. In this way, learning activities would also reach those professionals, who normally would not attend a palliative care event’. 59 Allocated time to participate in these activities is deemed an essential prerequisite to success in educating HF and PC HF physicians and nurses in how to best integrate PC into HF management (see CMOc 4). 87

CMOc 2.6: communication skills

It is clearly not enough to suggest formalised education as a solution to integrating PC into HF management, rather the evidence suggests that it is important to consider what specifically any education should focus on. 75 The evidence strongly suggests that HCPs across care settings would benefit from training in communication skills. 30,55,73,116,127,133 Improved communication skills are linked to increased competence and confidence, which in turn is likely to have an impact on earlier integration of PC into HF management. 55,58,84,134–136 Evidence suggests that training in how to conduct direct PC conversations with patients and their informal caregivers may help increase HF physicians and HF nurses’ competency in sensitive communication. 67,77,87,91,108,126,137 Furthermore, it is evident that inter-professional and interprovider education focused on communication for HF and PC physicians and nurses may also aid in building relationships, improve the flow of communication between disciplines and result in improved care co-ordination. 34,87,138 The CT programme is a useful example of co-ordination of care which ensured ease of communication between disciplines. As Bouamrane et al. state, ‘[with the CT programme] it was seen as easier and more straightforward making it more likely for individuals to be willing to just pick up the phone and contact others as required’. 87 It is also important to note that, the introduction of CT was particularly successful where it served to build on pre-existing good links or relationships. 87

CMOc 2.7: educating patients with heart failure and their informal caregivers

As discussed earlier, a significant barrier to a needs-based approach to PC is that many patients with HF and their informal caregivers have misconceptions of what PC is and when it is appropriate to avail of these services (see CMOc 1). Therefore, educating patients with HF and their informal caregivers early in the disease trajectory about the life-limiting nature of HF and PC options is essential. 77,87,119,120,139 Two key educational opportunities were identified: the importance of HF physicians and HF nurses having direct conversations with patients, and a more generic and wider public information campaign relating to PC in HF management. 55,77,87,119,120,137 Bouamrane et al. 87 suggest that patient-centred education should include discussions about prognosis, and education regarding the clinical progression of HF including associated symptoms and functional decline. Direct conversation with the HF clinician initially is crucial to ensure the patient fully understands their condition, how PC can benefit them and the options available. 55 However, some HF physicians and HF nurses have concerns about the appropriate timing to open this conversation, which can impede opportunities for patient education early in the illness trajectory. For example, a patient’s condition and related psychological state may hinder a discussion, as Stocker et al. 63 suggest: ‘Sensitive discussions of palliative issues are complicated by the fact that many patients experience symptoms which confound their ability to think clearly’. As Dionne-Odom et al. 140 report, ‘Cardiologists commented that it was important to offer PC “early, but not too early”’. Finally, as a participant in Bouamrane et al. ’s87 study explains: ‘… there is also some patients who if you told them at an earlier stage they wouldn’t do well, you know, psychologically that would impact on them … ’ It is likely that training in PC would reduce some of the uncertainties in opening conversations about PC; however, HF physicians and HF nurses may also find it helpful to have structured education at clinical appointments132 whereby they can signpost to PC public health initiatives as a positive second step in educating patients with HF and their informal caregivers. 77 It must also be noted that there are patients with HF who may not want to know more about their condition. Therefore, it is necessary to ensure that all initiatives are non-obligatory as the decisions of these individuals must be respected. As Hjelmfors et al. 77 suggest, HF-specific patient education materials on PC can be used. Another option may include using a patient needs assessment as an educational opportunity and signposting to HF support groups who are knowledgeable about the benefits of PC. 87,139 Although HF physicians and HF nurses concerns regarding timing of PC discussions are important considerations, it is evident that raising awareness of PC earlier rather than later in the disease trajectory, through the most appropriate means for the individual patient, is important for ensuring needs-oriented care is delivered to patients with HF and their informal caregivers alike. 34,55,61,73,93,127 It is also important to note that patient education is likely to be a useful tool to encourage patient empowerment which could further help in patients championing for their PC needs. 88

CMOc 3: winning hearts and minds, using leadership and examples of benefit to change the culture for palliative care in heart failure

The overarching CMOc 3 highlights how winning hearts and minds is an important consideration when integrating PC into HF management. These are explained in detail in sub CMOcs 3.1–3.3. Two aspects of this are clearly illustrated through the literature: (1) the importance of champions; and (2) the importance of knowledge translation of benefits to service providers and service users. Champions are important across all levels. The included literature clearly illustrated how HF and PC physicians and nurses can win the hearts of those responsible for integrating PC and HF. 34,83,87,117,119,141 Winning hearts is demonstrated primarily through their everyday practice, communicating the benefits of integrating PC and HF, and advocacy for more multidisciplinary teamwork across settings. 34,83,87,117,119,141 The literature reports the multiple benefits of integrating PC into HF management including improved patient, informal caregivers and healthcare system outcomes,14,34,81,85,87,131,132,142 and how important it is that service providers and service users are made aware of these benefits so they understand the role of the benefits in improving patient outcomes.

CMOc 3.1: the importance of champions to advocate for integrating palliative care into heart failure management

Championing the benefits of PC to patients and colleagues involves multiple activities, including garnering organisational support and required resources, dissolving boundaries in communication with colleagues, modelling practice which demonstrates the benefits of PC, raising awareness, and taking time to develop interdisciplinary liaisons. 34,83,87,117,119,141,143,144 Multiple clinical roles including HF physicians, HF nurses, PC physicians, PC nurses and GPs are reported as being well placed to champion for the early integration of PC into HF management. 34,83,87,117,119,141 The evidence suggests that PC champions can help to influence their colleagues through their practice and also through communicating the benefits of early intervention to meet the holistic needs of patients and informal caregivers living with HF. 34,87,117,119,141,143 In multidisciplinary HF teams, the literature reports that an interdisciplinary approach must be championed by a respected and influential leader. It is also important that they advocate for the need for respectful understanding of the value of each other’s clinical roles and patient-centred care. 34,87,144 Authenticity is essential for champions: it is necessary that they can communicate the benefits of PC in HF management but also are genuinely passionate about the benefits for patients. As Bouamrane et al. 87 explain:

… we’ve got two individuals that are in the programme who are such passionate speakers and also passionate in how they actually manage this group of patients, although we suspected there were people out there to begin with. I think having them both join the programme, and work so well with the programme, has exceeded our expectations as well …

With appropriate education and support, all members of the MDT can become champions for PC needs. This can help to attain engagement and overcome resistance from more indifferent colleagues to identify and manage patient needs in collaboration with PC, hence guarding against a siloed approach. 34,83,87,88,111,117,119,141,143,144

CMOc 3.2a and 3.2b: evidencing benefits

A key historical barrier to integration of PC into HF management cited in the literature was the relatively weak evidence base for the benefits of integrating PC into HF management. 141 More recent literature demonstrates a growing evidence base showing the benefits of integrated PC for patients with HF, from relieving symptoms, providing psycho-social support, reducing hospital visits, admissions and time spent in hospital, and meeting the priorities of care that matter most to patients. 14,34,81,85,87,131,132,142,145 However, this significant increase in the evidence base has not resulted in higher levels of integrated care; rather, more subtle barriers have emerged, such as the lack of service provider and service user knowledge and appreciation of the diversity of PC interventions and their benefits. 138 CMOc 2, which highlights the importance of education, and has implications for this section. When service providers receive education showing tangible benefits for their patients, they can come to appreciate its value for improving patient outcomes. 88,110 The literature also supports the age-old adage that ‘seeing is believing’, as was the case for service users. When patients with HF had positive experiences of PC integrated into their HF management, they were much more likely to be advocates for integrated PC. 14

CMOc 4: facilitating practice change considering the impact of wider context and organisational issues on palliative care integration

The overarching CMOc 4 highlights the importance of collaboration between specialties (i.e. PC and HF) in MDT working, which was widely cited throughout the literature. 14,22,23,34,85,87,88,124,128,131,142,146–148 There are important nuances and detail that underlie CMOc 4 regarding what factors facilitate and impede practice change in relation to integrated PC in HF management. First, the evidence suggests it is important to consider the composition of the MDT across care settings, to ensure that all relevant specialties are included, providing access to a breadth of clinical expertise. It is evident from the literature that positive working relationships can be enhanced through education and training to learn about each other’s strengths and skills. 22,87,148 Furthermore, clearly defined roles and responsibilities in collaborative models encourages needs and value-based care provision and communication between services. 14,85,88,142,146 Second, the importance of making use of discipline-specific strengths across settings to encourage timely recognition of PC needs was emphasised. 55,59,87,88,146,149 The literature also emphasises the importance of trusting relationships between the MDT members and the problems created by established clinical hierarchies within clinical teams in integrating PC into HF management. 30,55,71,78,149,150 Finally, enhancing and consolidating approachable working relationships between HCPs from differing specialties with the central focus on patient-centred care was key to diminishing fragmentation and increasing individually tailored, co-ordinated care. 23,87,124,148

CMOc 4.1: composition of multidisciplinary teams

It is evident that many patients with HF would derive benefit from the early integration of needs-based PC provided by a suitably skilled MDT to initiate discussions, alleviate burdensome symptoms and signpost to supportive resources. 22,23,34,87,131,147,148 Across a wide range of national healthcare structures and local service configurations, sources suggest that a broad range of disciplines should be included in the MDT; however, input is identified as resource dependent. 23,87 Disciplines include PC specialists, geriatricians, nurses, social workers, chaplains, pharmacists allied health professionals and care workers. 22,23,34,87,122,131 The CT programme report87 emphasises the importance (and success) of adapting existing resources and service redesign as opposed to recruiting additional staff. However, we need to be mindful that this publication is dated 2014, and while service redesign drawing on existing resources would remain the ideal, given current resource issues within the health service, more research is required to ascertain if service redesign would work in the current understaffing climate.

The importance of collaborating through multidisciplinary work is deemed critical to success, and should involve efficient regular team meetings, an individual appointed to co-ordinate care, communication and information sharing to ensure optimum needs-based care for patients and informal caregivers. 22,23,34,87,131,132,137 One commonly undernvolved discipline highlighted by Stevenson et al. 147 is clinical pharmacists. These authors argue that pharmacists should be an integral part of the MDT to provide the required expertise to optimise medication regimens, and avoid potential adverse outcomes from polypharmacy (taking multiple medications). 25,147,151,152 Overall, it is important that decisions are synchronised through the MDT process, providing access to a breadth of clinical expertise. 23,87,147,148 Having the perspective of medication experts is seen as an invaluable asset to MDTs, not only for medication regimen review but also for pain and non-pain symptom management. 147 Furthermore, as Hill et al. 23 suggest, it is important to ensure the availability of HF medication. One approach to promote this lies in ‘anticipatory prescribing’, namely writing prescriptions for medications that might be needed as a matter of urgency in the near/intermediate future in accordance with local governance arrangements. 23

CMOc 4.2: co-ordination of multidisciplinary teams

The evidence suggests that to integrate PC into HF teams there is a need for interdisciplinarity across care settings which requires better treatment co-ordination and direction of resources. 14,22,23,34,85,87,88,131,132,142,145–148 There is a strong body of evidence emphasising the importance of consultation between practitioners in community-based care and HF physicians. 55,59,87,88,146,149 As explained in CMOc 3, communication between the different HCPs working in different settings is deemed essential to the co-ordination of MDTs. 48,88 For example, sources highlighted that it is important to strengthen communication between these HCPs to ensure that important information on PC needs is passed across from the HF physician to the GP. 55,59,87,88,146,149 Sources also indicated that this should include a prompt from the HF physician to have a PC conversation to help increase GPs’ confidence in opening conversations with patients and informal caregivers. 55,59,87,88,146,149 Evidence also suggests that effective working across care settings allows expertise to be taken from secondary care back to community, enhancing support of primary care teams caring for patients with HF at home. 14,131,145 There is evidently a need to understand each of these roles and their importance in the MDT, which should be integral to education on integrating PC into HF management (see CMOc 4). 85,88,128 In particular Graham et al. 85 indicated that there needs to be better clarification of who is primarily responsible for the patient’s medical care in the community, suggesting that it would be beneficial to appoint a point of contact to aid patients in navigating the medical system, overseeing the variety of care tasks and delineating which providers are responsible for which tasks at which time. Similarly, other sources suggest that MDT working can be enhanced by identifying a lead co-ordinator of care to integrate inputs from different disciplines. 23,34,87,131 As Hill et al. 23 suggest, the responsibilities of the team members within such MDTs should be defined, and it may be helpful to nominate a HCP to act as interlocutor between the patient/informal caregiver and service provider. A multidisciplinary co-ordinated approach to PC for patients with HF has multiple benefits; it challenges the misconception that PC is only for EoL interventions while enabling high-quality parallel planning during the HF illness journey. 14,132,145

CMOc 4.3: trusting relationships

While the literature often frames HF physicians as having an active, biomedical frame of mind, HF nurses generally are portrayed as more inclined to a holistic approach, and more apt to acknowledge that patients require PC at an earlier stage. 30,58,71,78,119,150 A 2021 survey of cardiovascular nurses and physicians in Australia and New Zealand found that 94% of HF physicians have a distinct reluctance to refer to PC when patients are classified as stable and NYHA Class II‒III compared with 65% of nurses. 58 The literature signifies that there is a difference between nurses’ and HF physicians’ perception of the appropriate timing for PC. 30,58,71,78,150 Sources identify that there is not only a difference in perception, but also a difference in the dynamic of relationships that HF physicians and HF nurses form with patients and informal caregivers. A trusting relationship with the patient and informal caregiver is deemed an important aspect when initiating a conversation about PC needs. 55,71,78,149 HF nurses would appear to be better placed to discuss palliative issues, as the evidence clearly shows they see the patient and their informal caregivers more frequently, develop a trusting bond, and can make time to discuss these issues at length if needs be. 55,59,71,78,88,149 The resource of time is a significant issue which requires more in-depth exploration and will be discussed more fully in CMOc 5. Some HF physicians and primary care physicians mentioned that the HF nurses should be given the most prominent role in these PC discussions given their insight into the patient and informal caregivers’ needs. 71,90,149 However, two sources55,92 suggested that due to the chronic nature of their condition, patients with HF may have a closer relationship with cardiology specialists (comparing to other disciplines); therefore, the HF physician may be best placed to discuss PC needs. Overall, more sources suggested that patients would confide in HF nurses and would honestly convey their needs,71,90,149 with one source suggesting that some HF physicians may be seen as unapproachable. 55 The overriding consensus was that the quality of the relationship with the patient was more important than the grade or discipline of the HCP in guiding who should be responsible for having PC conversations. 55,71,77,78,149 A trusting relationship is evidently key to assessing patient needs and conducting PC conversations with patients with HF and their informal caregivers alongside the evident importance of continuation of care (see CMOc 5). 55,71,78,149 With the current developments of the nursing profession adopting more autonomous roles in the UK, nurses will have the advanced knowledge and skills to champion PC integration as they often have a key position within the HF team. 30,150 Therefore, it may be helpful when integrating PC into HF management for HF nurses to take a stronger leadership role in the assessment and management of the needs and preferences of patients with HF. 30,150

CMOc 4.4: clinical hierarchy

Heart failure nurses are the HCPs who have the most regular contact with the patient and their informal caregivers throughout the HF journey. This can result in them having the most comprehensive appreciation of the patients’ holistic PC needs. Nonetheless, the clinical hierarchy in which they work appears to stifle their willingness (or ability in medico-legal systems where they have less autonomy) to initiate PC conversations. 30,78,150 The role of the HF nurse varies across geographical location, for example in Poland and Lithuania HF nurses are an important part of the MDT; however, they have less autonomy due to medico-legal considerations within such countries. 23,33 In other European countries (e.g. Russia and Serbia), nurses working in HF do not have a recognised specialist role. 23,33 Sources identify this difference in geographical location as being an important point to remember when considering the roles and responsibilities of HF nurses. For example, Hjelmfors et al. 77 explain that within their Swedish study, roles and expectations might be different than other countries. Generally, the literature suggests that HF nurses are more aware of the need for and value of PC,58 but in many countries the HF physician must be in agreement, otherwise PC will not be smoothly integrated into HF management. 71,150 Although both HF physicians and HF nurses report that discussing prognosis and EoL care is an important part of their work, they have different responsibilities in these conversations. 74,77 The HF nurses take a supportive role,30,77,150,153 while the HF physicians often initiate the discussion. In one study, a HF nurse described instances where they were left to deal with the patient and informal caregivers’ distress post-PC conversations. 74 One source suggested that HF nurses may feel disempowered by the lack of regard for their input and opinion by those further up in the clinical hierarchy. 71 Although the literature suggests that HF nurses are most suitably placed to discuss PC with patients with HF, if the HF physician has not started these conversations, some HF nurses within certain countries are reluctant to initiate. 30,71 Although the literature suggests that HF nurses are an essential part of the HF MDT43,154 and are suitable placed to discuss PC with patients with HF, if the HF physician has not started these conversations some HF nurses within certain countries are reluctant to initiate. HF nurses’ discourse suggests that they try to convince doctors to transition from a purely biomedical to a more palliative-oriented approach (i.e. informally discuss holistic needs and advance care planning issues), especially when the HF physician’s instructions are not aligned to patients and informal caregivers’ wishes. 30,71 There is clearly a clinical hierarchy in cardiology which can create barriers to integrating PC and HF management and, in some cases, may cause disharmony in cardiology teams. 30,71,74 Communication issues are alluded to in the literature as a possible barrier to HF nurses’ decision-making around timely integration of PC with HF management. Therefore, adequate training on respectful communication within the clinical hierarchy may be required (see CMOc 2). HF nurses have the most regular contact with patients and informal caregivers throughout the HF journey and this combined with their eagerness to provide early intervention for PC needs may indicate that the responsibilities of HF nurses could be increased in alignment with the medico-legal context of where they are geographically located. 30,71,74,153

CMOc 5: achieving culture change, using educational opportunities to change the culture for palliative care in heart failure

The overarching CMOc 5 highlights the barriers and facilitators which impact prioritising integrated PC in HF management. There are important issues raised in CMOc 5 concerning the nuances that facilitate and impede practice change and these are explained in CMOc 5.1–5.3 below. First, the literature emphasised that time pressures often caused by inadequate staffing was a barrier to integrating PC into HF management. 59,61,63,67,71,75,84,89,155 The evidence indicates that the reorganisation of existing services is urgently required to provide a more equitable healthcare system for patients with HF. 84,85,87,105,113,129 Equity in PC provision should be regardless of geographical region, regardless of whether patients want to remain at home and should be based on need rather than disease (i.e. PC in HF management should be prioritised in a similar way to PC in cancer). 84,85,87,105,113,129,145 For example, Graham et al. 85 state that it is necessary to re-examine the way in which resources are distributed in the community considering that patients with HF have a variable disease trajectory and require different levels of support over that trajectory. Considering that this does not align with the way that PC resources (e.g. nursing hours, PC unit beds, personal support worker hours, etc.) are currently distributed in the community patients with HF typically have less resources, resulting in suboptimal PC. 85 Second, sources suggest that involvement of and partnership with the patient and their informal caregivers at an early stage using shared decision-making must be prioritised to create goals of care early in the HF disease trajectory. 23,57,95,114,118,132 Finally, continuity in care is highlighted as a priority as stated in CMOc 4 given that co-operation and collaboration between disciplines improves when HCPs utilise each other’s areas of expertise throughout the patient’s illness trajectory. This results in multidisciplinary HCPs and patients feeling more connected and maintaining trusting relationships with their care providers. 55,61,86,107,114,119,156

CMOc 5.1: organisational issues impeding practice change

From a cardiology perspective, time constraints often limit HCPs’ ability to have a conversation with patients and their informal caregivers about PC needs. 71,85,134 The literature emphasises that given the pressures on the cardiology team, mainly due to staffing constraints, there is limited time to communicate complex issues which causes aversion to initiating PC conversations. 59,61,63,67,71,75,84,89,155 Potential barriers to the integration of PC into HF management include the lack of organisational resources, staff training and available time. 23,73,78,90,113,126,149 These organisational barriers evidently have an impact on limited communication, co-ordination and collaboration between HCPs which are described as barriers for timely recognition of PC needs in HF management. 88,126,132,156 The evidence emphasises that a lack of funding and services adds to difficulties in addressing patients with HF’s needs, and urgent investment in PC and HF management is required. 78,87,106,113,129 Despite evidence from the CT programme suggesting that integrating PC into HF management does not impinge on time as significantly as was feared,87 a number of more recent sources suggest system-level improvements, such as adequate PC beds85 and community resources21,146 are required to provide optimum PC for patients with HF. 84,85,87,105,113,129

CMOc 5.2: shared decision-making

Preferences for treatment and care of patients and their informal caregivers need to be taken into account and addressed more systematically throughout all stages of HF. 55,67,76,83,86,153,157 Involvement of, and partnership with, the patient and their informal caregivers at an early stage of their HF journey using shared decision-making is essential to enhance the likelihood of meeting goals of care. 23,57,95,114,118,132 Emphasising and respecting QoL, autonomy and preferences of the patients and their informal caregivers are essential in the shared decision-making process. 55,67,83,86,153 As Hill et al. 23 and Waller158 explain, tools and programmes that assist patients and informal caregivers undertaking difficult discussions and supporting shared decision-making on treatment options, should be developed and implemented. Similarly, Schichtel et al. 59 emphasise the value of shared decision-making tools to facilitate the conversations to give patients a sense of control over what they do or do not want to discuss and similarly help HF physicians and HF nurses to understand patient’s preferences. The evidence confirms that an individualised assessment of patients’ needs and preferences is essential and will be aided by HCPs’ skills in communication. 55,86,96,116,131,157–159 The organisational aspect of integrating PC across structures and settings requires prioritised time to invest in shared decision-making between HCPs and patients’ with an understanding of the changing responsibilities and roles relevant to the patient’s healthcare trajectory. 23,34,55,57,76,86,114,116,118,131,159

CMOc 5.3: continuity in care

The evidence suggests that HCPs see a need for closer cooperation between the disciplines (cardiology, general medicine, PC) to ensure continuity at an early stage (see CMOc 4). 55,61,86,107,114,119,156 The evidence reports that continuity of care (especially of their treatment) improves when HCPs collaborate closely with colleagues from different disciplines across care settings when they have a shared understanding that they are all working towards the same patient-centred goal. 85,88,136 HCPs in cardiology reported a greater sense of satisfaction when working in partnership with PC physicians and PC nurses, knowing that they could accompany patients on their entire journey and therefore do not feel disassociated at a certain point in the relationship. 85,88,136 The literature strongly stated the importance of continuity of care to safeguard patients against feelings of abandonment; therefore, maintaining a role for HF physicians and HF nurses is paramount as patients often have strong bonds and trust in their long-standing HF physicians and HF nurses. 85,88,136 HF physicians’ expert opinion on clinical complexities of cardiac medications and devices is also essential at all stages of the patient’s journey to benefit patients, their informal caregivers, and physicians and nurses in PC. 85,89 With strong lines of communication and willing collaboration between PC and HF specialists across care settings, the complex symptoms in HF can be managed, providing optimum holistic care to improve the patient’s QoL and improve continuity in care. 55,61,62,71,86,90,107,113,119,156,160 A further point is reducing patient burden when PC is integrated into HF management, as this comanagement of care helps to guard against fragmentation of care allowing for a more seamless transition at different stages of their illness trajectory. 67,85,89,155 Comanagement of care, sharing information and sharing expertise through patient-centred meetings and interdisciplinary case reviews are deemed essential. 55,61,86,107,114,119,156 It is evident that the interface between PC and cardiac teams needs to be negotiated to ensure continuing links and clear lines of communication to improve management and support available to patients with HF. 55,61,62,71,73,86,87,90,107,113,119,155,156,160

CMOc 6: the need to embed clear, visible guidelines to integrate palliative care into heart failure management

The overarching CMOc 6 highlights the final points for consideration when embedding PC into HF management. Additional factors which underpin CMOc 6 are explained in CMOc 6.1–6.2. The narrative below describes and explains why visible guidelines are essential to bridge the gap between clinical practice and guidelines. First, the evidence suggests that guidelines need to clarify roles, responsibilities and decision-making to ensure that HCPs can provide expert care despite the uncertainty of the HF illness trajectory. 26,34,85,88,91,125,161 Second, to make guidelines relevant, integrated care pathways must be supported at policy level to facilitate stronger collaborative relationships between cardiology, primary care and specialist PC (see CMOc 4 and 5). 34,85,87,91,125,162

CMOc 6.1: guidelines for integrating palliative care into heart failure management

Guidelines for integrating PC into HF management exist. For example, the World Health Organization (WHO) and the ESC suggest PC should be available and integrated at an early stage into the routine care for patients with HF alongside disease modifying treatment and PC in HF management. This is supported by a growing body of research. 26,34,79,85,88,91,125,145,161,163 However, the evidence suggests that there is a gap between the evidence and translation into everyday clinical practice, with guidelines on integration of PC into HF management being not being embedded into practice. 26,34,79,85,88,91,125,161 Although international experts have recently reached consensus on a large number of criteria for referral to SPC,164 currently HF physicians and HF nurses operate from ‘broad guidance’ rather than integrated PC and HF specific guidance125 when considering PC access. The lack of visibility and implementation of integrated PC and HF specific guidelines are presented as a barrier to decision-making, defining roles and responsibility and care pathways reducing the potential for optimal care for patients with HF who have PC needs. 34,57,71,85,91,125,163 Although HF guidance [e.g. The Canadian Cardiovascular Society, HFA of the ESC, Heart Failure Society of America (HFSA)] do not give details of specific integrated models, there is consensus that care should be co-ordinated. However, there is disagreement over at what point PC should be considered for patients with HF and when it is appropriate to initiate PC. 87,163 Although guidelines discuss the ‘team’ involved in the palliative management of patients with HF, there needs to be clarity over involvement across care settings, defining roles and responsibilities of HCPs from a broad range of social and health service sectors. 85,87,91,125,163 Evidence strongly suggests that guidelines for PC in HF management and implications for their implementation need to be more specifically tailored for patients who have HF, recognising the distinctive challenges faced by this population, including the uncertain illness trajectory and the various procedures and devices which may be used in their HF management. 150,165,166 Alongside ensuring the visibility and implementation of current guidelines as part of routine practice, specific guidelines need to be formulated on how to proceed with appropriate protocols for various circumstances, for example, the role of palliative sedation for terminal-stage patients who have HF,166 potential difficulties with polypharmacy147,151,152 and how ICDs are managed when the patient is approaching EoL. 26,69,70,100

CMOc 6.2: policy and integrated care pathways

Integrated care pathways are needed to provide a structured collaborative approach towards the provision or models of PC. 34,85,87,91,125,167 The literature suggests that consistent guidance, policy changes, and a shared vision of how to implement an integrated PC and HF care pathway across all care settings (primary, secondary and tertiary) is necessary to counteract the ongoing deficiencies in management of this patient population. 57,65,87,162 As Higginbotham et al. 57 state, this pathway needs to include a clearly defined decision-making algorithm in order to optimise the patients’ and informal caregivers’ experience both when identifying needs and providing palliation. As noted in CMOc 4 and 6.1, clarifying staff roles and responsibilities and provision of routine assessment of the need for PC is essential as part of this pathway to facilitate clear communication and early access to PC services when appropriate. 57,65,114,167 Despite agencies (e.g. WHO) making progress to ensure that PC is equitable across all chronic conditions, it is essential that everyday clinical practice reflects policy stipulations and access to PC is based on need, not prognosis. 34,116,117,158,167 Policy-makers must consider the need for organisational restructuring to help provide the infrastructure necessary for the provision of equitable care. This infrastructure should equip HCPs to deliver generalist PC as part of routine HF management and access to SPC when required irrespective of geographical location or prognosis. 57,117,167 Clarity is also needed in policy documentation as to who leads PC for patients with HF. Despite statements by NICE and the British Heart Foundation that this is a cardiology role, there is still a lack of clarity among providers. Given this ongoing uncertainty around roles, guidelines must be used and prioritised. 34,109,117 Other recommendations emerging from the literature support pre-existing policy statements. 50 As stated in CMOc 5, goals of care and treatment decisions must be facilitated through a shared decision-making process early in the illness trajectory, with due consideration of the needs of patients and their informal caregivers. 23,25,57,114,118,132 Shared education (see CMOc 2) in PC is essential to equip HF and PC physicians and nurses to integrate PC into HF management. 34,48,55,61,87,88,105–110,121 It is evident through the literature that policy changes and organisational restructuring are essential to facilitate stronger collaborative relationships between specialists (e.g. HF and PC) and across care settings (e.g. primary, secondary and tertiary settings) to ensure that patients with HF and their informal caregivers receive optimum care at the earliest opportunity. 34,85,87,91,113,125

Shared education and experiential learning within and between disciplines across all settings (CMOc 2.1)

Shared learning is an essential intervention strategy to bridge the cultural divide between HF and PC by highlighting the common goals of both PC and HF specialties (to improve patient outcomes), and to increase understanding of what PC is (holistic care that can be delivered alongside active HF management based on patient need, not prognosis) and what it is not (for patients with cancer and EoL care only). Stakeholders further supported findings on the importance of informal education, through experiential learning, which can include PC staff attending cardiology MDT meetings. During the MDT meetings, mutual team education and support can help HCPs get to know each other, understand each other’s roles, and build and reinforce team ethos and common goals. Stakeholders fully agreed with findings that knowledge of PC and HF is important, but also skills and how HCPs discuss/talk about PC with patients is vital. In their experience, and as supported in the literature, clinical exposure through watching/observing/shadowing can have the greatest impact on learning. There is also an important role for simulation training in exposing HCPs and trainees to clinical scenarios to provide experiential learning in a safe space, to allow learning from mistakes. International stakeholders shared useful learning from exchange programmes for HF professionals and PC professionals to experience each other’s roles, for example HF nurses’ placement in PC and vice versa.

These intervention strategies are crucial for overcoming key blockages to integrated PC uncovered in the literature, such as the pervading biomedical culture that tends to focus predominantly on the medical needs of patients with HF and on life-prolonging treatments. The biomedical culture within which cardiology teams receive their education, train and work helps explain why early integration of PC in HF management has been so problematic and slow to become part of routine practice. According to the ‘opportunity’ component of the COM-B model, cultural norms and social cues are a key determinant of behaviour. Culture refers to the shared and fundamental beliefs, normative values and related social practices of a group that are so widely accepted that they are implicit and no longer scrutinised. 168 Because individual, organisational and social culture is implicit, it is an unseen but very powerful force driving behaviour.

Stakeholders acknowledged the life-sustaining culture among cardiology healthcare professionals, driven by training in a medical model and continuous improvements in therapies. Cardiology as a specialty has been at the forefront of successes in modern medicine, with people with HF living longer in response to evidence-based advances in mechanical circulatory support devices, coronary revascularisation, cardiac resynchronisation and medication management (e.g. beta-blockers and angiotensin-converting enzyme inhibitors). 169 This modern-day success still operates in the context of medicine’s historical focus on molecular biology and technology, dating as far back as the 1800s, which tended to overlook the more holistic dimensions of ill health. 170 Changes in the nineteenth century combined medicine with physical and life science, which resulted in the well-known ‘biomedical model’. This refers to a collection of views resulting in set beliefs about disease and its treatment, focusing medicine towards a predominately technical and scientific discipline170 which is at odds with a holistic PC approach.

Stakeholders re-emphasised the importance of cardiology and PC teams understanding each other’s roles, with joint education needed to bring specialties together. PC is a relatively new specialty which has taken years to build up expertise in cancer care. Some PC clinicians fear taking on patients who have HF as it is out of their comfort zone. No one specialty needs to do it all, so a key aspect of PC education for all HCPs is to provide a good understanding of generalist PC and also how to recognise when specialist PC is appropriate. Those working in PC need to receive education and training, working with HF colleagues, to understand the specific PC needs of patients with HF. For those working with patients living with HF, training in PC should also be mandatory.

Communication skills training (CMOc 2.8)

Effective communication is a core PC skill and essential for the successful integration of PC into HF management. This core intervention strategy should therefore be embedded in UG, PG and CPD education for all HCPs caring for patients with non-malignant illness such as HF. The literature strongly supported this strategy, showing that the HCPs (most prominently physicians in HF) required to initiate integrated PC into patients’ HF management did not believe they had adequate communication skills and as a result lacked confidence to have meaningful PC conversations from the point of a HF diagnosis, if appropriate, or soon after a diagnosis (CMOc 2.8). The ‘if appropriate’ caveat is important as not all patients are ready or want to discuss the life-limiting nature of HF, and that must be respected. Communication skills training should therefore also cover how to assess the communication and information needs of individual patients to ensure their perspective on what they want is heard and addressed. 61

Public health approach/messaging (CMOc 2.9)

A public health approach/positive messaging around PC was identified as a core intervention strategy to help dispel myths and public misunderstanding around PC. For example, both PC and HF were referred to as ‘loaded terms’ in the literature and by stakeholders, which, if misunderstood by patients and their informal carers, can generate strong emotional responses which made clinicians less motivated to talk about them. This overlaps with the reflective motivation component within the COM-B model, which proposes that reflecting on previous negative experiences can be a demotivator and prevent a behaviour from occurring (in this case integration of PC). In support of this theory, the literature showed that when clinicians experience discomfort with the terms PC and/or HF they may use language to soften a diagnosis/prognosis of HF, and avoid PC conversations because, like their patient, they do not fully understand that PC does not mean EoL care only, and do not want to erode the patient’s hope. However, the unintended consequence is that patients may be less aware of the seriousness of their illness or that they could be benefiting from a more holistic approach to their HF care that could help manage physical symptoms and improve their psychological, social and spiritual well-being. Stakeholders also raised similar issues around terminology throughout the stakeholder meetings. They discussed the confusion around the term ‘palliative care’, agreeing that PC is still largely associated with cancer and EoL care. To add to that, a diagnosis of HF can also sometimes be interpreted by patients as meaning impending death, with their heart about to fail at any moment. Although there was much debate among stakeholders, with patient partners strongly advocating for a change in the terminology of ‘palliative care’ to ‘supportive’ or ‘comfort care’ and a change in terminology from heart ‘failure’ to heart ‘function’ (see https://palliatheartsynthesis.co.uk/some-thoughts-on-terminology-a-patients-view/), there was consensus that the most important thing is for the meaning behind the terms to be understood by service providers and service users. That is: that PC is a beneficial component of care to help patients live well, and that it can be introduced if/when needed from the point of HF diagnosis to more advanced stages of the illness.

Evidence-based examples of good practice (CMOc 3) and guidelines embedded in undergraduate and postgradudate education (CMOc 6)

The final educational intervention strategies under the capacity component of the COM-B model included PC education that includes evidence-based examples of good practice and guidelines on who should be doing what, when and how in relation to integrating PC and HF for all HCPs involved in HF management. The reasons why both educational components are required for integrating PC into HF management are expanded on further under Opportunity and Motivation.

Protected time for and choice of educational setting (for example online, face to face, or hybrid) (CMOC 2.7)

As a recap, the opportunity component of the COM-B model proposes that individuals must have the required physical (time and resources) opportunities for behaviour change to occur. Therefore, providing evidence-based educational strategies is not enough to create behaviour change without due attention to the required opportunities. The literature and stakeholders both stressed the importance of having protected time for registered staff to attend training, and also highlighted the importance of ensuring that opportunities are maximised, such as holding training at the workplace and in the preferred format (which was face to face preCOVID-19 – this would need to be re-evaluated in a post-COVID-19 context).

Reconfiguration of services (CMOc 4) to:

• address required time and resources

• support MDTs working to build trusting relationships

• provide opportunities for shared learning that highlights common goals.

The literature and stakeholder discussions were also awash with references to lack of physical opportunity (lack of time and resources) to integrate PC into HF management. Stakeholders acknowledged that HF nurse specialists do consider holistic care including PC as key parts of their role; however, adequate staffing is necessary to provide time, and manage patient caseloads. Service developers and planners need to be cognisant of the importance of having adequate time throughout the patient’s journey and not just see PC discussions as a one-off conversation. There are issues around regional provision and integration of PC in HF as this varies across regions. In some areas, stakeholders referred to it as ‘fitting a square peg in a round hole’ when they were describing patients who have HF trying to access into local PC services. When considering resourcing across staff, provision is required and time needed for all relevant HCPs, including physiotherapy, occupational therapy, etc. as MDTs are crucial for building trusting relationships/highlighting common goals for improved patient outcomes and creating opportunities for shared learning within and across disciplines and settings. Planners and commissioners may express concern at the extra funding required but need to be made aware of longer-term savings from early integration of PC, as evidenced in the research literature. Stakeholders also highlighted the importance of learning from existing integrated PC and HF services which have successfully reconfigured their services without additional funding.

Guidelines for integrating palliative care and heart failure should be visible, easily accessible and their use prioritised, so that staff have clarity over expectations and roles, and patients receive the right care, from the right people, at the right time (CMOc 6)

Guidelines evaluate and summarise existing evidence in order to assist HCPs make evidence-based decisions around management of specific conditions for specific patient groups, and in consultation with patients and their informal caregivers. Guidelines can also be used for benchmarking against best practice, and as an educational tool to improve care quality and patient outcomes. 43 The importance of having guidelines was highlighted by our review findings, which identified the lack of clarity among HF nurses, HF physicians and GPs around who is responsible for initiating PC conversations, when this should happen and how often, as a key barrier to integrating PC and HF.

However, as with education, it is not enough to simply propose an intervention strategy without a full understanding of how it works, and in what circumstances. For example, the first position paper presenting guidelines for integrated PC for HF dates back to 2009,171 followed over a decade later by the most recent guidelines in 2020,23 yet little has changed in terms of their implementation26,27,30 and such implementation is noted to be inconsistent. 172

The realist analysis and synthesis of the literature helped uncover what strategies are required to optimise ‘use’ of integrated PC and HF guidelines. Unless these guidelines are visible, easily accessible and prioritised in routine clinical practice, they will not create behaviour change. As covered under the capacity component, embedding guidelines in UG, PG and CPD education is a key strategy to heighten their visibility and accessibility. Prioritising guidelines in clinical practice via policy support is also crucial to ensure their use in routine practice. These findings are supported by the wider literature on optimising implementation of guidelines, which include strategies such as strengthening awareness of specific guidelines with key stakeholders; supporting organisational changes to facilitate practitioners use of guidelines’ implementation; and motivating key stakeholders to use the guidelines173 This leads us into the motivation component of the COM-B model.

Increased awareness and seeing benefits of palliative care (CMOc 3)

According to the COM-B model, motivation is a core component necessary for behaviour change, meaning that the behaviour must be more desirable and important than other competing priorities. CMOc 3 identified the importance of increased awareness and seeing the benefits of PC for HF as key intervention strategies. However, stakeholders acknowledged cardiology as an evidence-driven discipline, and as such HF physicians may need to know what ‘dose’ of PC is required and have compelling evidence of why they need to integrate PC. However, what counts as evidence matters, and it can be challenging to generate evidence on effect sizes with complex phenomena – such as the integration of PC with HF.

Respected, influential champions (CMOc 3.1)

Stakeholders noted that evidence may win minds, but we also need to convince hearts, and so emphasised the importance of winning both hearts and minds. This is a term that can be understood in a number of ways, but essentially conveys an attempt to achieve a desired goal using emotive and intellectual appeals. The synthesis of the international evidence also supported the importance of conveying the emotive and intellectual need for integrating PC and HF via credible champions, seeing direct patient benefit, and evidence-based education. As already mentioned above, stakeholders emphasised the importance of sharing examples of good practice through visits and placements as this provides an excellent opportunity for clinicians to ‘see’ evidence of patient and health service benefit. Equipping and enabling all key players involved with PC and HF (e.g. patients, consultants, nurses and carers) to champion the value and need for integrated PC and HF can also help win over those who may not have considered PC as an important component of HF management. The role of patient champions can promote attitude change in cardiology HCPs and can help to break down barriers – as was the experience of some stakeholders from their own services.

Stakeholders recommended ensuring that evidence of benefit is relatable to key audiences, and this is reflected through their active involvement in refining implications (see Appendix 4). For example, in their experience, the cardiology community is data driven and value evidence of benefit from RCTs. Those in policy and commissioning value health economic data most, with patients valuing more patient specific outcome data.

MEDLINE

Host: Ovid

Data parameters: MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE

Date range searched: 1946 to present (Daily update)

Date searched: 11 November 2021

Searcher: CD

Hits: n = 842

EMBASE

Host: Ovid

Date range searched: 1974 to present (Daily update)

Date searched: 11 November 2021

Searcher: CD

Hits: n = 1219

PsycInfo

Host: Ovid

Date range searched: 1806 to present (weekly update)

Date searched: 11 November 2021

Searcher: CD

Hits: n = 153

AMED (Allied and Complementary Medicine)

Host: Ovid

Date range searched: 1985 to November 2021 (Monthly update)

Date searched: 11 November 2021

Searcher: CD

Hits: n = 112

CINAHL

Host: EBSCOhost

Date range searched: Unknown (from database inception to present)

Date searched: 11 November 2021

Searcher: CD

Hits: n = 742

HMIC (Health Management Information Consortium)

Host: Ovid

Date range searched: 1979 to September 2021 (Bimonthly update)

Date searched: 11 November 2021

Searcher: CD

Hits: n = 34

OpenGrey

Host: www.opengrey.eu (now archived)

Date range searched: Unknown (from database inception to present)

Date searched: 12 November 2021

Searcher: CD

Hits: n = 3

‘heart failure’ AND (palliat* OR hospice* OR ‘end of life’ OR ‘terminal care’ OR ‘supportive care’)

NICE Evidence search

Host: www.evidence.nhs.uk (now closed)

Date range searched: Unknown (from database inception to present)

Date searched: 12 November 2021

Searcher: CD

Hits: n = 1290 (Screened first 500 ‘on screen’, ranked by relevance)

‘heart failure’ AND (palliat* OR hospice* OR ‘end of life’ OR ‘terminal care’ OR ‘supportive care’)

Google

Host: www.google.com (Incognito window)

Date range searched: Unknown (from database inception to present)

Date searched: 12 November 2021

Searcher: CD

Hits: n = 143 (20,200,00 estimated; viewing 100 per page and screening ‘on screen’ only 143 were available to review)

‘heart failure’ AND (palliative OR hospice OR ‘end of life’ OR ‘terminal care’ OR ‘supportive care’)