COLLABORATING WITH PALLIATIVE CARE TEAMS TO PROVIDE END OF LIFE
CARE FOR PATIENTS WITH HEART FAILURE: AN INTEGRATIVE REVIEW

by

Melanie Starzyk
BScN., University of Alberta, 2005

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF SCIENCE IN NURSING: FAMILY NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
October 2017
© Melanie Starzyk, 2017

Abstract
Advanced heart failure (HF) can be difficult for nurse practitioners (NPs) to manage in primary
care due to the unpredictable nature of the condition. Further, barriers that patients with HF
experience in regards to receiving end of life (EOL) care hinder NP collaboration with palliative
care teams. The goal of the project is to answer: How can NPs working in a primary care setting
collaborate with palliative care teams to provide patients who have HF with EOL care? A
literature search was conducted using the Cumulative Index of Nursing and Allied Health,
PubMed Medline, PsychInfo, Social Work Abstracts and the National Guideline Clearinghouse
electronic databases. Evidence was also gathered using backward and forward reference
searching, and highly relevant grey literature from the BC Heart Failure Network. The Canadian
Interprofessional Health Collaborative (CIHC) framework was used to describe the theoretical
underpinnings of this paper by outlining the factors involved to achieve interprofessional
collaboration. There were 33 articles retrieved during the literature search to inform how NPs
can collaborate with palliative care teams for patients with HF at EOL. There were no articles
that answered the research question directly. Instead, barriers and issues for patients with HF
receiving EOL care were identified in the findings. Nurse practitioners can collaborate with
palliative care teams by addressing the barriers to EOL care for patients with HF that relates to
communication, leadership, role clarification, team functioning, and conflict resolution. Nurse
practitioners should be encouraged to collaborate with palliative care teams to improve
accessibility to palliative care for patients with HF at EOL. Future research is needed to directly
inform how collaboration can occur with palliative teams to provide patients who have HF with
EOL care.

ii

Table of Contents
Abstract ........................................................................................................................................... ii
Table of Contents ........................................................................................................................... iii
List of Tables ................................................................................................................................. vi
List of Figures ............................................................................................................................... vii
Acknowledgements ......................................................................................................................... ii
Dedication ...................................................................................................................................... iii
Chapter 1 ......................................................................................................................................... 1
Introduction ..................................................................................................................................... 1
Chapter 2 ......................................................................................................................................... 2
Background and Context................................................................................................................. 2
Concepts ...................................................................................................................................... 3
Heart failure ............................................................................................................................. 3
End of life. ............................................................................................................................... 4
Palliative care. ......................................................................................................................... 5
Nurse practitioners. .................................................................................................................. 8
Primary care. ............................................................................................................................ 8
Palliative care team. ................................................................................................................. 9
Collaboration. ........................................................................................................................ 10
The Model of Palliative Care .................................................................................................... 11
Team Management of Heart Failure ......................................................................................... 12
Palliative care referrals.. ........................................................................................................ 13
Unpredictable Disease Trajectory ............................................................................................. 13
Curative-restorative care versus palliative care. .................................................................... 14
Palliative care referral timing. ............................................................................................... 14
Prognostication of Heart Failure ............................................................................................... 15
Lack of Consensus Regarding the Definition of Palliative Care in Heart Failure .................... 16
Lack of Communication ............................................................................................................ 17
Summary ................................................................................................................................... 18
Chapter 3 ....................................................................................................................................... 20
Research Methods ......................................................................................................................... 20
Inclusion and Exclusion Criteria ............................................................................................... 20
Theoretical Framework ............................................................................................................. 21

iii

Levels of Evidence .................................................................................................................... 23
Chapter 4 ....................................................................................................................................... 24
Findings......................................................................................................................................... 24
Interprofessional Communication ............................................................................................. 26
Leadership ................................................................................................................................. 29
Challenges with the ability to predict the heart failure disease trajectory. ............................ 29
Early referral timing. ............................................................................................................. 30
Initiate advance care planning. .............................................................................................. 31
Role Clarification ...................................................................................................................... 34
Identify the palliative team members. ................................................................................... 34
Designate a leadership role. ................................................................................................... 35
Team Functioning ..................................................................................................................... 36
Use a holistic perspective. ..................................................................................................... 36
Build expertise. ...................................................................................................................... 37
Resolve uncertainties about the referral process to palliative care. ....................................... 38
Interprofessional Conflict Resolution ....................................................................................... 39
Chapter 5 ....................................................................................................................................... 42
Discussion ..................................................................................................................................... 42
Interprofessional Communication ............................................................................................. 43
Take Leadership ........................................................................................................................ 46
Address challenges with heart failure prognostication. ......................................................... 46
Initiate early referral timing. .................................................................................................. 47
Initiate advance care planning. .............................................................................................. 51
Address Role Clarification ........................................................................................................ 52
Identify the palliative team members. ................................................................................... 52
Designate a leader. ................................................................................................................. 52
Promote Team Functioning ....................................................................................................... 54
Use a holistic perspective. ..................................................................................................... 54
Build expertise. ...................................................................................................................... 55
Resolve uncertainties about the referral process to palliative care. ....................................... 58
Engage in Conflict Resolution .................................................................................................. 59
Limitations ................................................................................................................................ 60
Implications for Practice ............................................................................................................... 61
Future Research ............................................................................................................................ 62

iv

Conclusion .................................................................................................................................... 63
References ..................................................................................................................................... 65
Appendix A: Evidence Matrix of Literature Retrieved ................................................................ 79
Appendix B: Concept Matrix of Factors to Address in Achieving Collaboration ........................ 96
Appendix C: Collaborating with Palliative Care Teams to Provide End of Life Care for
Patients with Heart Failure.......................................................................................................... 100

v

LIST OF TABLES
Table
1.

Page
Headings, Medical Subject Heading Terms, and Search Terms Used in the
Literature Search…………………………………………………………………

75

2.

Comprehensive Search Strategy Used to Gather Evidence……………………...

76

3.

Inclusion and Exclusion Criteria of Research Methods Literature Search………

21

4.

Levels of Evidence………………………………………………………………

23

vi

LIST OF FIGURES
Figure

Page

1a.

Transition Model of Care……………………………………………………….

12

1b.

Trajectory Model of Care……………………………………………………….

12

2.

Heart Failure Illness Trajectory…………………………………………………

16

3.

Literature Search Flow Diagram for Search Conducted December, 2016……...

78

4.

The National Competency Framework................................................................

22

vii

Acknowledgements
I would like to express my deepest thanks to my advisory committee members Shannon
Freeman, PhD and Fiona Hutchison, MSc NP (F) for their continued commitment and guidance
in the process of composing this paper. My committee members allowed me to see the true value
in writing to contribute to furthering knowledge in my profession.
I have been fortunate to care for patients with heart failure in a community heart function
clinic setting. This experience has allowed me to play a role in the care that patients with heart
failure experience at end of life and as such, I have found that often their end of life needs go
unmet. In my experience, palliative care is not particularly implemented well despite the
emergence of this topic amongst the heart failure community and subsequent resource
development. One of the main issues is that palliative and end of life care can be difficult to
identify in heart failure due to the unpredictability of the condition. Second is that in my
experience, palliative care and end of life are not often discussed in practice with busy clinic
visits. If discussions do take place, they are often limited to code status and medication
withdrawal. Talks that do occur with patients are often limited to “you should get your affairs in
order” or “there’s not much else we can do”. Without comprehensive care discussions, the needs,
wishes, values, and preferences of patents with heart failure are not brought to the forefront and
implemented during end of life. Third, care providers frequently draw upon guidelines to direct
practice and in the case of heart failure care during end of life the available resources to guide
this care are often not utilized. As a result of these issues, patients approach end of life feeling
frightened and alone. As a practitioner, I have seen the emotional turmoil this has placed on our
patients with heart failure and have myself experienced a sense of helplessness in regards to how
to resolve this gap in care.

ii

Dedication

I dedicate this project to:


My children, Oliver and Isabel, whose unconditional love continually inspire my drive to
achieve;



My husband, Chris, whose support allowed me to persevere in the program;



My parents, Emily and Ben, whose love and commitment to helping with Oliver and
Isabel allowed me to focus on my studies;



My in-laws, Stephanie and Dziadek, who were also consistently open to helping with
Oliver and Isabel; and finally,



My two sisters-in-law, Arleta and Kathy, who would always be available at the last
minute to help with Oliver and Isabel.

iii

CHAPTER 1
Introduction
The unpredictable nature of advanced heart failure (HF) can make this condition difficult
to manage in primary care. Even though guidelines exist that provide direction for managing HF
in the advanced stages, not all patients receive care that completely reflects these
recommendations (Wordingham, McIlvennan, & Dionne-Odom, 2016). Guideline
recommendations indicate that palliative care teams should be coordinating care for patients with
HF at end of life (EOL) (Yancy et al., 2013) yet there is a limited amount of evidence to support
this in practice (Wordingham et al., 2016). Providing care for patients with HF at EOL can be
challenging for primary care providers as palliative care service tends to be limited in primary
care settings (Yancy et al., 2013). Despite the availability of resources to guide care for patients
with HF at EOL, the current use of these resources in primary care practice often go
underutilized (Kimel, Simpson, & Ignaszewski, 2014). As primary care providers, nurse
practitioners (NPs) play a key role in managing the care for patients with HF at EOL. To
optimize and improve EOL care for patients with HF, collaboration is needed amongst care
teams given the lack of uptake of available resources to guide EOL care.
The project seeks to answer the question: How can NPs working in a primary care setting
collaborate with palliative care teams to provide patients who have HF with EOL care? It is
imperative to note that answering how NPs can collaborate is a rather complex topic. The
methodology of the project is in the form of an integrative review. Review of the findings
provides practice recommendations for NPs including clinical implications and areas needed for
future research.

1

CHAPTER 2
Background and Context
The rate and prevalence of HF in adults, those over 18 years of age, is increasing
(Jaarsma, 2005). Compared with all other health conditions for older adults aged 65 years and
greater, HF is responsible for most admissions to hospital (Howlett, 2009). According to the
Canadian Chronic Disease and Injury Indicator Framework (2016), HF prevalence among those
greater than 40 years of age is 3.6% with an incidence rate of 522.6 per 100,000 persons (Public
Health Agency of Canada, 2009). The prevalence of HF is particularly noteworthy because the
majority of patients are older adults (Ahmed, 2003). Heart failure is a common diagnosis upon
discharge from hospital, also amongst older adult populations (McAlister, Stewart, Ferrua, &
McMurray, 2004) with an average one year mortality rate of 33% (Lee et al., 2004). In light of
the high mortality rate, not all patients with HF receive the palliative EOL care that they should.
End of life care, a component of palliative care, is considered to be care that is offered
once a patient approaches death. Estimates show that only 15% of Canadians have access to EOL
care when they need it (Quality End of Life Care Coalition of Canada [QELCCC], 2017), a
concerning reality that heavily impacts patient quality of life (QoL). As a result, many Canadians
die without adequate pain relief, feel isolated with a loss of dignity, and experience fear as they
approach death (QELCCC, 2017). As HF is a progressive and life-limiting condition, it is
essential that primary care providers identify when a patient is nearing or at EOL. Due to the
unpredictable nature of the HF disease process, identification of EOL is often difficult. To
provide patients who have HF with EOL care and to better support the patient’s QoL vision, NPs
should collaborate with palliative care teams. This chapter will identify and define the main
concepts including HF, EOL, palliative care, NPs, primary care, the palliative care team, and

2

collaboration. Additionally, this chapter will explore the barriers to patients receiving palliative
care in the setting of HF as these barriers considerably hinder NP collaboration with palliative
care teams. Barriers that impact multidisciplinary care for patients with HF at EOL include the
unpredictable disease trajectory of HF, a lack of consensus regarding a standard definition of
palliative care in HF, and a lack of communication.
Concepts
Heart failure. There are several classifications and stages of HF that NPs should
consider while collaborating with palliative care teams for patients at EOL. For the purposes of
this paper, HF will be defined as “a clinical syndrome defined by symptoms suggestive of
impaired cardiac output and/or volume overload with concurrent cardiac dysfunction” (British
Columbia [BC] Government, 2015, para 8). According to the Canadian Cardiovascular Society
consensus conference recommendation (2006), HF classification is according to symptom
severity with functional capacity categorized by the New York Heart Association (NYHA)
system I-IV; Class I (no limiting symptoms), Class II (symptoms with less than ordinary
activity), Class III (symptoms with regular activity), and Class IV (symptoms with no exertion)
(Arnold et al., 2006). Further, the American College of Cardiology and the American Heart
Association (ACC/AHA) Task Force (2005) classifies HF into stages A though D; Stage A
(asymptomatic, no structural heart disorder), Stage B (asymptomatic, structural heart disorder
present), Stage C (symptomatic; current or past structural heart disorder), and Stage D (patients
with HF at end-stage) (Hunt et al., 2005).
The signs and symptoms of HF commonly include: dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, fatigue, weakness, exercise intolerance, dependent edema, cough, weight
gain, abdominal distention, nocturia, and cool extremities (Arnold et al., 2006). Other signs and

3

symptoms less commonly associated with HF include: cognitive impairment, altered mentation
or delirium more common in the elderly, nausea, abdominal discomfort, oliguria, anorexia, and
cyanosis (Arnold et al., 2006). Symptoms of advanced HF may include recurrent exacerbations,
functional limitations, resistance to pharmacotherapeutic therapy, increased diuretic dosing,
worsening renal dysfunction, hypotension, weight loss, and recurrent implantable cardioverter
defibrillator (ICD) shocks (Hauptman & Havranek, 2005). A unique feature of HF is that there
can be movement between NYHA class and stage. The HF disease process does not always
follow a progressive predictable decline and proceed from one stage to the next. For example, a
patient in NYHA class IV, Stage C may undergo heart valve replacement surgery and then may
have NYHA class II symptoms and be in Stage A post-recovery.
End of life. The Canadian Institute for Health Information (CIHI) (2007) indicates that
EOL can be estimated based upon the four main types of EOL trajectories that exist. These
trajectories include sudden death, terminal illness, organ failure, and frailty (Lunney, Lynn, &
Hogan, 2002). In BC, the Ministry of Health (2013) developed an EOL action plan that defines
palliative care and EOL care but not the term end of life specifically. The action plan defines
EOL care as “care [that is] associated with advanced, life-limiting illnesses, and focuses on
comfort, quality of life, respect for personal health care treatment decisions, support for the
family, psychological, and spiritual concerns” (BC Ministry of Health, 2013, p. 2). The National
Institute on Aging (NIA) (2017) defines end of life care as “support and medical care given
[during] the time surrounding death [however] such care does not happen only in the moments
before breathing ceases and the heart stops beating” (para. 2). Of importance when determining
which patients with HF are at EOL and are requiring EOL care, the American Heart Association
(AHA, 2017) defines this stage as advanced heart failure. This advanced stage is when there is

4

little or no symptom improvement despite typical HF therapies including lifestyle restrictions,
and when symptoms are occurring with no exertion (AHA, 2017). Thus by recognizing the signs
of advanced HF, NPs can better understand when collaboration is needed to provide care at EOL.
The meaning of EOL can be interpreted in several ways, which may pose challenges for
NPs trying to collaborate with palliative care teams. The term end of life is often used
synonymously with end of life care although particularly when and how this transition occurs in
HF is not well-known. Nevertheless, both terms signify a pivotal stage in life for the patient with
HF as palliative care is beneficial to supporting the patient’s needs, preferences, and wishes.
If the term EOL is not fully understood by NPs, then there may be difficulty specifically
deciding how to implement EOL care for patients with HF. Misunderstandings regarding EOL
may be a barrier to accessing and implementing resources used to guide HF care during EOL in
the primary care setting. End of life care has been described by the Canadian Hospice Palliative
Care Association (CHPCA) (2013) as existing on the end of an illness continuum that begins
with an acute stage, leads to a chronic state, and then approaches the end of the continuum. The
CHPCA (2013) describes that EOL care encompasses advanced illness and is life threatening.
For the purposes of this paper, EOL will be defined using the CHPCA definition of EOL care as
it describes this type of care occurring along a continuum rather than during a fixed state, which
is a reflection of how patients with HF experience this stage.
Palliative care. The World Health Organization (WHO) (2016) defines palliative care as
“an approach that improves the quality of life of patients and their families facing the problem
associated with life-threatening illness” (para. 1). Further, the WHO (2016) indicates that
palliative care is a means to relieve suffering through “early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (para.

5

1). The Canadian Society of Palliative Care Physicians (CSPCP) (2016) indicates that palliative
care “includes, but is not limited to end-of-life care” (p. 6). Similarly, the CHPCA (2016) defines
palliative care as “a special kind of healthcare for individuals and families who are living with a
life-limiting illness that is usually at an advanced stage” (para. 1). The CHPCA (2016) indicates
that palliative care services are particularly advantageous to implement early in a disease
trajectory (2016).
In the context of this paper, the term palliative care will be defined using the CHPCA
definition of palliative care as this definition provides a clear indication when to initiate care (i.e.
early in the disease trajectory), for whom (i.e. patients with a life-limiting illness) and for what
type of care to provide (i.e. pain and symptom management). As palliative care and hospice
palliative care both encompass a vast spectrum of early-initiated care that aims to provide
holistic enhanced QoL for patients and families facing a life-threatening condition, both terms
will be used interchangeably in this paper (CHPCA, 2013).
According to Murray, Kendall, Boyd, and Sheikh (2005), the main goal of palliative care
is to enhance QoL in preparation for a death that meets the spiritual, psychological and social
needs of the person. Palliative care is thus continuously provided along a continuum of lifethreatening illness. In comparison, EOL care is provided during the end of an illness continuum
although is still part of palliative care. There are commonalities that exist between both palliative
care and EOL care and the main distinguishing factor is invariably time. Palliative care can exist
at any point in time during the course of HF illness while EOL is associated with a particular
point in time in HF, likely the point at which death is nearing.
According to the CHPCA (2017), the origins of palliative care date back to the fourth
century in Europe when Christians cared for sick people. The term palliative care originated in

6

the 1960’s and became associated with the notion of EOL (Lanken et al., 2008). Dr. Balfour
Mount, a Canadian physician, was the first to coin the term palliative care in 1974, which
denoted providing treatment to alleviate symptoms for dying patients (Feldberg, Ladd-Taylor, &
Li, 2003; Ottawa Citizen) (as cited in Lutz, 2011). Dr. Mount, the forefather of palliative care in
Canada, in 1973 arranged a seminar based on Elizabeth Kubler-Ross’s book On Death and
Dying (Kimel et al., 2014). It was during this time that Dr. Mount identified the gap in
knowledge about care for the dying (Kimel et al., 2014). From there, Dr. Mount organized a pilot
project in Montreal that featured the first inpatient consultation palliative program alongside a
patient ward and a follow-up grief and mourning program (Kimel et al., 2014). Dr. Mount’s
work was revolutionary, considered to have transformed the care of the dying and was also
considered paramount in highlighting the need for care that optimizes QoL (Kimel et al., 2014).
The term hospice evolved from the Latin Hospes that denoted traveller; this movement
saw homes established to care for the dying (Robbins, 1983) (as cited in Lutz, 2011). The terms
hospice and palliative care both convey the same standards of practice (CHPCA, 2013). As a
result, the term hospice palliative care was developed in the 1970’s to acknowledge the union of
the terms (CHPCA, 2013). Hospice palliative care recognizes that ideas, beliefs, and attitudes
surrounding illness and death are constantly changing and encompass a wide spectrum of
adaptation (CHPCA, 2013). The CHPCA (2013) indicates that there was a long-standing belief
that hospice palliative care need only be implemented in the few weeks leading up to death,
although this belief has since changed. Hospice palliative care has evolved in recent times to
encompass the entire spectrum of illness, not just the immediate period just prior to death
(CHPCA, 2013). Hospice palliative care has been defined by the CHPCA (2013) as “aim[ing] to
relieve suffering and improve the quality of living and dying” (p. 6). As communication and

7

decision-making are central to palliative care and given both patients and families are considered
integral in this process, they are both included in the concept of palliative care (Goodlin, 2009).
Many terms have been used interchangeably with palliative care, which creates
misunderstandings for primary care providers regarding the meaning of palliative care (Hui et
al., 2012). For example, the terms EOL care, care of the dying, and terminal care has been used
synonymously with palliative care. Misunderstanding regarding palliative care service, like
confusion regarding EOL, is a barrier to NP implementation of resources to provide patients who
have HF with EOL care. It is therefore imperative to distinguish between EOL and palliative care
for patients with HF as the two terms have different meanings.
Nurse practitioners. As primary care providers, NPs are registered nurses (RNs) with
advanced education and training that allows them to diagnose and treat and array of health
conditions, order diagnostics, and prescribe medications (Canadian Nurses Association [CNA],
2011). Regulation for NP practice in BC was initiated in 2005 (College of Registered Nurses of
British Columbia [CRNBC], 2016). Using a holistic approach NPs can practice in a variety of
settings, which includes community care, long-term care, hospitals, and NP-led clinics (CRNBC,
2016; CNA, 2016). Nurse practitioners incorporate patient decision-making into care, increase
access to primary care, lessen system-based pressures, are considered well-valued, and provide
exceptional chronic disease management (CNA, 2016). Fundamentally, NPs consolidate medical
diagnoses and treatment with nursing-based principles and standards (CNA, 2016).
Interprofessional collaboration is patient-centered (CRNBC, 2017a) and is an NP competency
that occurs throughout all levels of care provision.
Primary care. It is important to distinguish primary care from primary health care as the
two concepts are often used interchangeably but are actually two different concepts with

8

differing meanings (Muldoon, Hogg, & Levitt, 2006). To delineate between the two, primary
care can be thought of as the service provided by primary care providers while primary health
care involves patient care in relation to public system functions (Muldoon et al., 2006). Primary
care does not include the system functions of health care (Muldoon et al., 2006). The
Government of Canada (GOC, 2012) defines primary care as “the element within primary health
care that focuses on health care services, including health promotion, illness and injury
prevention, and the diagnosis and treatment of illness and injury” (para. 1). Thus primary care is
concerned with all factors that impact health including level of education, income, housing, and
the environment (GOC, 2012).
Within Canada, primary health care serves to provide the delivery of care through initial
contact providers including general practitioners, NPs, and pharmacists (GOC, 2012). Many
patients with HF are managed within primary care, an aspect of primary health care. For the
purposes of this discussion, primary care will refer to an ongoing and comprehensive provision
of care by a primary care provider while primary health care will refer to care provided in the
context of health systems (Muldoon et al., 2006).
Palliative care team. Specific members of the palliative care team vary depending on the
care needs of each individual patient. In terms of care delivery, the CHPCA (2013) indicates that
hospice palliative care is “most effectively delivered by an inter-professional team of healthcare
providers who are both knowledgeable and skilled in all aspects of care within their discipline of
practice” (p. 7). Additionally, Fendler, Swetz, & Allen (2015) indicate that the components of
the palliative care team consist mainly of primary care, cardiology, and palliative care in addition
to patients and their caregivers.

9

Individual health care members mentioned in the literature have specifically identified
physicians, advanced care providers, and RNs (Fendler, et al., 2015) highlighting that there is a
lack of mention of the NP role on the palliative care team. Nurse practitioners may guide HF care
throughout the entire course of the illness. As NPs coordinate EOL care needs for patients with
HF as the primary care provider, the role of the NP on the HF palliative care team is needed. In
regards to this paper, the members of the palliative care team for patients with HF at EOL will
include NPs, physicians, specialists, RNs, allied health services, patients, their family members,
and caregivers as these are the typical team members involved in providing HF care.
Collaboration. Providing patients who have HF with EOL care requires collaboration.
Collaboration has been defined as “the situation of two or more people working together to
create or achieve the same thing” (Collaboration, 2016). According to the WHO (2010) and on a
global scale, collaborative practice is when “multiple health workers from different professional
backgrounds provide comprehensive services by working with patients, their families, carers,
and communities” (p. 13) to coordinate effective care throughout all practice settings.
According to Buckman, Byock, & Fry (2000) communication is considered the most
crucial component of providing effective patient-centered care (as cited in Albert, Davis, &
Young, 2002). It has been noted that communication can enhance patient-family care satisfaction
and support overall patient compliance (Albert et al., 2002). To build from this, the Canadian
Interprofessional Health Collaborative (CIHC) (2010) identifies that the underpinnings of
patient-centered care include collaborative practice. Interprofessional collaboration has been
defined by the CIHC (2010) as “a partnership between a team of healthcare providers and a
client in a participatory, collaborative, and coordinated approach to shared-decision making
around health and social issues” (p. 24). To develop this partnership, the CIHC (2010) indicates

10

that collaborative leadership, role clarification, team functioning, and interprofessional conflict
resolution be taken into consideration. Hence, collaboration is not only considered a means of
communication but is also a partnered approach. The CIHC framework (2010) will form the
basis of the discussion of this project by focusing on the factors involved that NPs can use to
achieve interprofessional collaboration and provide patients who have HF with EOL care.
The Model of Palliative Care
The model of palliative care in Canada has evolved over time to one that now encompass
measures that should be implemented early in the course of the illness trajectory versus just prior
to death. Advances in health care have also led to longer life expectancies which focus attention
on chronic illness and life-limiting disease management (GOC, 2016). The pain and suffering
that patients who are palliative experience in the time leading to death, whether days or years,
sought the need to establish a palliative care approach that was not localized to hospitals but was
extended to the community where the patient could chose to die at home (GOC, 2016). Also, HF
illness trajectories and palliative care in Canada have evolved from a transition model to a
trajectory model of care as shown in Figure 1 (Murray et al., 2005). To date, neither Canada, nor
the provinces or territories have established palliative care strategies or policies in place to help
guide palliative care goals for the population as a whole (GOC, 2016).
Nurse practitioners provide care to patients with HF at different points in the disease
trajectory and can provide EOL care in the primary care setting. Therefore NPs are essential in
the provision of palliative care for patients with HF particularly at EOL and should play a
notable role on palliative care teams.

11

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In 2009, a BC provincial strategy led by Cardiac Services BC was initiated, the BC Heart
Failure Network, which sought to improve HF care across BC within all health authorities
(2016). The BC Heart Failure Network aims to promote collaboration amongst all other BC
health authority regions in terms of developing HF quality indicators, patient and provider care
resources, educational support, research and guidance (2016).
Palliative care referrals. As part of a multidisciplinary collaboration, palliative care
referrals should be initiated to provide patients who have HF with EOL care. Collaboration with
the palliative team is necessary as palliative care interventions have been shown to reduce
symptom burden and enhance QoL during EOL (Gomes, Calanzani, Curiale, McCrone, &
Higginson, 2013). Despite these known benefits, HF referrals to palliative care continue to be
very small in number (Wordingham et al., 2016). A systematic HF approach to care has shown to
have better patient outcomes, improved QoL, more follow-up, and improved mortality rates
(Jaarsma, 2005). Therefore adding a specialty palliative approach to HF may also improve care.
For this reason, NPs in primary care should be responsible for coordinating this multidisciplinary
approach for their patients with HF, particularly as patients develop to an advanced stage of HF.
Unpredictable Disease Trajectory
Heart failure has an unpredictable disease trajectory as illustrated in Figure 2 (Hupcey et
al., 2009). The care management of HF is challenging to coordinate despite the availability of HF
guidelines to direct care through worsening and progressive stages (Wordingham et al., 2016).
Because of these care management challenges, Murray et al. (2002) indicate that HF
management for patients at a worsening point in the disease is not ideal. Additionally, HF
prognostication can be difficult to estimate as some patients will recover from an exacerbation
and some will not and subsequently become deceased. Thus for primary care NPs, recognizing

13

when patients with HF are nearing EOL may be difficult possibly leading to missed opportunities
to provide the benefit of palliative care when needed.
Curative-restorative care versus palliative care. Historically, a curative-restorative
care approach to illness management is typically employed and then exhausted before palliative
care is implemented (Lanken et al., 2008). Alternatively, another approach indicated by Lanken
et al. (2008) includes an interrelated model of curative-restorative and palliative care that
outlines that an increasing amount of palliative intervention corresponds with a reduction in
curative-restorative intervention. The most ideal, Lanken et al. (2008) suggests a combined
model by which a patient would receive a palliative approach alongside a curative-restorative
approach.
There is a misconception regarding the care that is delivered during palliative care; there
is a common thought that treatments to delay the progression of illness cease (Health Quality
Ontario, 2016). An approach to palliative care, on the other hand includes the need for the
approach to be early, including treatment to improve the QoL for the patient for the duration of
the illness (Zimmerman et al., 2014). Palliation should not be considered solely transitional care
(Figure 1a) as predicting the HF disease trajectory and mortality is challenging (Albert et al.,
2002). Hence to provide the most optimal holistic care, the need for palliative care should be
recognized by the NP at the point of diagnosis and should be discussed with the patient to align
patient wishes and values with the illness trajectory (Figure 1b and Figure 2).
Palliative care referral timing. Nurse practitioners should identify the optimal timing to
collaborate with palliative care teams to support patients with HF in receiving the benefit of
palliative EOL care. There are three phases in HF according to Jaarsma et al. (2009). Stage I
consists of chronic disease management that is typical of NYHA I-III and includes symptom

14

control and monitoring; Stage II is considered the palliative and supportive stage whereby a
patient may need inpatient care and the patient may be showing signs of NYHA III-IV; and
Stage III, which is considered the terminal phase (Jaarsma et al., 2009). Both Stage II and III
correspond with the ACC/AHA Stage C/D. Thus Stage II is a prime point at which palliative
care could be implemented, a point at which goals of care could be realigned to optimize
symptom management and QoL (Jaarsma et al., 2009). For the purposes of this paper, the
process of palliative care in HF should begin once care providers recognize the patient is
ACC/AHA Stage C and experiencing NYHA Class III symptoms.
Prognostication of Heart Failure
The survival rate in HF is estimated to be 66% in the first year, 50% over the course of
two years, and 35% over a span of five years (Kimel et al., 2014). Despite the high mortality
rate, palliative care measures are underutilized for patients with HF (Jaarsma et al., 2009;
Kaasalainen et al., 2011). Kimel et al. (2014) state that the reason for this care underutilization in
HF in comparison to other life-threatening conditions is because “prognostication is much less
reliable for HF” (Kimel et al., 2014, p. 225).
There are several prognostic tools available in HF (McKelvie et al., 2011). The Seattle Heart
Failure Model (SHFM) is one example of a prognostic tool that can be used by care providers
(McKelvie et al., 2011). Kimel et al. (2014) indicate that even though prognostication tools are
available, they should not replace the value of clinical judgement. Despite knowing that
prognostication in HF is challenging, the focus should be on symptom management early in the
HF disease process (Kimel et al., 2014). Care providers should recognize that patients with HF
whom have comorbidities, several symptoms, reduced QoL, and/or psychosocial issues need to
be referred to palliative care (Kimel et al., 2014).

15

Figure 2. Heart failure illness trajectory.
Phase ➀ - Initial symptoms of heart failure develop and heart failure treatment is initiated
Phase ➁ - Plateau of variable length reached with initial medical management, or following
mechanical support or heart transplant
Phase ➂ - Functional status declines with variable slope; intermittent exacerbations of heart
failure that respond to rescue efforts
Phase ➃ - Stage D heart failure, with refractory symptoms and limited function
Phase ➄ - End of life
Dotted lines represent sudden cardiac death that can occur anytime during the trajectory.
Note. Reprinted from Goodlin, S. J. (2009). With permission from The Canadian Care Network.
Lack of Consensus Regarding the Definition of Palliative Care in HF
To provide patients with EOL care, NPs should have an understanding of the meaning of
palliative care in HF when collaborating with palliative teams. As there are several ways to
describe progressive worsening in HF including advanced HF, end-stage HF, and EOL in HF,
the literature is often unclear in specifically describing when these stages occur. Differing views
on the end stages of HF further complicate matters for care providers trying to decide when to
provide patients who have HF with EOL care. Further making accessing palliative care difficult
is the lack of services that target palliative care for HF populations (Hupcey et al., 2009). To
16

highlight this issue, Pantilat & Steimle (2004) indicate that although palliative care has been
identified as an essential component to overall HF management, it has been reported that less
than 10% of patients with HF receive palliative care intervention. A common misunderstanding
among care providers is that palliative care is exclusively for those patients immediately prior to
death, which may account for an often untimely palliative care transition (Ward, 2002).
There has been only a limited number of pilot studies completed to date that have
evaluated multidisciplinary palliative care along the HF continuum due in part to a lack of
consensus regarding the meaning of EOL in HF (Fendler et al., 2015). There also appears to be a
lack of consensus specifically regarding when and where to initiate palliative care services aside
from the notion that early intervention is essential (Fendler et al., 2015). The lack of clarity
regarding the meaning of EOL in HF and an absence of clear indications for palliative referral
are barriers to patients receiving palliative care management.
Lack of Communication
In practice, care providers tend to refrain from using the term heart failure when
discussing the condition with their patients (Murray, Boyd, Sheikh, Thomas, & Higginson,
2004). Thus patients may not truly be informed that they have HF which leads to
misunderstandings regarding the diagnosis (Barnes et al., 2006). Barnes et al. (2006) found that
impaired communication about HF between the patient and the primary care provider often
stemmed from challenges with accurately diagnosing the condition, prognostic uncertainty, fear
of eliciting patient anxiety, and difficulties with conveying this information back to the patient in
understandable terms. Undermining a true understanding of the condition, the study showed that
health care providers would tend to avoid using the term heart failure and would instead use

17

euphemisms to describe the condition or would describe HF in terms of symptoms (Barnes et al.,
2006).
General practitioners recruited reported they felt more disruption in communication
particularly around diagnosis and prognostication of HF when there was an increase in the
number of care providers involved in the care management of patients (Barnes et al., 2006). To
enhance patient understanding of their HF condition, perceived disruption in communication thus
requires role clarification of the multidisciplinary team members individually. Communication is
considerably important amongst all multidisciplinary team members involved in caring for
patients with HF at EOL and needs to be delivered effectively to convey the care needs of the
patient.
Summary
Palliative care should be provided early in the HF illness trajectory instead of just prior to
death. Planning for EOL care in Canada continues to be uncommon (Fowler & Hammer, 2013)
and there are also many challenges that providers face in the provision of care for patients with
HF at EOL. First, the HF illness trajectory is one that is typically not well predicted. This
uncertainty paired with limited prognostication makes it difficult to identify if a patient with HF
is nearing EOL, which hinders planning for this stage. Also, EOL is just one small aspect of
palliative care (CHPCA, 2013) although defining EOL and palliative care in the context of HF
continues to be problematic. Second, referrals to palliative care are low for patients with HF as
well as referrals to HF clinics, an area of service more likely to implement palliative care
measures. Most patients with HF can be managed by general practitioners unless the patient is
experiencing a high symptom burden (Kimel et al., 2014). This is an indication that the primary
care environment is an ideal place for NPs to manage patients who have HF with prompt

18

recognition of patient decline and early palliative care service referral. Third, lack of
communication between care providers, their patients, and families complicates needed
discussions regarding HF at EOL. It is therefore important to explore how NPs working in a
primary care setting can collaborate with palliative care teams to provide EOL care for patients
with HF because of the unpredictable HF disease trajectory, a lack of prognostication, a lack of
consensus that defines palliative care in HF, and a lack of communication.

19

CHAPTER 3
Research Methods
To gather evidence to inform the project question: How can NPs working in a primary
care setting collaborate with palliative care teams to provide patients who have HF with EOL
care?, a literature search was performed. The Patient, Intervention, and Outcome (PIO) model
was used to form the research question and to guide the literature search strategy (Hoffman,
Bennett, & Del Mar, 2013). The Cumulative Index of Nursing and Allied Health (CINAHL),
PubMed Medline, PsychInfo, Social Work Abstracts, and the National Guideline Clearinghouse
databases were searched in December, 2016. Keyword search terms and medical subject
headings (MeSH) related to the research question included such terms as: nurse practitioner,
family physicians, primary care, collaboration, palliative care teams, end of life, terminally ill
patients, heart failure, and ventricular dysfunction (see Tables 1 & 2; Figure 3). In addition to the
database search, highly relevant grey literature sources were also retrieved from the BC Heart
Failure Network as they were found to be directly applicable to the NP role for palliative EOL
care in HF.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria were developed to identify articles related to the concepts
in the research question (see Table 3). Primary care was included as this setting is where NPs
may collaborate with palliative care teams to provide EOL care for patients with HF. In Canada,
the age of majority varies by province between 18 and 19 years (GOC, 2017). Studies that
included youth and children under the age of 19 years were excluded as this group is beyond the
scope of this project. Articles written in languages other than English were excluded. Only
research studies were included. Finally, date limiters were not chosen to narrow the search as

20

there is limited knowledge on the subject topic and all articles may be useful to inform the
research question.
Table 3
Inclusion and Exclusion Criteria of Research Methods Literature Search
__________________________________________________________________________
Inclusion
Exclusion
__________________________________________________________________________
Nurse Practitioners
Under 19 Years
General Practitioners
Non-English Language
Primary Care Setting
Non-Peer Reviewed Literature
Collaboration
Palliative Care Teams
End of Life
Heart Failure
__________________________________________________________________________
Theoretical Framework
A national interprofessional competency framework was developed in 2010 by the CIHC.
The CIHC consists of members from different health organizations and includes educators,
researchers, health professionals, and students within Canada and is a part of the College of
Health Disciplines from the University of British Columbia in Vancouver, Canada (2010). The
premise of the framework is the belief that education and collaborative practice with a focus on
patient-centered care is fundamental to healthcare team building and will simultaneously
improve patient experiences and subsequent outcomes (CIHC, 2010) (see Figure 4). The
framework was developed in response to a lack of interprofessional competencies that impact
patient care in Canada (CIHC, 2010). The first Canadian framework developed to guide
interprofessional collaboration, the CIHC (2010) framework can be applied to all health
professions. The CIHC (2010) national interprofessional competency framework identifies that
21

the underpinnings of patient-centered care include collaborative practice. Interprofessional
collaboration has been defined by the CIHC (2010) as “a partnership between a team of
healthcare providers and a client in a participatory, collaborative, and coordinated approach to
shared-decision making around health and social issues” (p. 24). To develop this partnership, the
CIHC lists four domains that include collaborative leadership, role clarification, team
functioning, and interprofessional conflict resolution, that are supported by the domains of
interprofessional communication and patient/client/family/community centered-care (2010).

Figure 4. The National Competency Framework.
Note. Reprinted from The Canadian Interprofessional Health Collaborative (2017). With
permission from John, H. V. Gilbert granted May 23rd, 2017.

22

Collectively, the six domains of the CIHC framework contribute to effective
interprofessional collaboration (2010). Hence, collaboration is not only considered a means of
communication but is also a partnered approach. Therefore, the CIHC (2010) national
interprofessional competency framework has been chosen for this project as it directly describes
the theoretical underpinnings of this paper by outlining the factors involved to achieve
interprofessional collaboration.
Levels of Evidence
The level of evidence is the identification of the research design used in the study and is
based upon a hierarchical order (Collaborative Center for Integrative Reviews and Evidence
Summaries [CCIRES], 2011) (see Table 4). The evidence classification below includes the
following levels of evidence that have been used to grade the methodologies of the articles
retrieved in the literature search (CCIRES, 2011) for the purpose of identifying what types of
evidence currently exist to inform the research question.
Table 4
Levels of Evidence
Level of Evidence
Level A

Description
 Meta-analysis of large or small sample randomized control
trials (RCTs) or meta-syntheses of qualitative studies
Level B
 Well-designed controlled studies that includes randomized
and non-randomized designs, prospective or retrospective
studies, and integrative reviews
Level C
 Qualitative studies, both descriptive or correlational,
integrative reviews, systematic reviews, or RCTs with
inconsistent results
Level D
 Peer-reviewed professional organization standards; the
recommendations are supported by clinically-based studies
Level E
 Case reports, expert opinions, case studies, consensus of
experts, and literature reviews
Level MA
 Manufacturers recommendations and anecdotes
Level LR
 Laws and regulations
(Collaborative Center for Integrative Reviews and Evidence Summaries [CCIRES], 2011)
23

CHAPTER 4
Findings
The CIHC framework posits that collaboration is not solely limited to communication
(2010). Collaboration involves “developing and maintaining effective interprofessional working
relationships with learners, practitioners, patients/clients/families and communities to enable
optimal health outcomes” (CIHC, 2010, p. 8) and is based on the principles of “respect, trust,
shared decision-making, and partnerships” (p. 8). For collaboration to occur according to the
CIHC framework (2010), the principles of communication, patient/client/family/community
centered-care, leadership, role clarification, team functioning, and conflict resolution should be
acknowledged in practice. In the context of the CIHC framework, NPs can apply these principles
to understand how to collaborate with palliative care teams for patients with HF at EOL.
The final search of the literature resulted in a total of 33 articles (see Figure 3). The
majority of the evidence was level C (n=23), given most of the studies were methodologically
similar and utilized a qualitative design, followed by level E evidence (n=8). Specifically the
levels of evidence included: a level A systematic review and meta-analysis combined study
(n=1), level B and C prospective cohort studies (n=2), level C guidelines (n=3), level C
systematic reviews (n=2), a level C retrospective cohort study (n=1), a level C pilot study (n=1),
level C descriptive designs (n=14), level C and E literature reviews (n= 6), a level E scientific
statement (n=1), a level E consensus conference (n=1), and a level E case report (n=1) (see
Appendix A). The majority of the literary evidence was found to have taken place in the United
States (U. S.) (n=19) and the United Kingdom (U. K.) (n=6). Two articles and one guideline
were published in Canada and four articles were published in Australia, Belgium, Germany, and
Sweden respectively. The three guidelines and the scientific statement were published between

24

2011 and 2013. Eight of the articles were published between 2002 and 2007. Twenty two articles
were published between 2008 and 2017. Regional grey literature EOL tools recommended from
the BC Heart Failure Network, to guide BC care providers in managing EOL care for patients
with HF, were also included as the content was considered highly relevant to the research
question. Based on the literature retrieved, factors that NPs can use and should address to
achieve collaboration with palliative care teams were grouped according to the domains of the
CIHC framework (2010) (see Appendix B).
To collaborate with palliative care teams, NPs should recognize the barriers to EOL care
for patients with HF. Although collaboration in healthcare aims to improve health outcomes
(CIHC, 2010), NPs need to identify barriers to EOL care that may prevent patients with HF from
receiving care that reflects the patient’s preferences, values, and wishes. Of the 33 articles
retrieved, 19 articles identified barriers to receiving EOL care for patients with HF. These
barriers include lack of communication, challenges with the ability to predict the HF disease
trajectory, uncertainty regarding management decisions, and uncertainties about the referral
process to palliative care. Nurse practitioners can provide EOL care for their patients with HF by
addressing the barriers to EOL care through working collaboratively with palliative care teams.
In review of the findings, there was little mention of NPs as the primary provider for
patients with HF at EOL. Instead, the literature discussed primary care physicians providing such
care. While there is a gap in the literature that describes the NP role for patients with HF at EOL,
in practice, NPs do provide care to patients with HF at EOL. Therefore, it is reasonable to
analyze the research findings from a primary care provider perspective and apply the findings to
both primary care physicians and NPs. Even so, despite findings that suggest how physicians can

25

collaborate with palliative care teams for patients with HF at EOL, the literature that describes
this process is not clear.
Interprofessional Communication
Interprofessional communication is an essential component of interdisciplinary
collaboration (CIHC, 2010). Without clear communication, NPs may have difficulty
collaborating with palliative care teams to provide their patients who have HF with EOL care.
Thus NPs need to understand that a lack of communication has been found to be a common
barrier to EOL care for patients with HF (Appendix B). Literature shows that amongst study
participants, there was confusion regarding which specific palliative team member would be
fulfilling a particular role in the palliative care planning for patients with HF at EOL (Wotton et
al., 2005). In particular, there was a lack of communication regarding the overall coordination of
palliative care (Wotton et al., 2005). Like Wotton et al. (2005), Lewis & Stephens (2005) also
found that overall a lack of communication played a notable role in preventing optimal palliative
care for patients with HF at EOL.
Further, Kaasalainen et al. (2011) found that poor communication between clinicians was
a barrier to successful collaborative efforts in managing the care of patients with HF at EOL.
This can be exemplified by a pharmacist in the study stating “we’re trying to encourage the
physician to communicate with the pharmacist via the prescription, I’ve had patients try to
reorder medications that the doctors had intended to stop” (Kaasalainen et al., 2011, p. 47). Poor
communication was also experienced between patient participants and their care providers
(Kaasalainen et al., 2011). This lack of communication is reflected in the statement, “I guess the
doctors were telling me there wasn’t much they could do…but just the other day I was at the
heart clinic and they said there were still things they could do for me” (Kaasalainen et al., 2011,

26

p. 50). Gaps in informed consent and poor understanding of the HF disease trajectory and
prognosis were found to be the result of poor communication (Rogers et al., 2000; Murray et al.,
2002) (as cited in Lewis & Stephens, 2005). Overall, a common finding was that an insufficient
amount of information was relayed to palliative patients with HF (Aldred et al., 2005; Dougherty
et al., 2007; Horne & Payne, 2004; Murray et al., 2002) (as cited in Hopp et al., 2010).
Consequently, the experiences of patients with HF collaborating with the health care system
were found to be inadequate during EOL (Hopp et al., 2010).
Patients may struggle between trying to preserve their longevity and trying to accept a
palliative label (Kaasalainen et al., 2011). Similarly, resistance to embrace palliative care has
also occurred amongst family members and was found to be due to a reluctance to accept their
loved one would be facing death (Kaasalainen et al., 2011). Unpredictability in the HF disease
trajectory can lead to patient misunderstandings regarding their health status at EOL
(Kaasalainen et al., 2011). Patient misunderstandings are particularly evident when there is a
mismatch between how the patient feels and an advanced HF prognosis (Kaasalainen et al.,
2011). For example, given the unpredictable trajectory in HF, a patient may have an
improvement in symptoms and still be considered to be in an advanced stage of HF. Thus if
patients do not have a firm understanding regarding their HF prognosis, collaboration may be
difficult to achieve. Findings also show that patients who decline palliative care service did so
often as a result of a lack of understanding for or a failure to acknowledge the need for the
transition to palliative care service (Kaasalainen et al., 2011). Therefore to promote
collaboration, NPs should communicate with patients and resolve misunderstandings so patients
with HF can receive the benefit of palliative care at EOL. By promoting this partnership with the
palliative care team, NPs can support the patient to resume control over their care (CIHC, 2010).

27

Shared decision-making was found to be an integral aspect of communication for patients
with HF at EOL (Allen et al., 2012). Davidson et al. (2004) discussed The St. George Heart
Failure Model that included collaborative palliative care. To address poor communication,
Davidson et al. (2004) attributed successful palliative care services as being very willing to
provide “education, mentorship, and expert consultancy when required” (p. 72). Anticipation,
timing, and review have been identified as communication techniques used to facilitate shareddecision making for patients with advanced HF (Allen et al., 2012). For example, an annual heart
failure review to discuss goals of care can be used to anticipate health events (Allen et al., 2012).
The guideline by McKelvie et al. (2011) gave direction regarding how EOL discussions should
be structured for patients with HF. Specifically, two communication tools (McKelvie et al.,
2011) were identified that can be used collaboratively by NPs and palliative teams to provide
EOL care: the Assessing Patient Readiness for EOL Discussions and the Framework for
Conducting EOL Discussions with HF Patients (McKelvie et al., 2011). The communication
tools can provide NPs with an opportunity to collaboratively engage in EOL conversations with
patients with HF while also promoting a patient-centered approach to EOL care.
Collectively, the findings show that poor communication adversely affects the care of
patients with HF at EOL (Davidson et al., 2004; Lewis & Stephens, 2005; Wotton et al., 2005;
Hopp et al., 2010; Kaasalainen et al., 2011) (Appendix B). Poor communication was noted
amongst healthcare systems, between clinicians, and through patient interactions. There was no
evidence to suggest how NPs in particular can resolve issues with communication that prevents
collaboration for patients with HF at EOL. Nurse practitioners should understand that barriers to
communication may prevent collaboration from occurring. It should be said that collaboration
can still occur between palliative team members even when communication is considered poor.

28

Effective communication between palliative team members benefits patients with HF by
facilitating a team understanding of patient care goals and through promoting collective decision
making and responsibility (CIHC, 2010) during EOL.
Leadership
Leadership supports the process of collaboration (CIHC, 2010). Nurse practitioners
should take leadership to address challenges with predicting the HF trajectory, initiate palliative
care referrals, and initiate advance care planning (ACP) (Appendix C) to provide EOL care for
patients with HF. Predicting the HF disease trajectory, initiating palliative referrals and initiating
ACP were found in the literature (Seamark, Ryan, Smallwood, & Gilbert, 2002; Hanratty et al.,
2002; Goodlin et al., 2004; Lewis & Stephens, 2005; Gott et al., 2007; Hauptman, Swindle,
Hussain, Biener, & Burroughs, 2008; Boyd et al., 2009; Beckelman et al., 2011; LeMond &
Allen, 2011; Kaasalainen et al., 2011; McKelvie et al., 2011; Allen et al., 2012; Dev, Abernethy,
Rogers, & Connor, 2012; Michigan Quality Improvement Consortium, 2012; De Vleminck et al.,
2014; Dunlay et al., 2014; Evangelista et al., 2014a; Evangelista, Liao, Motie, De Michelis, &
Lombardo, 2014b; Gadoud et al., 2014; Kavalieratos et al., 2014; Fendler et al., 2015; Afshar,
Geiger, Muller-Mundt, Bleidorn, & Schneider, 2016; Chandar et al., 2016).
Challenges with the ability to predict the HF disease trajectory. Missed opportunities
for collaboration with palliative teams may occur if NPs have difficulty predicting prognoses for
their patients with HF at EOL. In the findings, primary care providers identified an inability to
accurately predict when patients with HF reached EOL or were near death (Hanratty et al., 2002;
Seamark et al., 2002; Goodlin et al., 2004; Lewis & Stephens, 2005; Gott et al., 2007; Hauptman
et al., 2008; Boyd et al., 2009; Kaasalainen et al., 2011; McKelvie et al., 2011; De Vleminck et
al., 2014; Kavalieratos, et al., 2014). To address the challenges with predicting prognosis,

29

prognostication tools were identified in the literature for patients with HF at EOL (McKelvie et
al., 2011).
Tools for HF prognostication for patients with HF at EOL include the Enhanced
Feedback for Effective Cardiac Treatment (EFFECT) Heart Failure Mortality Prediction, the
Seattle Heart Failure Model (SHFM), the Heart Failure survival score (HFSS), and generic tools
such as the surprise question, the Palliative Performance Scale (PPS), and the Karnofsky
Performance status (McKelvie et al., 2011). To “provide some prognostic guidance” (2011, p.
327) for patients with HF at EOL, NPs should take leadership and consider the use of these tools
in practice.
Early referral timing. Findings show that palliative care referral timing is an important
aspect in providing EOL care for patients with HF (Bekelman et al., 2011; LeMond & Allen,
2011; Michigan Quality Improvement Consortium, 2012; Evangelista et al., 2014a; Evangelista
et al., 2014b; Gadoud et al., 2014; Kavalieratos et al., 2014; Dunlay et al., 2015; Fendler et al.,
2015; Afshar et al., 2016). Yet, there is no current consensus that defines the specifics of
referrals including how this should take place or when the timing of palliative care services
should occur. Even though early palliative referrals are preferred for patients with HF at EOL,
early referrals do not always occur in practice (LeMond & Allen, 2011). The timing of referrals
to palliative care for patients with HF is commonly based upon provider preference (LeMond &
Allen, 2011), which may postpone the EOL care that patients need. Delayed referrals to
palliative care for patients with HF at EOL can be exemplified in a study by Gadoud et al. (2014)
whom investigated entry timing for both patients with cancer and patients with HF. Gadoud et al.
(2014) found that 30% of patients with HF in the study were not registered for palliative care
until one week before dying and that approximately 50% of patients with HF were only

30

registered six weeks before dying (Gadoud et al., 2014). This trend in delayed referrals to
palliative care can be further supported by Dunlay et al. (2015) who found clinician participants
reported discussing EOL preferences with patients who have HF primarily only when the
condition of the patient deteriorated.
Nurse practitioners should take leadership and use the Supportive and Palliative Care
Indicators Tool (SPICT) and the Gold Standards Framework (GSF) to collaboratively work with
palliative care teams to provide EOL care. The SPICT was identified as a useful tool that can be
used by care providers to recognize the need for palliative care in HF because it lists general
health and disease indicators to help assess when a palliative approach may be needed (Afshar et
al., 2016). The GSF, an approach now utilized worldwide to enhance palliative care, was also
identified in the findings as a way to address patient care needs at EOL (Afshar et al., 2016). The
GSF also highlights healthcare organizational practices that can be targeted to improve palliative
care (Afshar et al., 2016). Although patient characteristics that suggest a palliative approach may
be needed for patients with HF (Afshar et al., 2016), there was no literature found that
specifically outlines the exact time that palliative care referrals should be initiated.
Initiate advance care planning. Collaboration with the palliative care team occurs
during the process of ACP, a time when providers are promoting EOL care that is patientcentered and adapted to meet the needs of the patient (CHPCA, 2010). Nurse practitioners can
collaborate with palliative care teams by taking leadership and initiating ACP by sharing and
developing a care plan that reflects the patient’s values, and wishes for EOL. While shareddecision making during the process of ACP engages patients to make EOL decisions that suit
their preferences, ACP can be used by NPs to collaborate with palliative care teams to tailor the
care plan to the patient’s wishes for EOL.

31

The need for ACP for patients with HF at EOL was found to be a central aspect of EOL
care in the literature (McKelvie et al., 2011; Dev et al., 2012; Michigan Quality Improvement
Consortium, 2012; Afshar et al., 2016; Chandar et al., 2016) because it is a way to communicate
patient preferences. Findings suggest ACP for patients with HF should occur to support patient
decision making at EOL (McKelvie et al., 2011; Dev et al., 2012; Chandar et al., 2012; Ahia &
Blais, 2014; Afshar et al., 2016) to enhance patient-centered care. Advance care planning is also
necessary for EOL planning given the unpredictable disease trajectory in HF (Ahluwalia &
Enguidanos, 2015). Further, ACP can “var[y] greatly by subspecialty” (Chandar et al., 2016, p.
5) suggesting that leadership is needed to initiate the process of ACP between a variety of
settings.
One aspect of ACP is the development of advance directives (i.e. the living will).
Evidence to support advance directives for patients with HF at EOL, comes from the Study to
Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) (Dev
et al., 2012). The SUPPORT trial “provides the most comprehensive summary of advance care
planning maneuvers in the advanced HF setting” (Dev et al., 2012, p. 314). Evidence from the
trial suggests that to consistently plan for the completion of advance directives, care providers
should engage patients and provide them with advantages towards completing the directive (Dev
et al., 2012). There was although no recommendation for the use of advance directives in
practice for patients with HF specifically at EOL or for collaborative purposes. As patient
engagement is collaborative and as patients with HF are members of the palliative team, ACP is
a way for NPs to take leadership and collaborate to provide EOL care for patients with HF.
In regards to location, 75% of cardiologists and 84% of primary care providers agreed
that ACP should begin in the outpatient setting (Chandar et al., 2016). In comparison to specialty

32

providers who may only see a patient on one occasion, NPs in primary care may see their
patients on multiple and successive occasions. Therefore NPs can initiate and discuss patient
wishes regarding ACP in primary care.
To collaborate with palliative care teams for patients with HF at EOL and in relation to
ACP, NPs can take leadership and initiate the use of the Advanced Heart Failure Personal Action
Plan EOL tool and the implantable cardioverter defibrillator (ICD) deactivation clinical practice
guideline from the BC Heart Failure Network (2017b). As the BC Heart Failure Network is
committed to collaborative practice within BC, the action plan has been specifically developed to
be used in practice and shared between the patient and providers caring for patients with HF at
EOL (BC Heart Failure Network, 2017a). Specific to both HF and EOL care, these documents
are highly relevant to this project as they have been implemented into practice and are currently
being utilized by primary care providers, including NPs throughout BC (2017b).
Both the action plan EOL tool and the ICD deactivation guideline can be used
specifically for collaboration between NPs and palliative care teams by sharing ACP specific
information that will support a standardized palliative team approach towards ACP and overall
HF EOL care management (BC Heart Failure Network, 2017d). For example, the personal action
plan can be completed together by the patient and the NP to document collaborative decisions for
symptom and psychological management as well as the collaborative team approach needed to
succeed in meeting those management decisions (BC Heart Failure Network, 2017c). The patient
can then share the personal action plan with other members of the palliative care team to convey
EOL preferences in regards to ACP, such as during a cardiologist follow-up visit. All members
of the palliative care team can utilize the personal action plan by the BC Heart Failure Network

33

(2017c) to collaborate by promoting a common understanding of the patient’s preferences for
EOL care.
Role Clarification
Through role clarification, “practitioners understand their own role and the role of others
and use this knowledge appropriately to establish and achieve patient/client, family, and
community goals” (CIHC, 2010, p. 12). Aspects of role clarification, including identifying team
member roles and designating a leadership role to oversee EOL care for patients with HF, were
identified in six of the articles (Hanratty et al., 2002; Davidson et al., 2004; Daley, Matthews, &
Williams, 2006; Boyd et al., 2009; Fendler et al., 2015; LaDonna et al., 2016) (Appendix B).
Identify the palliative team members. Nurse practitioners may have difficulty
providing a coordinated and collaborative approach to HF management at EOL if the specific
team members involved are unknown. To facilitate a team-based collaborative approach, team
members should be identified because of the complexity of HF care management, particularly
during EOL (Fendler et al., 2015). Identification of individual palliative team members is
essential as there may be multiple team members with varied levels of training that support
patients with HF at EOL in a specific and unique way (Fendler et al., 2015). The term palliative
care team is well-known in healthcare although an understanding of the individual members that
comprise the team remains vague in practice as inclusion may vary between teams.
The patient, the carer, the primary care provider, the palliative care medical specialists,
palliative care nursing, occupational therapy, pastoral care, physiotherapy, social workers, and
volunteers were identified as part of the palliative care team by Davidson et al. (2004).
Additionally, members from day therapy, psychologists, practical nurses, and hospice inpatient
caregivers have been identified as other possible individual palliative team members (Daley et

34

al., 2006). A family member or caregiver, a nurse, a family physician or cardiologist,
nephrologists to manage advanced renal dysfunction, palliative care specialists, other specialists,
pharmacists, and other non-specified allied health professionals have also been identified as
members of the palliative care team (LaDonna et al. 2016). Nevertheless, the findings lack
clarity for NPs regarding the purpose of the palliative care team member composition and
specific role responsibilities for the care of patients with HF at EOL. As collaboration is a central
component to a team management approach to HF, organizing role responsibilities should occur
to optimize the health outcomes for the patient (CIHC, 2010).
Designate a leadership role. Multiple palliative team members managing patients with
HF at EOL can create uncertainties regarding individual team roles (Daley et al., 2006). This can
be exemplified in a study that found “one [participant] described how he felt no one ‘in
authority’ was overseeing him, which caused him concern” (Daley et al., 2006, p. 598). In HF
disease management, the primary care provider may also refer to other specialities such as
cardiology and possibly nephrology (i.e. in cases of progressive renal dysfunction) for HF
management assistance that results in a shared approach to care.
Despite the lack of evidence that outlined specific palliative team role responsibilities, the
findings suggested “a key professional to coordinate care, provide personalized information and
support self-management” (Boyd et al., 2009, p. 770). Similarly, Hanratty et al. (2002) stated
“…it should be the physician who’s interested [in HF care management], the general
practitioner, the district [specialist] nurse” (Hanratty et al., 2002, p. 583). Further, several of the
study participants also believed that the general practitioner was the fundamental team member
in palliative care for patients with HF (Hanratty et al., 2002). Nurse practitioners can assume a
leadership role and facilitate collaboration with the rest of the palliative team because an ideal

35

palliative team leader is a central care provider (Hanratty, 2002; Boyd et al., 2009; Fendler et al.,
2015).
Team Functioning
To facilitate effective interprofessional collaboration, team members should “develop a
set of principles for working together that respects the ethical values of members” (CIHC, 2010,
p. II). Elements of team functioning in the literature were found to include, promoting a holistic
perspective and building expertise (Davidson et al., 2004; Diop, Rudolph, Zimmerman, Richter,
& Skarf, 2017; Hauptman et al., 2008; Kaasalainen et al., 2011; McKelvie et al., 2011; Yancy et
al., 2013; Brännström & Boman, 2014) (see Appendix B).
Use a holistic perspective. A holistic perspective is one that incorporates the physical,
psychological, spiritual, and psychosocial aspects into care and strengthens the care provider’s
awareness of the patient’s needs (Zamanzadeh, Jasemi, Valizadeh, Keogh, & Taleghani, 2015).
Collaboration contributes towards promoting a holistic perspective for patients with HF at EOL
(Kaasalainen et al., 2011) because it helps palliative teams work towards reaching patient goals.
This is demonstrated by one nurse describing “[the] need for a good multidisciplinary team that
looks at things like function, things in the home, energy-conserving techniques…somebody
[patients] can talk to about their fears” (Kaasalainen et al., 2011, p. 47). To support team
development practices in achieving multidisciplinary care (Diop et al., 2017; Kaasalainen et al.,
2011), NPs should promote a holistic perspective for patients with HF at EOL given a holistic
perspective underlies all aspects of the nursing profession (Zamanzadeh et al., 2015).
Findings show that “the studies with improvement in the largest number of outcomes
prioritized the integration of interdisciplinary HF and PC [palliative care]” (Diop et., 2017, p.
89). To understand how to provide this all-inclusive care, optimal team functioning requires that

36

team members “share information needed to coordinate care with each other and patients,
families, and communities to avoid gaps, redundancies, and errors that impact both effectiveness
and efficiency of care delivery” (CIHC, 2010, p. 14).
In the literature it is also suggested that health outcomes for patients with HF at EOL may
improve with the combination of primary care HF and palliative team comprehensive care (Diop
et al., 2017). Diop et al. (2017) noted QoL outcomes improved by 83%. Brännström and Boman
(2014) found a statistical improvement in higher QoL measures from baseline (p=0.02) amongst
patients with HF at EOL who were involved in the new model of holistic palliative care, the
palliative advanced home care and heart failure care (PREFER) model, in comparison to the
control, those who received usual care. The comprehensive, holistic palliative care model
proposed by Davidson et al. (2004) posits a multidisciplinary approach to EOL care in HF
although there was little description of how to implement the model in practice. Yancy et al.
(2013) indicated comprehensive palliative care is of benefit for patients with HF at EOL to
improve QoL although there was no specific direction for practice implementation.
Build expertise. Building expertise in EOL care for patients with HF is needed. To
support the palliative team in caring for patients with HF at EOL, NPs should build HF symptom
management expertise to better provide continuity of care. Despite established recommendations
that guide HF in terms of medical treatment, there is a lack of evidence that outlines specific
palliative care measures during the EOL period for persons with HF (Kaasalainen et al., 2011).
Building expertise was identified by Kaasalainen et al. (2011) as a need in HF management
during EOL while McKelvie et al. (2011) outlined symptom management for patients with
advanced HF. Care providers should consider that these recommendations have not been
formally peer-reviewed. Findings also give direction for the organization of HF care that

37

suggests utilization of the chronic care model (CCM) based on the Canadian Heart Health
Strategy and Action Plan (McKelvie et al., 2011).
In the study by Kaasalainen et al. (2011), most of the health professionals reported that
further HF expertise was needed to manage patients at EOL. Study participants expressed a “lack
of confidence” (p. 46) in the overall treatment for HF, including pharmacological management
and technology (i.e. ICD) (Kaasalainen et al., 2011). Nurses and the physicians voiced concern
over the multiple numbers of medications that patients with HF are often prescribed at EOL and
noted uncertainties surrounding when opioids ideally should be added to the regime (Kaasalainen
et al., 2011).
Nurse practitioners can address knowledge deficits in the care of patients with HF at EOL
by contributing to the knowledge base regarding pharmacological and technological treatment. In
particular, NPs can use the findings by McKelvie et al. (2011) who provides symptom
management guidance for practitioners in managing care for patients with HF at EOL. Also, the
BC Heart Failure Network EOL tools include clinical practice guidelines for heart failure
symptom management that can be used by NPs to build expertise and strengthen team
functioning (2017b).
Resolve uncertainties about the referral process to palliative care. Patients with HF
may not receive the benefit of palliative care at EOL if uncertainties related to palliative care
referrals exist. While palliative referral processes and criteria may differ across health
jurisdictions, referrals to EOL care have been found to be relatively uncommon in practice for
patients with HF (Hauptman et al., 2008).
Despite identifying these uncertainties regarding the palliative referral process, there was
no clear indication that suggests how NPs may resolve this issue. Hauptman et al. (2008) found

38

that 64% of cardiologists, 45% of geriatricians, and 68% of internal medicine physicians and
family practice general practitioners were uncertain about the right time to initiate a palliative
referral. Further, 47% of cardiologists, 56% of geriatricians, 44% of internal medicine physicians
and family practice general practitioners in the study were concerned about their patients with
HF not being accepted by palliative care services despite completion of a referral to the team
(Hauptman et al., 2008). Thus as a result of uncertainty, NPs may experience challenges
collaborating with palliative care teams if the palliative referral process is not clear for patients
with HF at EOL. Also, NPs may not refer patients to palliative care if barriers to acceptance are
likely to be encountered.
Interprofessional Conflict Resolution
Interprofessional conflict resolution supports “developing a level of consensus among
those with differing views; allowing all members to feel their viewpoints have been heard no
matter what the outcome” (CIHC, 2010, p. IV). Resolving conflict is thus necessary to achieve
successful interprofessional collaboration (CIHC, 2010). Even though conflict is often avoided,
conversely team members should “value the potential positive nature of conflict” (CIHC, 2010,
p. III). Findings show that conflict can arise when “an intervention desired by a patient may
appear discordant with the patient’s stated goals and/or medical realities, and clinicians must
explain why it is not warranted” (Allen et al., 2012).
In setting goals of care for patients with HF at EOL, a six-step approach identified in the
literature includes the identification and resolution of conflict (Ahia & Blais, 2014). One family
member stated “Dad has always been a fighter, so we’re not giving up. We believe in miracles”
(Ahia & Blais, 2014), exemplifying that family may not want to accept an EOL HF prognosis,
which may result in conflict within the palliative care team. Nurse practitioners should recognize

39

potential sources of conflict between members of the palliative care team that may prevent
collaboration for patients with HF at EOL. Such sources of conflict may be the result of “role
ambiguity, power differences, and differences in goals” (CIHC, 2010, p. IV). Ahia and Blais
(2014) noted the steps in identifying and resolving conflict. These steps include recognizing the
source of the conflict (e.g. gaps in knowledge, uneven treatment goals between physicians,
emotionally-related issues, family issues, and grief), focusing on the conflict with the goal to
resolve it, and utilizing statements that express empathy (Ahia & Blais, 2014). Although not
identified specifically in the case report as part of the medical team, NPs can use the six-step
approach outlined in Ahia and Blais (2014) to set goals of care. By setting these goals and
identifying and resolving conflicts, the patient’s wishes can become aligned with HF medical
management (Ahia & Blais, 2014). Conflict may persist between palliative team members
although attempts to resolve conflict should be made by NPs to collaborate in providing EOL
care for patients with HF.
To improve patient-centered EOL care for patients with HF, NPs can also implement
measures suggested by Allen et al. (2012) that focus on conflict resolution. These include: (Allen
et al., 2012)


Emphasizing the therapies the patient is currently receiving relative to how such therapy
aligns with their goals of care.



Addressing the patient’s emotional motivation behind the HF management.



Clarifying any misunderstandings regarding HF therapies.
In summary, barriers and issues related to patients with HF receiving EOL care have been

identified. To collaborate with palliative care teams to provide EOL care for patients with HF,
ways to address these barriers and issues in the findings can therefore be used by NPs. These

40

ways to collaborate focus on communication, taking leadership, role clarification, promoting
team functioning, and conflict resolution.

41

CHAPTER 5
Discussion
As noted in the literature, many patients with HF at EOL do not receive the palliative
care they need (Wotton et al., 2005). For that reason, to provide EOL care that reflects patient
preferences, wishes, and values, NPs should work together collaboratively with palliative care
teams. Despite recognition that collaboration is needed for patients with HF at EOL, the term
collaboration is used loosely and specifics on how practitioners should collaborate are lacking in
the literature. By utilizing the CIHC framework (2010), NPs can collaborate with palliative team
members by optimizing communication, taking leadership, clarifying team roles, optimizing
team functioning, and resolving conflict (Appendix C).
Even though the literature does not exclusively focus on communication-based strategies
to facilitate collaboration as might be expected, communication is essential to the process of
collaboration (CIHC, 2010). There are communication tools specific to HF that can guide NPs in
discussing EOL with patients (McKelvie et al., 2010). To resolve misconceptions that may
prevent the patient with HF at EOL from receiving palliative care, patient engagement should
occur as an aspect of collaborative communication (Appendix C). Additionally, NPs can take
leadership to engage and collaborate with palliative care teams. This can be done by utilizing HF
prognostication tools to communicate prognosis with patients and other providers, initiating early
palliative care referrals, and initiating ACP discussions to communicate patient care preferences
for EOL (Appendix C). Moreover, NPs can collaboratively engage in palliative team role
clarification by defining and communicating the roles of individual team members and by
liaising with the palliative team for leadership and direction (Appendix C).

42

Furthermore, NPs can collaborate by optimizing palliative team functioning through the
implementation of a holistic perspective that incorporates the PREFER model. Nurse
practitioners can also build expertise through information sharing with the team and can
communicate uncertainties about the referral process to palliative care (Appendix C). Lastly, to
resolve conflict that may arise amongst the team, NPs can collaboratively engage in
interprofessional conflict resolution by utilizing the six-step approach outlined by Ahia and Blais
(2014) and by utilizing the steps towards conflict resolution by Allen et al. (2012) (Appendix C).
Interprofessional Communication
Communicating patient and family needs is integral to establishing holistic patient care in
palliative care. Jaarsma, Brons, Kraai, Luttik, & Stromberg (2013) suggested that a
multidisciplinary approach to HF occur across the disease trajectory. A multidisciplinary
approach may lead to enhanced communication and more consideration given to patient values, a
more efficient recognition of referral to specialists, and perceived improvement during EOL for
patients with HF (Jaarsma et al., 2013). Additionally, as there is a shortage of specialist palliative
care services throughout Canada (CSPCP, 2016), Fendler et al. (2015) have suggested that a
shared-care multidisciplinary model, one that enhances the stream of care between primary and
specialist care, be used for all patients with HF. Lead coordination of the palliative care team at
the beginning stages of illness is considered a favourable step in organizing a multidisciplinary
approach (Fendler et al., 2015). Communication is required as part of interprofessional
collaboration as it supports the principles of team work, conveys an understanding of care
decisions, works to encourage trusting relationships, and seeks to efficiently use information
with the goal of improving patient health outcomes (CIHC, 2010). Providers can use
communication to support collaborative practices by promoting patient/client/family/community-

43

centered care, effective leadership, team functioning, role clarification, and resolution of conflict
(CIHC, 2010).
Poor communication within healthcare systems, between clinicians, and between care
providers and patients can lead to ineffective collaborative relationships and possible conflict
among palliative team members. In review of the literature, ways communication can be used to
collaborate for patients with HF at EOL were unclear. Lewis and Stephens (2005) described
ineffective communication practices for patients with HF at EOL, although only mention a
“multidisciplinary approach” (p. 565) as a potential solution. Additionally, the St. George Heart
Failure Model described by Davidson et al., (2004) succeeded as a result of effective
communication practices between teams, “in particular the readiness of the palliative care service
to provide education, mentorship, and expert consultation when required” (p. 72). However, in
this statement by Davidson et al. (2004) it is unclear what the types of communication are used
to collaborate.
Patients desire an efficient transition to palliative care when they have been adequately
prepared over the course of care provider discussions (Kaasalainen et al., 2011). The guideline
identified two communication tools, the Assessing Patient Readiness for EOL Discussions and
the Framework for Conducting EOL Discussions with HF Patients that can be used to inform NP
practice (McKelvie et al., 2011). Nurse practitioners can also share these tools with the palliative
care team for future collaboration with patients with HF. For example, the Assessing Patient
Readiness for EOL Discussions tool can be shared by providers on the palliative team and used
as a continuous collaborative tool versus on just one occasion. This should be done because
patients with HF may choose to discuss EOL periodically as they may not retain large amounts
of information. To support patient readiness, the Framework for Conducting EOL Discussions

44

with HF Patients tool can be shared and used between providers, as patients with HF at EOL are
likely to have multiple care interactions. Hence, a collaborative approach can be used to guide
EOL discussions in a consistent manner with the use of the communication tools identified by
McKelvie et al. (2011). It is important that NPs also consider other established palliative EOL
tools that focus on communication that may be available.
Lack of communication (Wotton et al., 2005; Lewis and Stephens, 2005; Kaasalainen et
al., 2011), confusion (Wotton et al., 2005), and patient misunderstandings (Kaasalainen et al.,
2011) were found to impact the collaborative process for patients with HF at EOL. As such, NPs
should be consistent with the way they communicate. Communication should guide EOL
discussions while also supporting the patient as a member of the team and should be authentic
and transparent while conveying respect and trust (CIHC, 2010). Nurse practitioners should also
be attentive towards non-verbal cues (CIHC, 2010).
Issues with communication should be addressed by NPs on an ongoing basis during the
care of patients with HF at EOL. The CIHC competencies to communicate effectively that can be
used by NPs include “establish[ing] teamwork communication principles, actively listen[ing] to
[all] team members, communicat[ing] to ensure [a] common understanding of care decisions,
develop[ing] trusting relationships, [and] effective[ly] using information and technology” (2010,
p. III). An annual HF review recommended by Allen et al. (2012) is a practical example that
provides NPs with an opportunity to support communication and collaborative efforts with the
palliative team. Although meeting annually to discuss HF EOL care is important in supporting
the patient’s needs, NPs should arrange for the team to meet more than on an annual basis.
Meetings can be arranged to take place quarterly as patients with HF at EOL may experience a
high symptom burden (Gadoud et al., 2014); an approach better suited towards addressing

45

ongoing palliative care needs and treating symptoms. Palliative team members could meet via
teleconference and an agenda item could focus on the review of communication that occurred
amongst the palliative team since the previous meeting. Nurse practitioners should thus
recognize that communication is an important consideration to providing patients who have HF
with EOL care.
Take Leadership
Address challenges with heart failure prognostication. Difficulties with HF
prognostication may result in palliative care referrals occurring too late in the trajectory
(Hanratty et al., 2002). Although challenges with HF prognostication are a barrier towards
patients with HF receiving EOL palliative care (Hanratty et al., 2002; Goodlin et al., 2004; Lewis
& Stephens, 2005; Gott et al., 2007; Hauptman et al., 2008; Kaasalainen et al., 2011; De
Vleminick et al., 2014), many of the articles did not indicate how to resolve this issue. Despite a
lack of evidence, NPs can take leadership and improve HF prognostication by implementing the
tools identified in the literature including the EFFECT Heart Failure Mortality Prediction, the
Seattle Heart Failure Model (SHFM), the Heart Failure survival score (HFSS), and generic tools
such as the surprise question (i.e. asking oneself if you would be surprised if the patient passed
away within the year), the Palliative Performance Scale (PPS), and the Karnofsky Performance
Status (McKelvie et al., 2011). By utilizing HF prognostication tools on an ongoing basis, NPs
can identify EOL earlier in the HF trajectory and lead the initiation of EOL care.
Both the PPS and the Karnofsky Performance Status (McKelvie et al., 2011) may be used
by NPs to evaluate functional limitations for patients although should not be relied upon to
assess mortality as these tools are not specific to HF. The EFFECT Heart Failure Mortality
Prediction tool is not a clinically appropriate choice for NPs to assess mortality risk from HF in

46

primary care as the tool is indicated for the hospital setting (Canadian Cardiovascular Outcomes
Research Team, 2016). The SHFM has been prospectively validated and is considered an
accurate tool for estimating one, two, and three-year survival rates (University of Washington,
2015) and thus can be used by NPs in primary care for HF prognostication. While use of the
SHFM is a tool to predict HF prognosis, the tool also provides an opportunity for NPs to
collaboratively engage with the patient so they have the opportunity to express their specific
preferences for treatment during EOL. The surprise question can be used to guide NPs to
consider the use of the SHFM. From there, the SHFM score can be utilized by NPs not only for
HF prognosis but also collaboratively to communicate prognosis with the patient and when
appropriate with palliative team members for transition to EOL care.
In summary, while the surprise question and the SHFM are both useful in guiding NPs
with HF prognostication, it is important to consider that the tools lack diagnostic utility for EOL
(Levy et al., 2006; White, Kupeli, Vickerstaff, & Stone, 2017). Even in the setting of prognostic
uncertainty, NPs can use the available HF prognostic tools and their clinical judgement to guide
practice and discussions with patients and the palliative team to predict if the patient is nearing
EOL.
Initiate early referral timing. Referrals to palliative care offer NPs the opportunity to
collaborate with palliative teams to provide EOL care for patients with HF. Although early
palliative care referrals are preferred (LeMond & Allen, 2011), the timing remains vague. There
is a lack of evidence that suggests when NPs should initiate referrals to palliative care for
patients with HF. An appropriate approach to palliative care referrals is to initiate a discussion
with the patient and assess if palliative care aligns with the patient’s goals of care. By engaging
with the patient, NPs are thus taking leadership and collaborating in shared-decision making.

47

Nurse practitioners can provide patients who have HF with EOL care by contacting palliative
care services early on in the HF disease trajectory for care suggestions and advice. Palliative care
referrals should not be initiated if the patient does not envision palliative care as part of their
EOL plan. A HF palliative referral should take place prior to a patient reaching the EOL stage as
the CHPCA indicates that palliative care services should be implemented early in a disease
trajectory (2016b) and given palliative care occurs along an illness continuum.
Indicators that can be used to predict which patients with HF likely benefit from a
palliative care assessment include: (BC Heart Failure Network, 2017c)


Asking: Would one be surprised if the patient were to die in the following six to
12 months?



A poor performance status (i.e. diminished self-care, unable to leave the bed or
chair for most of the day, or deterioration); several hospitalizations within the
past six months; more home care that is required or the patient resides in a home
care facility; the presence of multiple comorbidities that cause deterioration.



The presence of two or more of the following: NYHA III-IV as a result of
valvular disease or coronary artery disease that cannot be reversed through
surgery or angioplasty; continuous breathlessness or chest pain in light of the
patient being treated with optimal medication therapy; renal dysfunction with a
GFR < 30 ml/min; cachexia; reduction in lean body mass; reduction in muscle
strength; anorexia; fatigue and abnormal chemistry values; presence of anemia
with a hemoglobin < 115; uric acid > 565; albumin < 32; and two or greater
occurrences whereby the patient required intravenous therapy within the past six
months (i.e. furosemide and/or inotropes) (BC Heart Failure Network, 2017c).

48

Stage II HF as outlined by Jaarsma et al. (2009) corresponds with ACC/AHA Stage C/D
and NYHA Class III/IV and is the stage at which early referrals to palliative care should be
made. Once recognizing when the patient has reached Stage II HF, NPs can educate their
patients that this is a preferred time for entry into palliative care (Jaarsma et al., 2009). In
practice however, NPs may find recognizing when the patient has reached Stage II HF
challenging particularly if the patient does not report worsening symptoms. To avoid the EOL
conversation occurring during an acute deterioration of health, NPs should consider initiating the
palliative referral prior to the patient requiring inpatient care.
Eligibility criteria for palliative care is a major challenge for NPs trying to collaboratively
initiate an early palliative referral during Stage II HF. In practice, palliative care teams in BC
often have eligibility criteria that precludes patient acceptance to a palliative care program if life
expectancy is more than six months (Northern Health [NH], 2015). If NPs try and refer patients
to palliative care early, the referral may be declined if the patient with HF at EOL does not meet
the palliative eligibility criteria thereby limiting the ability of initiating the referral early. Another
challenge for NPs is that life expectancy of six months or less is required for the patient with HF
to become eligible to receive palliative care benefits (BC Ministry of Health [MoH], 2017).
A recent guideline released by the BC Government (2017), The Palliative Care for the
Patient with Incurable Cancer or Advanced Disease, indicates that palliative care should be
initiated early in the course of advanced disease. While recognizing the need for early palliative
care in chronic disease, the guideline does not address the current life expectancy eligibility
criteria barrier to access palliative care services that many patients with HF are likely to
experience.

49

Despite the barriers to receiving palliative care as mentioned above, useful practice tools
have been identified in the findings that can assist NPs in predicting the need for palliative care
in HF and in providing support for entry into a palliative care program. These tools include the
SPICT and the GSF (Afshar et al., 2016). The SPICT can be used by NPs “to identify people at
risk of deteriorating and dying… for holistic, palliative care needs assessment and care planning”
(The University of Edinburgh, 2017, para 1). Of note, Afshar et al. (2016) does not provide
specifics for how the SPICT can be practically applied for patients with HF at EOL. Nurse
practitioners can refer to the SPICT for patients who may be deteriorating or dying by
identifying indicators of worsening health such as patients requiring assistance with personal
care, weight loss greater than 5-10%, and a persistence of symptoms despite treatment
optimization (The University of Edinburgh, 2017). Nurse practitioners can also refer to the heart
and vascular disease section of the tool as a clinical indication for palliative care planning in HF
(The University of Edinburgh, 2017). Clinical indicators prompting the NP to initiate the
palliative care referral includes the presence of ‘NYHA class III-IV heart failure or extensive,
untreatable coronary artery disease; with breathlessness or chest pain at rest or on minimal
effort” (The University of Edinburgh, 2017, p. 1). As part of initiating the referral to palliative
care, the SPICT also prompts the NP to evaluate the current treatment regimen to optimize
medication therapies, to resolve the problem of polypharmacy, to evaluate the need for specialist
referral for consistent difficulties with symptom burden, and to collaboratively engage in
conversations for patients with HF at EOL and their family regarding the future plan, decisionmaking, and care coordination (The University of Edinburgh, 2017).
In addition to the SPICT, the GSF was also identified by Afshar et al. (2016) as a clinical
tool that providers can use to approach palliative care for patients with HF at EOL. Similarly to

50

the SPICT, Afshar et al. (2016) did not indicate specifically how the GSF should be implemented
in practice. Nurse practitioners can utilize the GSF, “a systematic, evidence based approach to
optimising care for all patients approaching end of life”, (para. 3, 2017) including enrolling in
training programmes to better provide EOL care.
Initiate advance care planning. Advance care planning is needed for patients with HF at
EOL (McKelvie et al., 2011; Dev et al., 2012; Michigan Quality Improvement Consortium,
2012; Afshar et al., 2016; Chandar et al., 2016). A lack of ACP practice tools and provider time
restraints inhibit ACP discussions for patients with HF at EOL (Chandar et al., 2016). Nurse
practitioners can utilize the Advanced Heart Failure Personal Action Plan from the BC Heart
Failure Network (2017a) as a tool related to ACP to collaborate with the patient and to record
patient preferences for care and decisions related to care (2017a).
Nurse practitioners should consider that even though there was a lack of ACP tools
specific to HF in the findings, the BC guideline, My Voice: Expressing My Wishes for Future
Health Care Treatment is an ACP document often used in practice for patients with HF during
EOL. To collaboratively engage the patient in establishing their goals of care for EOL, NPs
should continue to use the My Voice ACP document, in addition to the action plan by the BC
Heart Failure Network (2017a). To support the patient’s wishes for EOL, these ACP tools just
mentioned should also be shared with the HF palliative care team.
Advance care directives and living wills are forms of ACP that patients may prefer to
discuss with NPs in primary care. Nurse practitioners should encourage and plan for ACP
discussions given ACP facilitates a patient-centered care focus. Provider time restraints have
been found to hinder ACP (Chandar et al., 2016) thus ACP discussions for patients with HF at
EOL should be allotted appropriate clinic time and planned for in advance.

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Address Role Clarification
Identify the palliative team members. Nurse practitioners should identify and utilize
the strengths of each palliative team member. To collaborate, team members “must frequently
determine who has the knowledge and skills needed to address the needs of patients/clients to
allow for a more appropriate use of practitioners” (CIHC, 2010, p. 12). Although several team
members are part of the palliative care team as suggested in the findings (Davidson et al., 2004;
Daley et al., 2006; LaDonna et al., 2016), there is little evidence in the literature that describes
the NP role as a part of the team. Nurse practitioners should recognize that patients with HF at
EOL are also members of the palliative care team. By recognizing the contributions of each role,
the team members are collaboratively integrating the expertise of others (CIHC, 2010) to
promote a patient-centered focus of care for patients with HF at EOL.
Nurse practitioners should engage with palliative care teams to request a review of
current palliative and HF resource documents available in each health authority as part of role
clarification. Many palliative and HF resource documents may only refer to physicians providing
such care. To reflect that NPs provide primary care to patients with HF at EOL, NPs should
request that all health authority-wide documents be updated to include physicians and NPs in the
terminology if within NP scope of practice.
Designate a leader. Palliative teams designate a leadership role to provide structure and
support for the team and to achieve predetermined goals. To promote collaboration, individuals
on the palliative team should recognize which members have the capacity and skill to fulfill the
needs of the patient and provide insight into the use of practitioner time (CIHC, 2010).
Designating a leadership role is therefore needed to coordinate a team approach (Hanratty et al.,

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2002; Boyd et al., 2009, Fendler et al., 2015) and to oversee the care needs of patients with HF at
EOL (Hanratty et al., 2002; Boyd et al., 2009; Fendler et al., 2015).
Patients with HF and their families “highly valued a key health professional in a
supportive, continuing relationship with them who could coordinate and plan their care
proactively, offer personalized information, and foster self-management” (Boyd et al., 2009, p.
769). There was a lack of literature to suggest how NPs specifically can take a leadership role in
overseeing the care needs of patients with HF at EOL. Family physicians were identified as the
most ideal team member to be responsible for coordinating EOL care for patients with HF
(Hanratty et al, 2002). The literature outlines that once a patient with HF is determined to be at
EOL, then the initial lead of the palliative team may be taken by the primary care provider as
palliative care may only be required periodically (Fendler et al., 2015). Nurse practitioners are
well-suited to assume the leadership role of the palliative team as NPs are autonomous providers
(CRNBC, 2017b) and manage the primary care needs for patients with HF from the beginning
stage to EOL. Alternatively, according to Fender et al. (2015), it is important to consider that “in
end-stage [HF] disease, palliative care specialists might take more central ownership of the
patient’s care” (p. 4).
A challenge with this approach for NPs is that they may have difficulty recognizing when
the patient is at end-stage HF given the unpredictable disease trajectory. It also remains unclear
when the leadership handover should occur with palliative care. Palliative care services in BC
are typically consultative therefore palliative care specialists assuming the main care of patients
with HF at EOL may not occur. Apart from these challenges in practice for NPs, leadership role
clarification regarding care for the patient with HF at EOL provides NPs with an opportunity to
collaborate with the palliative team by clarifying leadership.

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Promote Team Functioning
Complex care situations, such as EOL care for patients with HF, requires collective
planning, strategizing, and problem-solving to optimize care outcomes for the patient (CIHC,
2010). Interprofessional collaboration is thus able to take place when the team understands how
the complexity of care impacts the functioning of the team (CIHC, 2010) for patients with HF at
EOL (Appendix C). To promote optimization of palliative team functioning, NPs should provide
a holistic care perspective, build expertise in HF care for patients at EOL, and should resolve
uncertainties about referring to palliative care.
Use a holistic perspective. Holistic palliative care requires collaboration (Psotka et al.,
2017). Thus to facilitate collaborative care (CIHC, 2010) palliative care teams should share
information. The palliative advanced home care and heart failure care (PREFER) model
promotes holistic care for patients with HF at EOL and has been shown to provide relief from
symptoms and social issues (Brännström & Boman, 2014). Although “specialty nurses, palliative
care nurses, [a] cardiologist, [a] palliative care physician, [a] physiotherapist, and [an]
occupational therapist” (Brännström & Boman, 2014, p. 1144) were the team members who
provided the multidisciplinary care as part of the PREFER model, the NP role was not mentioned
specifically in the literature. However, the findings from the PREFER model that suggests how
collaboration can occur with palliative care teams to provide holistic care for patients with HF at
EOL can be applied to NPs as they provide advanced specialty nursing.
In practice, use of the PREFER model may provide NPs with opportunities for
collaboration to occur as the model foundation proposes that palliative care teams work closely
together in providing patient-centered care for patients with HF at EOL (Brännström & Boman,
2012). For example, patients with HF and their family members could be provided with contact

54

numbers to call a palliative team member if HF symptoms worsen (Brännström & Boman, 2012).
Additionally, a palliative home care team could be made available to respond to patients with HF
as needed and all palliative team members could meet biweekly to review the patient’s medical
treatment (Brännström & Boman, 2012).
Although the literature suggests the PREFER model could promote palliative team
collaboration (Brännström & Boman, 2014), the model has not been implemented in standard
practice for patients with HF at EOL. Nurse practitioners may experience several challenges in
organizing and implementing the PREFER model in practice as the model includes after-hour
care and palliative advanced home care teams (Brännström & Boman, 2012), services that NPs
may not have available. Despite these challenges with implementing the model, NPs can
continuously work with palliative teams to incorporate specific aspects of the model, such as the
availability of after-hour care. Nurse practitioners can implement other components of the
PREFER model in practice, such as providing specialized, team-based HF care at EOL that is
patient-centered, structured, and easily accessible (Brännström & Boman, 2014). Also, NPs can
include close family members and can support all members of the palliative team to provide
holistic care (Brännström & Boman, 2014). Thus despite the inability to implement all aspects of
the PREFER model as noted in the literature to optimize holistic care, NPs can still provide such
care through collaboration with the palliative team.
Build expertise. Information sharing is a necessary part of collaboration “to avoid gaps,
redundancies, [and] errors that impact both effectiveness and efficiency of care delivery” (CIHC,
2010, p. 14). Although the medical treatment of HF is well-established (Howlett et al., 2016),
there remains a lack of evidence that describes specific palliative care measures during the EOL
period in HF (Kaasalainen et al., 2011).

55

Symptom management for HF at EOL, adapted from the peer-reviewed Pallium Palliative
Pocketbook, identifies specific recommendations that NPs can use in primary care (McKelvie et
al., 2011). The symptom management recommendations by McKelvie et al. (2011) can be used
to build expertise in the areas pertaining to non-pharmacological and pharmacological symptom
management. Heart failure symptom management outlined by McKelvie et al. (2011) included
the initial therapy for each symptom and the recommended pharmacological starting dose, which
can be directly translated into NP practice for collaboration with palliative care teams. The BC
Heart Failure Network (2017b) EOL clinical practice guidelines for HF symptom management
should also be used by NPs and shared with the palliative team when providing care for patients
with HF at EOL. Thus NPs can collaborate with palliative care teams by sharing the symptom
recommendations by McKelvie et al. (2011) and the BC Heart Failure Network (2017b) to
promote the delivery of patient-centered palliative care at EOL.
While sharing the HF symptom management recommendations by McKelvie et al. (2011)
and the BC Heart Failure Network (2017b) facilitates collaboration between NPs and the
palliative care team to provide EOL care for patients with HF, NPs need to decide the ideal time
to share these recommendations. McKelvie et al. (2011) suggests symptom management
recommendations for patients with HF at EOL although does not indicate when the ideal time to
address these symptoms should be in practice. To develop an EOL care plan that supports
patient-centered care, NPs should share the symptom management recommendations with the
palliative team once the palliative referral has been made as “palliative care plays an important
role in relieving suffering and distress in patients [with HF] and caregivers” (Klindtworth et al.,
2015).

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McKelvie et al. (2011) also suggest that practitioners incorporate the elements of the
CCM. There is strong guideline recommendation for the use of the CCM to structure and deliver
EOL palliative care for patients with HF (McKelvie et al., 2011). The CCM, adapted from
Evidence on the Chronic Care Model in the New Millennium, can be implemented by NPs to
collaborate with palliative care teams through community assessment surveys, stakeholder
engagement, and healthcare funding and service proposals. Nurse practitioners can support
building expertise regarding care for patients with HF at EOL by developing or improving
elements of the CCM such as community resources and policies; healthcare organization; selfmanagement systems; delivery-systems, decision-support, and clinical informatics (McKelvie et
al., 2011). Elements of the CCM can be implemented by NPs through collaboration with the
palliative team. For example, NPs can engage and meet with the palliative team to discuss ways
to improve EOL community resources and can develop policies and connections that will
support the development of palliative out-patient programs for patients with HF (McKelvie et al.,
2011). A practical application of this can include the development of a patient and family support
group for patients with HF at EOL. To build expertise, NPs can be present during support group
sessions and can request a member of the palliative team, such as a palliative nurse consultant or
a palliative care physician, also be in attendance. Support groups can also be offered via
teleconference to overcome rural and remote accessibility issues.
To improve patient-centered EOL care, NPs can collaborate with palliative care teams by
arranging meeting intervals to implement elements of the CCM as suggested by McKelvie et al.
(2011). Nurse practitioners should consider that implementation of this model may be limited by
a lengthy process that may require health authority approval and financial resource support. Even

57

so, NPs can work collaboratively with palliative care teams through scheduled set meeting times
by deciding the particular elements of the CCM that would be a priority for patients with HF.
Nurse practitioners can also identify pre-existing available EOL resources that can be
used to support the development of elements of the CCM. For example, NPs can propose the
development of a working group with the purpose of creating reminders and templates in
electronic medical records (EMRs), often used in primary care regionally. By creating reminders
and templates in EMRs focused on assessing symptom management recommendations for
patients with HF at EOL, NPs can assess symptom burden during each patient encounter in
primary care to guide treatment.
Resolve uncertainties about the referral process to palliative care. Uncertainties
regarding the referral process to palliative care, particularly timing and patient acceptance, are
barriers towards patients with HF receiving EOL care (Hauptman et al., 2008). There were no
findings that suggest ways NPs can resolve referral uncertainties. Although as previously
mentioned in this paper, the ideal timing for a referral to palliative care for patients with HF at
EOL is preferred early in the HF disease trajectory (LeMond & Allen, 2011). Nurse practitioners
can refer their patients to palliative care prior to the patient reaching Stage II HF and preferably
prior to the patient being hospitalized as a result of worsening symptoms (Jaarsma et al., 2009).
In the findings cardiologists, geriatricians, internists, and family physicians were
uncertain if their patients with HF would be accepted to palliative care (Hauptman et al., 2008),
which may lead to a delay in referral. This delay can result in patients with HF not receiving
patient-centered palliative EOL care. Nurse practitioners can mitigate uncertainties regarding
referrals to palliative care for patients with HF by utilizing the EOL tools through the BC Heart
Failure Network (2017b). Nurse practitioners can utilize the clinical practice guidelines for

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symptom management EOL tools created by the BC Heart Failure Network (2017b) to provide
HF care that is patient-centered and focused on EOL.
Engage in Conflict Resolution
By asking patients if they have treatment concerns, NPs are collaboratively engaging
with the patient by reassuring them that their treatment is not being abandoned, that their
emotions are validated by the NP, and that it is important to clarify misunderstandings (Allen et
al., 2012). Nurse practitioners can also utilize the six-step approach to goal setting during patient
visits suggested by Ahia & Blais (2014) to resolve conflict by identifying current sources of
conflict, reflecting on previous causes of conflict, and in showing empathy (Ahia & Blais, 2014).
This approach, which emphasizes that conflict resolution is needed to collaborate with palliative
care teams for patients with HF at EOL, can be implemented by NPs to assess for gaps in
knowledge, differences in treatment goals amongst the team, grief, and family influences (Ahia
& Blais, 2014).
While NPs can implement the conflict resolution recommendations described by Allen et
al. (2012) and Ahia and Blais (2014) during each patient visit, this may not be easily achievable
for NPs in practice. This is because conflict may be difficult to resolve as palliative care involves
many complexities (Klarare, Hagelin, Fűrst, & Fossum 2013). For example, NPs are not able to
control for issues outside of practice that affect collaboration amongst the palliative care team
“such as social issues with substance abuse, interfamily relations, or legal implications of
impeding death” (Klarare et al., 2013, p. 1066). Nurse practitioners can assist with alleviating
social-related issues for patients with HF and can provide patient-centered multidisciplinary
support in these instances by referring to social work to resolve sources of conflict.

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Limitations
The main challenge that was revealed during this project is the lack of literature to
suggest how NPs specifically can collaborate with palliative care for patients with HF at EOL.
The ways NPs can collaborate with palliative care teams for patients with HF at EOL were
inferred from the findings, which suggest how physicians can collaborate. Even then, the
literature was largely vague and unclear as there were few suggestions for practice that described
particular details to assist in answering the how part of the research question such as when
collaboration should occur, specifically with whom, where, and on what grounds. The research
suggested ways that NPs can collaborate, mainly with the sharing of documents and tools and the
implementation of models for practice, although a more thorough approach to collaboration for
patients with HF at EOL needs to be described in future research. Another issue is that despite
NPs collaborating with palliative care teams to provide patients who have HF with EOL care, the
issue remains that many patients do not receive palliative care as a result of eligibility criteria
that limits access to this service.
The types of evidence retrieved in the literature search was found to be mainly level C
utilizing a qualitative design, followed by level E. Only two articles and one guideline were
published in Canada as most of the evidence was completed in the U. S. and the U. K. Therefore
some may view that the evidence lacks a Canadian perspective. Even though there was limited
Canadian evidence that can inform the research question, the guideline by McKelvie et al. (2011)
published in Canada was a pivotal article in the project. This is because McKelvie et al. (2011)
provided the most relevant evidence, which could be used to inform how collaboration can occur
to provide care to patients with HF at EOL. Additionally, as the majority of evidence found in
the literature search was level C, the results of the qualitative studies are unique to the sample

60

studied and difficult to replicate. Nevertheless, the qualitative research designs provided rich and
valuable subjective experiences of patients with HF at EOL and care providers that collectively
attributed towards informing the research question. The evidence is clear that collaboration is a
highly valued aspect of palliative care for patients with HF at EOL.
Implications for Practice
If NPs are unaware of the resources available to guide EOL care for patients with HF,
then without collaboration, these patients may not receive the holistic care they need during this
pivotal time. Nurse practitioners should be concerned that their patients with HF are not
receiving holistic care at EOL, as palliative care services can be inaccessible for many patients
with HF due to palliative eligibility criteria. Therefore, there are practice implications and
recommendations that NPs should consider. These practice implications include addressing
barriers to palliative care services for patients with HF at EOL and providing EOL care despite a
declined palliative referral.
The literature findings do not all reflect the reality of accessing palliative care in BC. A
barrier that NPs will experience trying to refer patients with HF at EOL to palliative care
includes a referral requirement that stipulates a physician written request, as is the case in NH
(2015). There may be confusion for NPs in trying to organize a referral to palliative care while
the current NH palliative strategy indicates a written physician request is required for service
(NH, 2015). Although NPs can collaborate with a physician to complete a written referral, NPs
should be authorized to request a referral to palliative care themselves as autonomous care
providers (CRNBC, 2017b). Therefore to provide continuity of care, NPs should be encouraged
to collaborate with palliative care teams, such as with the palliative team in NH, to request that

61

the next revision of the NH palliative strategy referral requirements be changed to include NP
requests for referral to reflect current practice.
Optimizing communication, promoting leadership, clarifying roles, promoting team
functioning, and resolving conflict are ways suggested in the findings that NPs should use to
collaborate with palliative care teams to promote a multidisciplinary approach. However, a
palliative referral may be declined by a palliative care program. Therefore, another implication
for NP practice is that despite a declined palliative referral, as the patient’s primary care
provider, NPs should take leadership and provide patients with HF at EOL a palliative approach
where appropriate. By providing a palliative approach, NPs may facilitate holistic care that is
tailored to reflect the patient’s preferences, wishes, and values for EOL.
Additionally, NPs should remember that patients with HF are an important member of the
palliative team. Hence the recommendations in the findings that suggest how NPs can address
the barriers to EOL care for patients with HF can also be used to collaborate with palliative
teams. For that reason, NPs do not need to wait for an approved referral to palliative care
services before EOL palliative care can be implemented by NPs.
Future Research
Future research is needed to explore how NPs can collaborate with palliative care teams
as the research findings were inferred, the research field on the topic was found to be relatively
new, and there were few Canadian studies that informed the research question. The evidence was
inferred from studies that focused on how physicians can collaborate as there were no articles
that informed the research question directly. As primary care providers, the findings can be
applied to NPs although evidence focusing exclusively on how NPs can collaborate with
palliative care teams for patients with HF would be beneficial towards expanding the field of NP

62

research. Also, the majority of the research was recent as the oldest article retrieved in the search
was from 2002 and the majority of articles were published between 2008 and 2017. While the
majority of the evidence informing collaboration in HF care for EOL was found published within
the past ten years it is likely that as the number of NPs emerging onto the field grows, research
describing collaborative practice for patients with HF is also likely to expand and inform
practice. As the findings are applicable to Canada, future research should focus on collaborative
practices for patients with HF at EOL within a Canadian context to account for the differences in
healthcare practices between countries.
Conclusion
There have been important revelations that have been made during the course of this NP
integrative review. Even though current guidelines provide recommendations for HF care at
EOL, there is little evidence specific to NP practice. There are resources and tools for the care of
patients with HF at EOL that can guide NPs towards collaborative care with palliative teams, but
these are often underutilized due to challenges with predicting the disease trajectory in HF and
recognizing EOL. Nurse practitioners should work towards closing the current gap between
knowledge and practice in providing collaborative EOL care for patients with HF so patients can
receive the benefit of holistic, multidisciplinary care that reflects their preferences prior to death.
To provide patients with HF with quality EOL care, NPs can collaborate with palliative
care teams by optimizing communication, taking leadership, clarifying palliative team roles,
promoting team functioning, and resolving conflict (CIHC, 2010) (Appendix C). The CIHC
framework was useful in conceptualizing collaboration and informing how interprofessional
collaboration is achieved in healthcare (2010). Therefore it is important for NPs to recognize that
collaboration is a continuous process and has multiple considerations.

63

In summary, in using the CIHC framework (2010), there are several ways that NPs can
collaborate with palliative care teams to provide patients who have HF with EOL care (Appendix
C). Although, NPs need to consider that there is no simple answer. Despite the current evidence,
there are knowledge gaps in the literature that should be addressed by NPs to inform future
practice. With the growing trend in NP practice, it is likely that literature to inform NP practice
for patients with HF, particularly at EOL will arrive in the near future.

64

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Table 1
Headings, Medical Subject Heading Terms, and Search Terms
Criteria
Nurse
Practitioner

CINAHL Headings
Nurse Practitioners
Family Nurse Practitioner
Physicians, Family

PsychInfo
Nurse Practitioners
Family Nurse Practitioners
Family Physicians

Terminal Care
Hospice Care
Palliative Care

MeSH Terms
Nurse Practitioners
Family Nurse Practitioners
Physicians, Family
Physicians, Primary Care
Primary Health Care
Collaboration
Cooperative Behavior
Terminal Care
Hospice Care
Palliative Care

Primary Care
Collaborative

Primary Health Care
Collaboration

Palliative Care
Teams
End of Life

Terminally Ill Patients
Hospice Patients
Advance Directives

Terminally Ill Patients
Hospice Patients
Advance Directives

Terminally Ill
End of life

Heart Failure

Heart Failure
Dyspnea, Paroxysmal
Ventricular Dysfunction
Ventricular Remodelling
Heart Hypertrophy

Heart Failure
Cardio-Renal Syndrome
Dyspnea, Paroxysmal
Edema, Cardiac
Heart Failure, Diastolic
Heart Failure, Systolic
Ventricular Dysfunction, Left
Ventricular Dysfunction, Right
Cardiomegaly
Cardiomyopathy, Dilated
Hypertrophy, Left and Right Ventricle

Heart Failure

75

Primary Health Care
Collaboration
Hospice
Palliative Care

Table 2
Comprehensive Search Strategy Used to Gather Evidence (December 1, 2016)
Search Terms

Database

Total Number
of Citations

(( “Family Nurse Practitioners”) OR (“Physicians, Family”) OR (“Nurse Practitioners”))
AND ((“Palliative Care”) OR (“Terminal Care”) OR (“Hospice Care”)) AND
((“Hypertrophy, Right Ventricular”) OR (“Hypertrophy, Left Ventricular”) OR (“Ventricular
Remodeling”) OR (“Heart Failure”) OR (“Heart Hypertrophy”) OR (“Ventricular
Dysfunction, Right”) OR (“Ventricular Dysfunction, Left”) OR (“Ventricular Dysfunction”)
AND (“Primary Health Care”))

CINAHL

10

(“Nurse Practitioners”[Mesh] OR “Family Nurse Practitioners”[Mesh] OR “Physicians,
Family”[Mesh]) AND (“Terminal Care”[Mesh] OR “Hospice Care”[Mesh]) OR “Palliative
Care”[Mesh] AND (“Heart Failure”[Mesh] OR “Cardio-Renal Syndrome”[Mesh] OR
“Dyspnea, Paroxysmal”[Mesh] OR “Edema, Cardiac”[Mesh] OR “Heart Failure,
Diastolic”[Mesh] OR “Heart Failure, Systolic”[Mesh] OR “Ventricular Dysfunction,
Left”[Mesh] OR “Ventricular Dysfunction, Right”[Mesh] OR “Cardiomegaly”[Mesh] OR
“Cardiomyopathy, Dilated”[Mesh] OR “Hypertrophy”[Mesh]) AND “Primary Health
Care”[Mesh])
(nurse practitioners OR family nurse practitioners OR family physicians) AND (terminal care
OR hospice care OR palliative care OR end of life) AND (heart failure OR cardio-renal
syndrome OR dyspnea, paroxysmal OR edema, cardiac OR heart failure, diastolic OR heart
failure, systolic OR ventricular dysfunction, left OR ventricular dysfunction, right OR
cardiomegaly OR cardiomyopathy, dilated OR hypertrophy)
(nurse practitioners OR family nurse practitioners OR family physicians) AND (terminal care
OR hospice care OR palliative care) AND (heart failure OR cardio-renal syndrome OR
dyspnea, paroxysmal OR edema, cardiac OR heart failure, diastolic OR heart failure, systolic
OR ventricular dysfunction, left OR ventricular dysfunction, right OR cardiomegaly OR
cardiomyopathy, dilated OR hypertrophy)

PubMed

112

76

(Nurse practitioners OR Family nurse practitioners OR Family physicians OR primary care
physicians ) AND ( palliative care OR hospice OR terminally ill OR end of life ) AND ( heart
failure OR dyspnea OR ventricular dysfunction OR ventricular remodelling OR heart
hypertrophy )

PsychInfo

14

(Heart Failure)

Social Work
Abstracts

26

“nurse practitioners OR family nurse practitioners OR family physicians OR primary care
physicians AND palliative care OR end of life OR hospice care OR terminally ill AND heart
failure”

National
Guideline
Clearinghouse

45

205

TOTAL RETRIEVED

77

Figure 3. Literature Search Flow Diagram for Search Conducted December, 2016

78

Appendix A
Evidence Matrix of Literature Retrieved (N=33)
Author,
(Date), and
Article
Location

Afshar et al.
(2016),
Germany

Study
Design and
(Level of
Evidence)
Literature
Review (E).

As Related to NP Project
Sample

Study Purpose

Study
Purpose

Search of the
databases
PubMed and
Scopus using
PRISMA
criteria.
Articles
published
within the past
5 years were
chosen
(N=127).

 Describe current
discussion points in
generalist palliative
care for non-cancer
patients at end of life.

 Answer: How
does collaboration
occur for patients
with heart failure
at end of life?

79

Key Findings

Strengths

Limitations

“Needs-based
care planning in
the end-of-life
phase is
facilitated by
actively
discussing care
issues in the
physician-patient
consultation as
early as possible
and including
family members
in the decisionmaking process”
(p. 3).
 Supportive and
Palliative Care
Indicators Tool
(SPICT) to
identify patients
with chronic
illnesses that
could benefit
from palliative
care.

 General
practitioners are a
key feature in end of
life care.
 Non-cancer
patients dominate in
generalist palliative
care.
 Content and
structure is essential
in the provision of
palliative care.
 Palliative care
needs should be
identified.
 Tool development
for practice and
palliative assessment
in general practice to
be initiated.
 Emphasis on the
“increasing need for
intervention studies
…now that papers
have so far mainly
focused on the
description and
analysis of the
current situation” (p.
5).

 Minimal discussion
regarding unique
challenges faced by
patients with heart failure
at end of life in need of a
palliative approach.

Ahia & Blais
(2014), United
States

Case Report (E).

Case report
(N=1) of a 71
year old male
with chronic
obstructive
pulmonary
disease, heart
failure, and
dementia.

 Describe effective
communication that
occurs at end of life
and how to
implement it into
practice.

 Answer: How
does continuity of
care occur for
patients with heart
failure at end of
life requiring
palliative care?

Allen et al.
(2012),
United States

Scientific
Statement,
Expert
Consensus (E).

Expert peer
review panel
according to
the Office of
Science
Operations for
the American
Heart
Association.

 Assist care
providers in
communication
techniques that
facilitate decision
making in heart
failure.

 Describe ways
to collaborate
with palliative
care teams.

80

“For setting goals
of care, align the
patient’s values
and preferences
with the medical
team’s goals” (p.
706).
“The use of a
functional status
scale such as the
Palliative
Performance
Scale can help to
further refine
prognostication
within the year”
(p. 706).
 An annual
review visit in
primary care with
heart failure
patients to
discuss symptom
burden, goals of
care, prognosis,
patient
preferences and
advance care
planning.
 Palliative care
to be discussed
when heart
failure advances;
ensure adequate
treatment
management and
evaluate whether
the management
matches the
patient’s goals.

 Primary care
physicians are
important in
providing palliative
care and in
determining patient
goals of care.

 The author’s perceived
beliefs may have
impacted the findings.

“Palliative care
teams can consist of
physicians, nurses,
social workers,
chaplains, and other
professionals who
work to ensure that
patient and caregiver
needs are assessed
and met” (p. 1937).

 Despite indicating that it
needs to be done, there is
little suggestion given
regarding how to provide
patients with heart failure
with end of life care.

Bekelman et
al. (2011),
United States

Descriptive,
Interviews (C).

Purposive
sampling.
Eligible
patients were
in New York
Heart
Association
Class II-IV
(n=33) adult
outpatients
and (n=20)
family
members.

 Examine patients
with heart failure and
caregiver experiences
and to better
understand the
impact of palliative
care.

 Answer: how
do patients with
heart failure at
end of life and
their caregivers
experience
palliative care?

Boyd et al.
(2009), United
Kingdom

Descriptive,
Interviews and
Focus Groups
(C).

Purposive
sampling
method.
Patients (New
York Heart
Association
Class III-IV),
family
members, and
health
professionals
(N=162).

 Describe the key
features of services
for people with
advanced heart
failure and evaluate
recommendations for
care.

 Explore how to
provide effective
patient-centered
care for advanced
heart failure
including
potential barriers.

Brännström &
Boman

Prospective,
Randomized

The palliative
advanced

 Evaluate the
palliative advanced

 Answer: How
should palliative

81

 Shared decision
making is
essential to
palliative care
heart failure
management.
 Patients with
heart failure and
caregivers would
prefer early
supportive care
aimed towards
adjusting to their
illness, symptom
management and
a team approach.
 Palliative care
preferred early
and coordinated
by a provider
knowledgeable
about their
condition and was
familiar with
them.
 Patients and
families preferred
one key health
professional to
coordinate care
for patients with
heart failure at
end of life.
 Difficulties
with
prognostication
delayed advance
care planning.
 Stepwise
approach to

 Identifies the use of
a collaborative care
model to address
patient concerns
regarding care
collaboration.

 Minimal suggestion
given regarding how to
implement a collaborative
care model to better
coordinate palliative care
for patients with heart
failure at end of life.

 Multidisciplinary
care and
communication is
important for heart
failure patients at end
of life.

 Minimal suggestion
given regarding how to
improve support
multidisciplinary care and
communication for heart
failure patients at end of
life.

 Study was the first
to “evaluate a new

 Despite indicating the
important team approach

(2014),
Sweden

(B).

home care and
heart failure
care
intervention
group (n=36)
or the usual
care (n=36).
Patients were
confirmed to
have heart
failure with
New York
Heart
Association
Class III-IV.

home care and heart
failure care
intervention for
patients with heart
failure in regards to
symptom burden, and
functional class.

Chandar et al.
(2016), United
States

Descriptive,
Survey (C).

Cardiologists,
oncologists,
primary care
providers, and
cardiology and
oncology
support staff
(N=117).

 Explore attitudes of
oncologists,
cardiologists, and
primary care
physicians in regards
to advance care
planning for patients
with advanced cancer
and advanced heart
failure.

care be provided
for patients with
heart failure at
end of life?

palliative care:
1) confirm
diagnosis,
2) patient
education,
3) establish an
advanced care
plan,
4) organize
services,
5) symptom
management,
6) identify endstage heart
failure,
7) breaking bad
news,
8) establish new
goals of care.
 Describe the
 15% of
barriers to advance cardiologists felt
care planning for
they should
patients with heart initiate advance
failure at end of
care planning
life.
discussions with
patients with heart
failure.
2) 68% of
oncologists felt
they should
initiate advance
care planning
discussions with
patients with
advanced cancer.
 68% of primary
care physicians
felt they should
initiate advance
care planning

82

approach for
congestive heart
failure management
by integrating
specialist palliative
home care and heart
failure care” (p.
1149).

in HF palliative care,
there is minimal
suggestion given
regarding how to
implement palliative care
for patients with heart
failure at end of life.

“A partnership with
primary care
providers may also
ease the discussion
of ACP; our findings
suggest that
oncologists were
more accepting of
collaborating with a
primary care
provider than
cardiologists” (p. 5).

 Minimal discussion
regarding how to
overcome barriers to
advance care planning for
patients with heart failure
at end of life.

Daley et al.
(2006), United
Kingdom

Descriptive,
Interviews (C).

Davidson et
al. (2004),
Australia

Literature
review, expert
consultation,
local needs
assessment (C,
E).

Dev et al.
(2012), United
States

Systematic
Review (C).

Referrals to
the Heart
Failure
Specialist
Nurse service
between 2002
and 2005
(n=491).
Community
palliative care
team referrals
(N=1500).
Ten patients ≥
80 years were
sampled in
regards to
emerging
themes.
Consecutive
deaths
between 19992000 in the St.
George Heart
Failure
service, homebased arm
(N=121).

 Explore
collaboration
between the Heart
Failure Specialist
Nurse service and
palliative care
services in the United
Kingdom.

 Explore patient
experiences in
regards to
receiving the
Heart Failure
Specialist Nurse
service in
collaboration with
palliative care
services.

 Explore if a
comprehensive
palliative care
approach model
within a heart failure
management
program.

 Explore the
effect of a
comprehensive
palliative care
approach model
within a heart
failure
management
program.

(N=19)
articles.

 Explore the need
for improved quality
and patient-centered
palliative care for
patients with heart

 Answer: How
do patients with
heart failure
experience
palliative care at

83

with patients with
heart failure; 34%
for patients with
terminal cancer.
 Qualitative
benefits from
attending the
support group
include helping
patients cope with
physical,
psychological,
and social
isolation, and a
loss of selfesteem and worth.
 The support
group generated
hope and purpose
for participants.
 Focus group
members revealed
an overall sense
of discomfort in
managing
palliative patients
coupled with a
knowledge deficit
in terms of
understanding
palliative
philosophies and
resources.
 Physicians are
often unaware of
advance
directives and
uncommonly

 Heart Failure
Specialist Nurses are
effective team
members in
providing care
throughout the illness
trajectory.
 Support groups in
heart failure are
effective.

 The study findings are
specific to the available
services and funding in
the location of the United
Kingdom and may not be
generalized to other
countries.

 Combined study
designs contributed a
broader
understanding
regarding the lack of
understanding of
palliative care for
patients with heart
failure at end of life.

 Emphasis on the need
for knowledge
development of palliative
care principles in relation
to caring for patients with
heart failure at end of life
although does not indicate
the type of knowledge.

 Support “to suggest
that, to achieve
widespread advance
directive completion,
care providers will

 Offered strategies for
improving end of life care
for patients with heart
failure although no
specific detail given.

De Vleminck
et al. (2014),
Belgium

Descriptive,
exploratory
using focus
groups and
purposive
sampling (C).

Five focus
groups in
March 2012
(N=36).

failure at end of life.

end of life.

discussed this
with their
patients.

 Identify barriers to
advance care
planning from
general practitioner
perspectives and gain
knowledge regarding
the differences
between different
illness trajectories.

 Answer: How
can barriers to
advance care
planning be
overcome to
provide palliative
care for patients
with heart failure
at end of life?

 Barriers to
advance care
planning include
lack of
communication,
challenges with
predicting the
heart failure
illness trajectory,

84

need to engage in
proactive counselling
and education of
patients” (p. 314).
 Despite this
support, “however,
there is not a
consensus
recommendation on
how to coordinate
advance care
planning between HF
providers, palliative
care specialists, and
the patient’s other
providers” (p. 314).
“The meta-message
is that intervention
must be matched to
patient goals of care
and needspersonalization is
critical” (p. 317).
 Recommendation
that the new
subspecialty
certification in
advanced heart
failure should include
a formal palliative
care curriculum.
 Study “is the first
qualitative study
providing in-depth
insight into the
similarities and
differences in the
barriers to initiation
of ACP between
cancer, heart failure,

 Perspectives limited to
general practitioners only.

Diop et al.
(2017),
United States

Systematic
Review and
Meta-Analysis
(A).

(N=15) studies
were isolated.
(n=10) were
prospective.
(n=5)
retrospective.

 Identify and
evaluate interventions
for heart failure
palliative care
patients.

 Answer: How
can team-based
palliative care
interventions be
implemented?

Dunlay et al.
(2014), United
States

Descriptive,
Surveys (C).

Physicians,
nurse
practitioners,
physician
assistants
(N=95).

 Investigate clinician
practice,
expectations, and
comfortability in
discussing care goals
and in providing
patients with heart
failure with end of
life care.

 Answer: How
are patients with
heart failure given
end of life care?



Evangelista et
al. (2014a),
United States

Descriptive,
Questionnaire
(C).

Patient
participants
were recruited
from an
inpatient
setting
through heart

 Explore outpatient
palliative care
services that are
consumed by New
York Heart
Association II-III
patients after

 Describe how
and when
palliative care
referrals occur for
patients with
advanced heart
failure.

85

and attitudes and
beliefs regarding
advance care
planning.
“The studies with
improvement in
the largest
number of
outcomes
prioritized the
integration of
interdisciplinary
HF and palliative
care” (p. 89).
“In total, seven
NP/PA (16%)
and two
physicians (4%)
reported never
discussing
prognosis” (p.
262).
“…, respondents
varied in who
they felt should
have
responsibility for
providing EOL
care” (p. 263).
Rates of referral
to palliative care
were higher for
tertiary care.
 All the patients
who pursued
additional
palliative care
services were
referred to a
pharmacist that

and dementia
patients, as perceived
by the GP” (p. 7)
“Through
categorizing study
design, palliative
interventions, and
outcomes, this
summary provides
direction for future
projects” (p. 90).

 Minimal discussion
regarding how to
overcome barriers to
advance care planning for
patients with heart failure
at end of life.

 The study
identified that the
most common
reasons for palliative
referral included
when there were no
other care options, to
augment planning for
future care, hospice
referral, and
symptom
management.

 The lowest responses
were from primary care
clinicians thus may lack
generalizability to nurse
practitioners.

 Provided support to
show that ongoing
versus episodic
palliative care
resulted in improved
symptom control.

 No explanation for how
palliative care referrals
occur.

failure
referrals (New
York Heart
Association IIIII) (n=36).

discharge from
hospital as a result of
exacerbation.





Evangelista et
al. (2014b),
United States

Descriptive,
correlational
and prospective,
single cohort
(C).

Participants
were given a
study packet,
and then a
telephone
interview was
arranged prior
to the
palliative
consultation.
A follow-up
telephone call
was arranged
three months
later.

 Explore if patients
with advanced heart
failure who receive
more than two
palliative care
consultations three
months after an acute
exacerbation have
more perceived
control, involvement,
and an improved
symptom burden.

 How do
patients with heart
failure at end of
life receive
palliative care
services?

Fendler et al.
(2015),
United States

Literature
Review (E).

(N=10)
articles.

 Describe the most
effective way to
implement palliative
care for patients with
heart failure at end of
life.

 Describe the
most effective
way to implement
palliative care for
patients with heart
failure at end of
life.

86

worked with the
palliative care
specialist.
20 patients
pursued social
work support.
19 and 16
patients were
referred to
occupational
therapy and
psychiatry
respectively.
13 patients met
with the chaplain.
 Patients
receiving ongoing
palliative care
reported better
perceived control,
involvement and
symptom
management.

 Palliative care
should be initiated
early in the heart
failure disease
trajectory.
 Collaboration
should occur in
heart failure.
 A leader should

 Provides support to
initiate palliative care
early in the heart
failure disease
trajectory.

 No link given between
perceived control and how
patients with heart failure
received end of life care.

 Identification of 
what team-based
heart failure
palliative care should
entail including how
providers should
implement it.

Unclear methodology.

Gadoud et al.
(2014), Unites
States

Descriptive,
Observational
(C).

Use of the
Clinical
Practice
Research
Datalink
database of
anonymous
electronic
medical
records from
primary care
to determine
patients
registered as
needing a
palliative
approach
(N=27 689).
The Clinical
Practice

 Answer: is there an
imbalance in the
palliative care
approach provided to
patients with heart
failure at end of life?

 Answer: When
are patients with
heart failure at
end of life
provided with a
palliative
approach?

87

be designated to
coordinate the
multidisciplinary
heart failure care.
 No agreed upon
timing of location
to implement
palliative care.
 Many
healthcare
providers makeup the team,
including patients
and families
although the three
main specialties
include primary
care, cardiology,
and palliative
care.
 In the heart
failure arm, one
third of heart
failure patients
were only entered
into the palliative
care registry one
week prior to
dying.

 Large, populationbased sample.

 Estimation was
designated regarding
sudden death; if the
number of sudden deaths
were over-estimated then
only 10% of patients with
heart failure were
recognized as requiring
palliative care.

Goodlin et al.
(2004), United
States

Consensus
conference and
literature review
(E).

Gott et al.
(2007),
United
Kingdom

Prospective,
Longitudinal
(C).

Hanratty et al.
(2002),
United
Kingdom

Descriptive,
Focus groups
(C).

Research
Datalink
database
represents 8%
of the
population of
the United
Kingdom.
Consensus
conference
comprised of
experts in
advanced
heart failure,
palliative
medicine,
geriatrics,
outcomes
measurement,
and health
care
improvement.
Decedents of a
longitudinal
study >60
years from GP
surgeries
(N=27).
General
practitioners
and
consultants in
cardiology,
geriatrics,
palliative care,
and general
medicine
(N=34).

 Identify the gaps in
the literature
regarding palliative
care for patients with
heart failure at end of
life.

 Answer how to
identify when a
patient with heart
failure is nearing
end of life


 Describe the dying
trajectories in heart
failure.

 Describe the
dying trajectories
in heart failure.

 Explore physician
perspectives
regarding the need for
palliative care in heart
failure including
barriers.

 Explore
physician
perspectives
regarding the
need for palliative
care in heart
failure, including
barriers.

88

 Multidiscipline
care is required
for palliative
patients with heart
failure to improve
their quality of
life.
Due to challenges
with
prognostication,
end of life
planning should
be done early in
the heart failure
disease process.
 Several types of
dying trajectories
found.

 The general
practitioner
should be the key
team player in
organizing
palliative care
services.
 Barriers to
achieving
palliative heart
failure care

 Emphasizes the
need for coordinated
and planned care of
heart failure patients
at end of life.

 No clear indications for
how interdisciplinary care
should be implemented
for patients with heart
failure at end of life.

 Identification of the
risk of inappropriate
resource allocation
that meets only a
small number of
patient needs.
 Provided practical
insight regarding
physician
perspectives in
caring for patients
with heart failure at
end of life.

 A common heart failure
trajectory was not
identified in the study.

 The study does not
provide a
multidisciplinary
perspective to palliative
care as the focus lies on
physicians.

Hauptman et
al. (2008),
United States

Pilot study,
Survey (C).

1) Pilot study
of family
physicians,
geriatricians,
and
cardiologists
(N=68)
2) Random
sample
cardiologists,
internal
medicine,
geriatricians,
family
practice
(N=1450).

 Explore physician
perspectives
regarding risk
stratification, device
management,
and care options in
advanced heart
failure.

 Explore how
challenges with
heart failure
prognostication
impacts palliative
care referral
timing, device
deactivation, and
patient
experience.

89

include health
care organization,
the unpredictable
disease trajectory,
and role
understanding.
 Priorities
should include
enhancing the role
of the nurse,
better primary
care support, and
improved
communication
between all health
professionals.
 15.7% of
physicians
indicated they felt
confident that
they could
consistently
predict death.
 Majority of
respondents
indicated they
could predict
death rarely or on
occasion.
 Discussion with
patients regarding
implantable
cardioverter
defibrillator
implantation was
typically
uncommon.
 Physicians
reported they
should be the

 In the care of the
physician with a
history of palliative
care training and
being in a group
practice were found
to be physician
characteristics that
led to higher
confidence levels.

 Unclear from the study
how physician
perspectives impact care
options for patients with
heart failure at end of life.

ones to inform
patients about
death and dying
versus other
healthcare
providers.
Hopp et al.
(2010),
United States

Systematic
Review (C).

Use of the
Cumulative
Index to
Nursing and
Allied Health,
Medline, and
PsychInfo
databases
(N=1046).
After
inclusion/
exlusion
criteria
(n=15).

 Identify how
patients with heart
failure experience
their condition.

 Explore how
patients with heart
failure perceive
care at end of life.

Ivany & While
(2013), United
Kingdom

Literature
Review (E).

Published
articles
between 2000
and 2013.
Articles that
met the
inclusion
criteria
(N=10).

 Identify patients
with heart failure
palliative care needs
and how nurses can
deliver quality
palliative care,
particularly in the
home environment.

 Describe how
patients with heart
failure receive
palliative care.

90

 Patients
experience
systems-related
challenges, life
disruptions, social
isolation,
symptom-burden,
and uncertainties
about life.
 Patients with
heart failure cope
through
management of
the condition,
working through
the process of
dying, and with
social support.
 Communication
is the key to
patient-centered
care yet is lacking
for patients with
heart failure
needing palliative
care.
 Prognostication
challenges make
it difficult to
initiate
conversations
about palliative
care.

 Identification that
patients with heart
failure may
experience poor
health care
coordination
compared with other
illnesses.
 The social worker
can be an advocate,
can provide
compassion, and can
coordinate care.

 Minimal suggestion
given regarding how to
improve the poor health
care coordination that
occurs for patients with
heart failure.

 Provides support
for the notion that
patients with heart
failure at end of life
have specific
palliative care needs
“that could be
effectively met by
specialist community
palliative care
services” (p. 444).

 Despite mentioning the
barriers to receiving
palliative care, there is
little suggestion given
regarding how to improve
palliative care for patients
with heart failure at end of
life.

Kaasalainen et
al. (2011),
Canada

Descriptive,
Interviews (C).

Purposive and
theoretical
sampling
(n=8) patients
in New York
Heart
Association
Class IV
(n=10)
informal
caregivers
(n=11) nurse
(n=3)
physicians
(n=3)
pharmacists.

 Describe the care
process that palliative
adults with heart
failure, families, and
care providers
experience in the
community.

 Describe how
palliative care is
coordinated for
patients with heart
failure at end of
life in Canada.

Kavalieratos
et al. (2014),

Descriptive,
Interviews (C).

Stratified
purposive

 Identify the
perceived barriers to

 Answer: How
do patients with

91

 There are
continued care
gaps in
community
services despite
the Gold
Standards
Framework.
 Challenges with
heart failure
prognostication
impacted
palliative care
services.
 Delayed
palliative care
referrals often
resulted in little
time spent with
the patient and
family.
 Family
members may
have hindered the
transition to
palliative care.
 All participants
felt continuity of
care was lacking.
 Health
professionals felt
the need to build
expertise in heart
failure.
 A lack of
communication
hindered
collaboration.
 Strategies to
improve palliative

“The findings from
this study highlight
the vulnerability of
those adults who are
dying from advanced
heart failure and their
family caregivers,
and the misalignment
of current end-of-life
services in a
Canadian
community” (p. 50).
“…challenges to
achieving these
desired outcomes of
care were related to
coordination of
services within the
health care system”
(p. 51).

 Minimal suggestion
given regarding how to
implement a more
collaborative approach for
patients with heart failure
at end of life.

“This is the first
[United States] study

 Despite indicating the
barriers to palliative care,

United States

LaDonna et al.
(2016),
Canada

Descriptive,
Interviews (C).

LeMond &
Allen (2011),
United States

Literature
Review (E).

sampling to
enlist primary
care,
cardiology,
palliative care
physicians,
and nonphysician care
providers.
Chain referral
allowed.
(N=18).
Patients with
advanced
heart failure
(New York
Heart
Association
Class III-IV)
recruited from
heart failure
clinics
(N=62).

Not specified.

palliative care that
affect patients with
heart failure.

heart failure at
end of life receive
palliative care
services?

care referral to
focus on
providing
additional training
during graduate or
postgraduate
training.

to explore barriers to
palliative care
referral for advanced
HF among providers
frequently caring for
these patients” (p. 8).

there is little suggestion
given regarding how to
overcome these barriers
for patients with heart
failure at end of life.

 Describe how
patients with heart
failure perceive their
care team and team
member roles.

 Identify the
potential
palliative team
members.


 The study identifies
that there are many
team members
involved in the care
of patients with
advanced heart
failure versus the
Canadian
Cardiovascular
Society 2008
Guideline that
describes the team of
mainly specialist
collaborations with
primary care
physicians.

 Some description of
each role given although
vague.

 Describe how
palliative care
interventions can be
implemented into the
care of patients with
heart failure.

 Answer: How is
palliative care
integrated for
patients with heart
failure at end of
life?

 2-19 team
members were
identified.
Caregivers,
nurses, family
physicians, and
cardiologists
were often
identified as
members of the
team.
 Additional team
members
perceived
included dentists,
foot care
specialists,
drivers,
housekeepers, and
spiritual advisors.
 Risk scores can
be used to
calculate life
expectancy.
 Health care
providers treating
advanced heart
failure should

 Objective
information regarding
prognostication has
not shown to improve
communication or
end of life care
decisions in the
intensive care setting.

 Despite indicating that it
needs to be done, there is
little suggestion given
regarding how to
implement palliative care
for patients with heart
failure at end of life.

92

regularly reassess
life expectancy to
know when to
plan for and
discuss palliative
measures.

Lewis &
Stephens
(2005), United
Kingdom

Literature
Review (E).

McKelvie et
al. (2011),
Canada

Guideline (C)

Search of the
Cumulative
Index to
Nursing and
Allied Health,
Medline,
National
Electronic
Library for
Health, and
the British
Society of
Heart Failure
between 19902004.
Canadian
expert
consensus
panel.

 Evaluate the
differences in a
palliative care
treatment approach
for patients with heart
failure versus those
with other lifelimiting illnesses.

 Explore how to
improve palliative
care for patients
with heart failure
at end of life.

 Heart failure
patients need a
palliative care
approach.
 The main
barrier to
palliative care in
heart failure is
care provider lack
of understanding.
 Communication
is lacking in heart
failure care
management.

 Provide
recommendations for
heart failure care in
the setting of renal
failure, sleep apnea,
palliative care, and
mechanical
circulatory support.

 Describe the
recommendations
for palliative
patients with heart
failure at end of
life.

 Palliative care
should be based
upon an
assessment of
needs and
symptoms versus
life expectancy.
 Use of an
interdisciplinary

93

 Improvements in
prognostic accuracy
not enough to
improve the care for
patients with heart
failure at end of life;
providers must have
the background
knowledge to followthrough.
 Advance care
planning needs to
occur or patients with
heart failure are
likely to die in an
inpatient setting.
 Identification that
frameworks are
needed to optimize
the care of patients
with heart failure at
end of life and to
prevent
fragmentation of
care.

 Evidence in
support of the chronic
care model.

 Minimal detail given
regarding how to
implement frameworks to
suggest care for patients
with heart failure at end of
life.

 No recommendation
given regarding how to
initiate palliative care
referrals.

Michigan
Quality
Improvement
Consortium
(2012), United
States

Guideline,
Expert
consensus (C).

PubMed,
Google, the
Respecting
Choices
website, and
the
Physician’s
Orders for
Life
Sustaining
treatment
websites.

 Provide advance
care planning
direction for
providers.

 Describe how
advance care
planning can be
used to
collaborate with
palliative care
teams.





Seamark et al.
(2002),
United
Kingdom

Cohort,
Retrospective
(C).

Two general
practices; one
urban, one
rural (N=548).

 Explore if it
possible to easily
identify: symptomatic
heart failure in
general practice; if
the mortality rate of

 Explore if
primary care
patients with
advanced heart
failure receive
palliative care

94

chronic care
model for
advanced heart
failure.
 Early patient
goal identification
and choices for
care.
 Early advance
care planning
discussions.
Advance care
planning should
include family
members, the
surrogate
decision-maker,
and others close
to the patient.
Any individual
can start the
advance care
planning
discussion.
 The advance
care planning
facilitator should
have knowledge
regarding the
patient’s
condition in the
progressive
stages of the
disease.
 Palliative care
was initiated in
less than half of
cases for those
patients not dying
suddenly or from

 Identification of
specific
recommendations for
practice.

 Minimal suggestion
given specifically in
regards to advanced heart
failure.

 Primary care
providers are
generally aware that
a palliative approach
is needed in
advanced heart

 There may be an
underestimate of
palliation in the study and
this may have skewed the
results.

Wotton et al.
(2005),
Australia

Descriptive (C).

Purposive
sampling of
senior
registered
nurses (N=17).

Yancy et al.
(2013), United
States

Guideline (C).

Expert
consensus
used to
formulate
suggestions.

patients with heart
failure mirror those in
published literature,
and if patients with
advanced heart failure
receive palliative care
towards death.
 Describe registered
nurse perceptions of
factors that impact
the care of palliative
end stage patients
with heart failure.

 Specify guidance
for the adult
diagnosis and
management of heart
failure.

towards death.

cancer.

failure.

 Explore if
palliative care
teams can work
with cardiac
teams to optimize
the care of
patients with
heart failure at
end of life.
 Identify the
recommendations
for palliative heart
failure care.

 Knowledge of
the patient and
health system
inadequacies
impact patients
with heart failure
at end of life.

 Recommendations
for practice based on
the study findings.

 Perceptions of patients
with heart failure
receiving palliative care at
end of life are limited to
one profession.

“Palliative and
supportive care is
effective for
patients with
symptomatic
advanced HF to
improve quality
of life” (p. 1835).

 Evidence in
support of palliative
care for patients with
heart failure at end of
life.

 No recommendations
given regarding how to
implement palliative care.

95

Appendix B
Concept matrix of factors to address in achieving collaboration.
Author and (Date)
Afshar et al. (2016)

Barriers and Issues for
Patients with Heart Failure
Receiving End of Life Care

Allen et al. (2012)
Bekelman et al.
(2011)
Boyd et al. (2009)
Chandar et al.
(2016)

Ability to predict the HF
disease trajectory.

Hanratty et al. (2002)

Ability to predict the HF disease
trajectory.

Goodlin et al. (2004)

Ability to predict the HF disease
trajectory.

Lewis & Stephens
(2005)

Ability to predict the HF disease
trajectory.

Dev et al. (2012)

Leadership
“”…it appears to be beneficial to use tools for the systematic and reliable identification of patients
for palliative care and their needs and wishes so that appropriate palliative care can be commenced
in a timely and appropriate manner” (p. 3)
“One example is the Supportive and Palliative Care Indicators Tool (SPICT)” (p. 3)
“Needs-based care planning in the end-of-life phase is facilitated by actively discussing care issues
in the physician-patient consultation as early as possible and including family members in the
decision-making process” (p. 3)
“Patient and family education about options for formulating and implementing advance directives
and the role of palliative and hospice care services with re-evaluation for changing clinical status is
recommended for patients with HF at end of life” (p. 1847).
“Patients and caregivers clearly expressed the need for help adjusting to the illness at or shortly
after the diagnosis and then over time when needed” (p. 1321).
“Only 15.0% of cardiologists felt that it was their responsibility to conduct ACP conversations and
write code status orders (CSOs) in their outpatient offices, and 57.7% reported never or rarely
participating in ACP discussions” (p. 3)

“In SUPPORT, patient awareness and completion of advance directives were limited; Teno et al.
reported that 62% of 1905 seriously ill hospitalized patients were knowledgeable about living wills
but only 42% were aware of durable power of attorney for health care” (p. 314).
“To achieve widespread advance directive completion, care providers will need to engage in
proactive counselling and education of patients, … however, there is not a consensus
recommendation” (p. 314).

96

De Vleminck et al.
(2014)

Ability to predict the HF disease
trajectory.

“Although the GPs identified end-of-life care conversations as an important aspect of general
practice, many of them were not familiar with the term ACP” (p. e84905)

Dunlay et al. (2015)

Ability to predict the HF disease
trajectory.

“Clinicians often discussed EOL wishes when a patient’s health status worsened” (p. 262)

Evangelista et al.
(2014a)
Evangelista et al.
(2014b)

“Participants who received additional palliative care (PC) services following the initial PC
consultation were more likely to show improvements in fatigue (P<0.001), pain (P=0.044), anxiety
(P=0.029), sense of well-being (P=0.035), dyspnea (P=0.008), and nausea (P=0.045)” (p. 77)
“A significantly greater proportion of participants who attended two or more palliative care
consults showed increases in their activation levels (P <0.001) following the intervention
compared to their counterpart” (p. 5).

Fendler et al. (2015)

“There is no clear consensus on the optimal timing and location of supportive care for patients
with heart failure, except that early and iterative intervention is preferred” (p. 4)

Gadoud et al. (2014)

“However, in the heart failure group, a third of patients were not entered onto the palliative care
register until the week prior to their death and nearly a half only in the six weeks prior to their
death” (p. 6)

Gott et al.
(2007)
Hauptman et al.
(2008)
Kaasalainen et al.
(2011)
Kavalieratos et al.
(2014)

Ability to predict the HF disease
trajectory.
Ability to predict the HF disease
trajectory.
Ability to predict the HF disease
trajectory.
Ability to predict the HF disease
trajectory.

LeMond & Allen
(2011)

Ability to predict the HF disease
trajectory.

McKelvie et al.
(2011)
Michigan Quality
Improvement
Consortium (2012)
Seamark et al. (2002)

Ability to predict the HF disease
trajectory.
Ability to predict the HF disease
trajectory.

“Among primary and palliative care providers, repeat hospitalizations over a short interval (eg, 3
in 6 months) suggested that palliative care might be appropriate” (p. 6)
“…I think that the trigger to get [the palliative care service] involved was knowing that my patient
was dying and that I didn’t have other medical options for them” (p. 6)
“Palliative care providers discussed how networking and peer education have resulted in greater
and earlier referrals by “winning over” previously skeptical colleagues” (p. 7)
“Although it is apparent that some aspects of palliative care should be considered early in the
disease course of HF, the appropriate timing of end-of-life discussions and referral to hospice care
is more problematic because of the variable nature of disease progression” (p. 4).
“We recommend that clinicians looking after HF patients should initiate and facilitate regular
discussions with patients and family regarding advance care planning” (p. 328).
“At the later stages, the facilitator should have experience with/knowledge of the patient’s specific
condition” (p. 2). “Discussions should occur with a significant change in prognosis” (p. 3).

Ability to predict the HF disease
trajectory.

97

Author and Date
Boyd et al. (2009)

Barriers and Issues for
Patients with Heart Failure
Receiving End of Life Care

Davidson et al.
(2004)
Daley et al. (2006)

Author and Date
Brännström &
Boman (2014)

Barriers and Issues for
Patients with Heart Failure
Receiving End of Life Care

Davidson et al.
(2004)
Diop et al. (2017)
Hauptman et al.
(2008)
Kaasalainen et al.
(2011)
McKelvie et al.
(2011)

“The heart failure nurse specialists had concerns about whether non-specialists could provide
optimal clinical management and patient/carer education” (p. 769).
“Patients and families highly valued a key health professional in a supportive, continuing
relationship with them who could coordinate and plan their care proactively, offer personalized
information, and foster self-management” (p. 769).
“The GP remains the primary case manager responsible for coordinating care and services” (p. 71)
“One [participant] described how he felt no one ‘in authority’ was overseeing him, which caused
him concern” (p. 598).
“The team cannot function effectively without a clear understanding of organizational and
leadership structure” (p. 4)
“ Early in disease progression, lead input is more likely to fall to a general practitioner or
cardiology service, with palliative care consultation as needed” (p. 4)
“In end-stage disease, palliative care specialists might take more central ownership of the patient’s
care (p. 4)
“…it should be the physician who’s interested, the general practitioner, the district nurse” (p. 583)

Fendler et al. (2016)

Hanratty et al.
(2002)
LaDonna et al.
(2016)

Role Clarification

Uncertainties about the referral
process to palliative care.

“Each patient participant identified 2-19 team members, including health professionals and
informal care providers” (p. 4)
Team Functioning
“The between-group analysis of the age-adjusted delta-value of health-related quality of life
(HRQL) from baseline to six months was significantly (p=0.02) better for patients in the PREFER
group than for controls” (p. 1146)
“Evaluation by the study team revealed that the nurses caring for dying patients needed increased
knowledge and further education about the palliative care approach” (p. 72)
“The studies with improvement in the largest number of outcomes prioritized the integration of
interdisciplinary HF and PC care” (p. 89)
“Most participants described the importance of optimizing interprofessional collaboration to meet
patient’s needs with a holistic perspective” (p.47)
“The majority of the health professionals interviewed identified the need to build expertise in
managing palliative care for patients with advanced HF” (p. 46)
“Generic symptom relief strategies may be applied concurrently with heart failure management”
(p. 328)

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Yancy et al. (2013)
Author and Date
Ahia & Blais (2014)
Allen et al. (2012)

Author and Date
Allen et al. (2012)

“Palliative and supportive care is effective for patients with symptomatic advanced HF to improve
quality of life” (p. 1835)

Barriers and Issues for
Patients with Heart Failure
Receiving End of Life Care

Conflict Resolution
“Identify and resolve conflicts” (p. 707).
“In some cases, an intervention desired by a patient may appear discordant with the patient’s stated
goals and/or medical realities, and clinicians must explain why it is not warranted. This is
particularly difficult in our national culture of entitlement and denial of morbidity and mortality”
(p. 1944).

Barriers and Issues for
Patients with Heart Failure
Receiving End of Life Care

Communication
“Shared decision making moves beyond informed consent. It asks that clinicians and patients share
information with each other and work toward patient-centered decisions about treatment” (p.
1928).

Davidson et al.
(2004)
Lewis & Stephens
(2005)
De Vleminck et al.
(2014)
Hopp et al. (2010)
Ivany & While
(2013)
Kaasalainen et al.
(2011)
McKelvie et al.

(2011)

Lack of communication.

Wotton et al. (2005)

Lack of communication.

Barriers and Issues for
Patients with Heart Failure
Receiving End of Life Care
Lack of patient understanding.

Author and Date
Kaasalainen et al.
(2011)

Lack of communication.
Lack of communication.
Lack of communication.
Lack of communication.
Lack of communication.


“The first step in the proposed framework is to assess patient readiness to participate in such
discussions” (p. 327)
“The longitudinal relationship with a trusted clinician, preferably with training in effective
communication skills, may facilitate such conversations” (p. 327)
Patient/Client/Family/Community Centered-Care

99

Appendix C
Collaborating with palliative care teams to provide end of life care for patients with heart failure.
Factors Contributing
Towards
Collaboration
Interprofessional
Communication

Take Leadership

Role Clarification

Promote Team
Functioning

How Nurse Practitioners Can Collaborate to Provide End of Life Care
for Patients with Heart Failure
1. Resolve poor communication
 Utilize Assessing Patient Readiness for EOL Discussions
 Utilize The Framework for Conducting EOL Discussions with HF Patients
2. Promote patient/client/family/community centered-care
 Resolve misunderstandings
 Annual heart failure review
1. Address challenges with heart failure prognostication
 Utilize the Seattle Heart Failure Model (SHFM) and the surprise question (i.e. asking oneself if
you would be surprised if the patient passed away within the year)
2. Initiate early palliative care referrals
 Engage in shared-decision making
 Define an early palliative referral: when a patient has reached Stage II heart failure
 Utilize the Supportive and Palliative Care Indicators Tool (SPICT) and the Gold Standards
Framework (GSF)
3. Initiate advance care planning
 Utilize the Advanced Heart Failure Personal Action Plan from the BC Heart Failure Network
 Utilize My Voice: Expressing My Wishes for Future Health Care Treatment
 Dedicate clinic time to initiate advance care planning discussions
1. Identify palliative team members
 Define the roles of individual team members
2. Consider designating a leadership role
 Nurse practitioners can assume the lead once end of life is recognized then may consider a
handover to palliative care
1. Use a holistic perspective
 Consider utilizing the palliative advanced home care and heart failure care (PREFER) model
100

Interprofessional
Conflict Resolution

2. Build expertise
 Utilize Managing Symptoms of Advanced Heart Failure
 Utilize the BC Heart Failure Network end of life clinical practice guidelines for heart failure
symptom management
 Utilize Core Elements of the Chronic Care Model
3. Resolve uncertainties about the referral process to palliative care
 Refer patients early in the heart failure disease trajectory
 Consider utilizing the six-step approach outlined by Ahia and Blais (2014)
 Utilize steps to achieve conflict resolution (Discuss current therapies, Address emotional
motivations, Clarify misunderstandings)

101