European Journal of Cardiovascular Nursing 6 (2007) 273 – 279

Living with heart failure; patient and carer perspectives ☆
J.F. Pattenden ⁎, H. Roberts, R.J.P. Lewin
British Heart Foundation Care and Education Research Group, Department of Health Sciences, Seebohm Rowntree Building Area 4,
University of York, York YO10 5DD, England, United Kingdom

Received 12 October 2005; received in revised form 17 January 2007; accepted 29 January 2007
Available online 26 March 2007


Patients with heart failure have multiple readmissions to hospital, a poor prognosis and varying quality of life. This paper explores how
patients with heart failure and their family carers cope with daily life. 36 patients and 20 family caregivers were interviewed in five centres in
the UK. Analysis showed that living with heart failure can be frightening, restrictive and distressing for both patients and their family carers.
Patients found most difficulty coping with functional limitation and adapting to living with heart failure, but also reported particular problems
due to side effects of medications, co-morbidities and a lack of psychosocial support and rehabilitation services. Those with less socio-
economic resources found it harder to cope. Patients from minority ethnic groups held different beliefs about the illness and its treatment, and
some had profound problems communicating with health and social care professionals that made managing the disease even more difficult.
Caring for a person with heart failure often has a considerable impact on the psychological and physical health of family caregivers.
Psychosocial support and rehabilitation services provided at diagnosis and after an acute episode would enable families to better manage
living with this syndrome.
© 2007 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: Qualitative; Living with chronic heart failure; Carers

1. Background detection and treatment have improved, patients are still
suffering from the impact of the syndrome and have high
Studies of heart failure patients using questionnaire mortality rates [1–3]. Frequent rehospitalisation is common
surveys reveal that patients and carers coping with chronic with as many as 40% of patients being rehospitalised within
heart failure have a poor health related quality of life. In six months of discharge after an acute event [4]. Heart failure
recognition of this burden, the British Heart Foundation is strongly associated with ageing and deprivation, and
(BHF) funded posts for 16 heart failure specialist nurses demographic shifts are leading to an increasing demand on
based in six centres around the UK. This article reports how the health service [5]. Patients typically have multiple
chronic heart failure affects the lives of patients and their medical conditions, complex medication regimens, [6]
carers, and their perceived needs for support before receiving unpredictable exacerbations, disabling symptoms that in-
help from a new specialist nurse service. clude fatigue and breathlessness, limited functional status
and a poor quality of life [7].
2. Introduction Recently the Department of Health, [8] and the Scottish
Intercollegiate Guidelines Network [9] have endorsed the
The incidence and prevalence of chronic heart failure use of specialist nurse-led services in primary and secondary
have increased dramatically over the past few years. Whilst care, as part of a coordinated approach to patient care. There
have been several studies of the effectiveness of nurse-led

Funding: The study was funded by the BHF. care. Those using multidisciplinary, nurse-led home or clinic
⁎ Corresponding author. Tel.: +44 1904 321335; fax: +44 1904 321382. based interventions, [10–12] case management [13] and
E-mail address: (J.F. Pattenden). enhanced discharge planning and home follow up [6] have
1474-5151/$ - see front matter © 2007 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Downloaded from at on November 9, 2015

nursing home or were unwilling to accept the specialist nurse Transcripts were read several times to familiarise research- service. but there is little consensus as to how this may be best measured and described [20]. ethnic group. we tried to sample as many different experience of living with heart failure. NYHA level of heart failure. their symptoms and how they manage day-to- gender.1. interviews were audiotaped. For this 3. Some studies consent was obtained immediately prior to interview. ers with the content and to develop a thematic framework. Data collection study we define quality of life as how an individual experiences life. Although the researcher with heart failure [21. However as many are not patient centred. We also asked them about their experiences of different geographical areas of the United Kingdom. Our study also fortable to talk about in front of their family member. Most of venient time and the language of choice for interview. capture which aspects of quality of life are important to Seven or eight patients from each centre were sampled from patients [17]. these studies used either generic or disease specific measures We employed purposive sampling based on the theoret- of health related quality of life (HRQL). The five categories used in functioning. thematic analysis to explore the impact of living with heart to give them a chance to raise any issues they felt uncom- failure on ten patients and their carers [23]. We obtained Ethical and Research Governance approval in After each interview we analysed the new data and if all centres. The principal researcher read the specialist nurse. goals. data collection included the interviewer's notes made during and after the 3. which Some studies of multidisciplinary team interventions for explained that they would be telephoned if they were selec- patients with heart failure report improved quality of life.3. and ethnicity in day living. Those agreeing to be inter- education and support [4]. 2015 . and being treated for. one in Scotland and the other 3. logical approach to describe peoples' experience of living and ranged from 60 to 90 min. Downloaded from cnu. The aim health services and treatment they had received in the past was to better understand their experiences and health and for their heart failure. symptoms and psychosocial variation of patients and settings. were unable to accuracy of transcription. were living in a was used to analyse the transcripts [24]. social care needs. their understanding of types of people as possible to include a wider range of the condition. they are most expressed a wish to be interviewed together (12 out of mostly middle aged or elderly and white. However. heart failure the conversation and facilitate exploration of participants' (LVSD). Pattenden et al. and whether this fits with his expectations We interviewed 36 patients and 20 carers in their homes in terms of health.11. A more recent study used attempts were made to have a few minutes alone with each. necessary developed new codes to inform subsequent We included patients newly referred to BHF heart failure interviews. by many authors [18. and in the case of the interviews conducted in (Left Ventricular Systolic Dysfunction). Constant comparative analysis make daily decisions about their own care.sagepub. and also much has 20). psychological and social wellbeing. All have closely examined quality of life using a phenomeno. Participants four patients and four carers. eligible adverse clinical outcomes and healthcare costs for patients patients and carers were given an information sheet inviting with heart failure have been reported as a result of patient them to participate in the study. and how this impacts on between December 2002 and August 2003. illness. As well as tape-recorded interviews. A semi-structured interview scheme was developed with changed in the pharmacological and non-pharmacological separate questions for patients and carers. viewed completed an interview response form. Two research secretaries transcribed interviews specialist nurse services with a diagnosis of heart failure verbatim. We conducted the study in five centres in the UK: two rural district general hospitals. Method interview to record any relevant contextual details. A reduction in At the first consultation with a specialist nurse. Although these studies describe requested interviewing the carer separately from the patient.274 J. the bilingual interviewer translated and transcribed patients who had previously been seen by a heart failure interviews into English.19]. / European Journal of Cardiovascular Nursing 6 (2007) 273–279 shown positive effects on readmissions. A trained bilingual researcher conducted interviews in Punjabi with 3. We did not include Punjabi. These tend to ical principle that it is good practice to ensure the maximum measure physical functioning.16]. Patients were also excluded if they had a transcripts whilst listening to the audiotapes to verify written case record of cognitive deficits. at on November 9. age. how patients with heart failure conceive their lives. and three urban hospitals in England.22]. ted for interview. where possible treatment of heart failure recently.F. and asking the patient to identify a con- [10. Analysis of data in Northern Ireland.Written informed physical.2. may not have the sensitivity and specificity needed to NYHA classification of severity of heart failure and centre. with participants' permission. they the sampling strategy were: gender. and a Gujarati speaking interpreter was used for interview with one patient. Quality of life has been defined and discussed the total of 124 who agreed to be interviewed. addresses these issues and explores patients' and carers' A semi-structured interview schedule was used to guide experiences of living with.14] others show little or no effect [15.

Emergent themes were morbidities.4. since they developed heart failure. one a daughter. 4A stage he was at. This could lead to research advisory group. Symptoms. breathlessness and The side effects of medications were frequently mentioned. cultural/religious issues and Many patients said how bad their memories had become language difficulties. less coding strategies and interpretations. However.5. multiple medications and co-morbidities mens. and said how breathlessness affected their ability to undertake even the simplest daily activities. knowledge of self-management to prevent discussed with the team. failure. greatest difficulty was the sheer quantity of drugs they had to Downloaded from cnu. as did was confirmed and all the coded data was entered into the some older patients who reported expecting to be able to do NVivo computer package to link sections of text from all less with age. regardless of age or gender. he said ‘I think I'll give them (carers) patient stage (range) group (tablets) all up and just take my chances’. his main carer and nurses responsible for the But some patients felt “shattered” after the slightest effort management of patients with heart failure. I'm 8 (5) 3F 1 1 1 65(55–74) 3W afraid I'm not a very good person when I've taken them 3-Rural 4M 4 69(56–79) 4W because they make me feel so ill.” most of whom had cardiomyopathy and young families. The mean age of interviewees is less a 10 minute walk. I tried to walk Patient characteristics are shown in Table 1. 2AC “And after I've had all these tablets in the morning. available resources and support. 3. / European Journal of Cardiovascular Nursing 6 (2007) 273–279 275 Explicit coding definitions and a coding frame was developed disabling co-morbidities made life extremely difficult for to enable characterisation of lines of text. changing roles for carers. members of the research team from different disciplines The narratives from some patients indicated that they were independently examined 20% of the data and compared their better able to cope than others.F. difficul. Final analytical concepts were agreed with the weren't improving or suddenly got worse. bated other symptoms. Characteristics of patients at first interview Centre No. affected their ability to sleep and exacer- confusion anxiety and depression. Symptoms such as tiredness. adapting life to heart failure. J.sagepub. of life. having “good days and process allowed for the comparison of participant accounts and bad days”. The interviews were many patients. was frightening. balancing the prescribed dose of medica. female. sitting on the footpath to get my breath back and rested. who felt they didn't always understand why things constructs. These were: Dealing with symptoms. as (patient 18. AC = Afro-Caribbean origin. Findings “I've been tired and exhausted for a long time…I'm worse now than I ever was with walking. the majority of patients mentioned interviews together where they covered similar issues. plus one specific to Other patients experienced nocturnal at on November 9. To check reliability of coding two exacerbation of disease. they shouldn't do really 7 (3) 3F 3 66(53–85) 3W 4-Rural 5M 1 2 2 62(45–76) 5W should they?” (patient 8. 1A fall. as they made them feel more ill and caused side effects such as Table 1 hypotension and gastrointestinal disturbances. The extent to which symptoms impacted on then coded line-by-line to enable identification of areas that life depended on: the severity of the heart failure and co- could be grouped together as themes. This Asian patients. This caused great distress to both patients and incorporation of deviant cases into the emerging thematic carers. with my feet in the road. 17 were female spouses. Of the 20 up the health centre Monday before last…it must have carers. 2015 . the impact of co-morbidities. aged 74) 7 (6) 2F 2 73(61–86) 2W 5-Urban 3M 1 2 66(52–81) 3W A loss of balance and dizziness. It was felt important to sample younger patients. For some the Key: W = White. patients. Pattenden et al. were of particular concern to most patients. A = South Asian origin.” (carer 5. keeping all of the hospital appointments and remem- bering the lifestyle advice they had been given. A thematic framework symptomatic patients reported a good quality of life. some younger. which included a patient with heart feelings of helplessness and hopelessness. It's uphill and every couple of minutes than in the entire patient group due to sampling younger I was sitting like a poor wino. Many patients expressed a fear that tions against their side effects and coping with painful and some medications were “doing more harm than good”. of patients Gender of NYHA Mean age Ethnic “I mean this time last year. aged 69) they could bring up issues different to those of older people. potentially leading to a 5 (2) 2F 1 1 69(58–79) 1W. Six main themes arose from the data. was especially distressing to both patients and carers as it ties of multiple medications. Many had These three themes are considered together as they little or no understanding of their heart failure and how to interactively impact on patients' functional status and quality manage it. and there taken an hour and 15 minutes to get back home…it's only were two male spouses. such as fatigue and anxiety. male. that was the 1-Urban 6M – 1 4 1 75(64–89) 2W. ankle swelling. This the unpredictability of symptoms. As a result some had become anxious about managing their complex drug regi- 3. wife of patient aged 65) 9 (4) 3F 1 – – 2 75(63–82) 3W 2-Urban 5M 1 2 1 1 58(36–68) 3W.

She had been told that she were particularly acute for those who did not speak English. aged 53) “The arthritis has never been as bad as what it's been this However not all patients reported severe negative year. low. some patients invitation and hope to God that things are a wee bit better reported being anxious for weeks after an acute episode. [name of hospital]…he doesn't have to live my life!” which in some patients had improved with treatment. This was 3. that had given them case the spouse contradicted her husband and revealed that pleasure. male. if apparent that some had voluntarily limited their activity levels I were on me own I'd be in trouble” (patient 25.6. so that we can go. would like to take the risk of dying rather than continue with at on November 9. Some 2. for example fluid and salt intake.” (patient 24. as were worries about other or knew how to prevent worsening of symptoms by controlling conditions getting worse because of the treatment. I know up here that I can't and you to do what they used to. lifestyle they were used to. Acute “No. [gesturing to the room] what you pulmonary disease. talked quite philosophically about the future. such as gardening or walking. and could sheet). That hits me here. They expressed feelings of guilt at being unable to he had been talking about suicide only a few weeks pre- help with household chores and being dependent on others. They rarely understood the cause of their heart failure of a cure was mentioned. arthritis. oh my God how were unable to afford it. such as a supportive family or having sufficient material resources. you know… she [transplant surgeon] was quite were particularly common. Downloaded from cnu. but having to were not getting any help. and at the prospect of living with a chronic Several patients expressed anxiety about the future. irritable and critical of others who were performing house. Male and female patients talked equally of becoming However. but I've spoken to the doctor and he says it's just “get on with it” and remain positive. this apparent acceptance could be misleading. women more frequently mentioned fear and anxiety. Some people found these more of a happy with the way I was.F. anxiety and depression often attributed to mediating factors. the quality of life that she had. particularly older a progression because of my age. just to get us out somewhere. which it states on here. 2015 . If I were on me own I wouldn't say specific advice on how to remain active safely and it was I'd go suicidal but I'd be a lot worse off than I am now. aged 56) female patients who had experienced frightening acute events were told there was no guarantee that they wouldn't Many patients said they were “in shock” after being given have another at any time. the lack illness. Facing an uncertain future. aged 69) patients had come through their depression and anxiety and adjusted to the life they had and its restrictions. and weighing themselves to check for renal problems. Some. thinking I All patients experienced frustration at no longer being able should be doing that. due to a fear that activity would exacerbate their symptoms and aged 66). rely on others caused the greatest distress. Few patients had been given any get very depressed. viously. and were terrified of going to sleep.” (patient women. Co-morbidities such as diabetes.7. admitted to being depressed. Confusion. chronic obstructive “I'm 53 and this is it. disability allowance or social services One patient. Poverty often com- pounded a patient's ability to manage to live a normal life. male. male. but many social relationships were common problems. “I just feel. like (drug information refused to focus on the loss of role and sickness. joint wise…. you know. Pattenden et al. assessments caused great distress for some.and it could be a side effect of these emotions — a few reported “making the best of it” and tablets. Three patients initially denied their feelings but. female. Two know” (patient 19. you know. As a result some patients and their Men seemed to talk more about depression whereas carers had become virtually housebound. long they would live and not being able to maintain the Where an inability to continue working was mentioned. In one activities. male. depression or anxiety. a few were receiving counselling or Changes in the patient's role within the family and a loss of regularly seeing a Community Psychiatric Nurse.sagepub. 3. very. lead to a hospital admission. Difficulties in accessing benefits such much longer have I got. worries about finances were also raised. (patient 16. gout and kidney problems see. Adapting my life to heart failure “…Sometimes you get very. and this is it. and resentful at the loss of spouse was not present. and so is [Dr] down at the problem to live with than their symptoms of heart failure. often caused worry and low mood. not knowing how fluid retention. / European Journal of Cardiovascular Nursing 6 (2007) 273–279 take.276 J. summing up her quality of life as poor. you some found themselves unable to forget the event. we don't go out anywhere. angina. next week I might not be here… especially if they needed to have adaptations to their home but that's my initial sort of fear. aged 52) as income support. Some patients were taking medication for their yet several acknowledged that it would be worse to be alone. we've got a wedding episodes were particularly distressing. the diagnosis. when the hold tasks they used to do. These problems expressed anger at her consultant. I just sit back and watch the old girl do it. Three female patients reported having bad nightmares was not yet ill enough to have a transplant but said that she and anxiety attacks whilst increasing the dose of beta.

Cultural and religious issues Many carers reported that their lives had completely There were noticeable cultural differences in the way the changed since their spouse or partner had developed heart five patients and carers of South Asian origin discussed heart failure. 3. and some would have liked some time off from caring duties. …If I had the money I'd have a basin with a chronic and debilitating illness. change and interpreter] said that this money is not right. failure. I thought. When he Language difficulties restricted opportunities for support manages to drop off then I lie down. When he lies down he Other issues that were raised concerned lack of social becomes breathless and it's as though there isn't enough contact and language difficulties. all spontaneously worsening. others without A few carers reported having to give up work or other English speaking family members reported waiting till activities. patients' autonomy and activity levels. both their own and others'. Pattenden et al. an inability to conduct ritual “I have to do everything. Discussion additional support from family members or access to respite care. deal with medica. He gets all flustered and wakes up and I wake up interpreter was essential for all the non-English speaking with him. I wake up and sit there.” (carer 33. male. electricity. since heart failure. This study highlights the daily difficulties experienced by Particular difficulties arose where financial difficulties patients with heart failure and their carers. tions.” health. was a major factor in their responsibility. cos the man is blue’. J. …yes he told me give him the heart spray. If only I could be helped a little.8. as well as their priorities. wife of patient. Included in this were comments about the importance of cleanliness and mobility. aged 64) at on November 9. One patient attributed relief from severe symptoms to (carer 1. “I rung him [the doctor] again. this one's too high…he [the NHS “It's three years since he was ill. In this study the data were collected travelling to and from hospital appointments. I just can't take it. rub his chest and when his ankles ache I some patients. They saw their illness as an opportunity to change Carers often felt they had responsibility for the manage- certain aspects of their lives such as pursuing further ment of the patient and took over the drug treatments and education or taking up a different activity.F. exercise and general health. which often led to them becoming isolated with morning when they could get a GP who spoke their language little time for themselves. installed lower down. It's patients in order to understand heart failure and its treatment.sagepub. Our bills can be three to four hundred forms… my wife can't either. If he's in pain and calls out I go ablutions before daily prayers proved to be distressing for running. telephone. I hold onto him as he walks. Two said this controlled the patient's activity level. particularly when they talked about the meaning of their condition and beliefs about the effects of treatment. wife of patient aged 76) a combination of prayer and medication. Every fifteen prayer. The availability of an oxygen. / European Journal of Cardiovascular Nursing 6 (2007) 273–279 277 “When I wash my feet I lift my legs up to the basin…and because of unemployment or the cost of day-to-day living it's so painful. I can't remember what he mentioned a belief in Allah and had a more philosophical told me. especially when thinking think it were about 4 o'clock in the morning. He's in a lot of pain at night. he's really poor’. I rub his chest and help him to stand.” (carer 35. Acute episodes were particularly stressful. I bathe him. The discipline and Some carers were close to complete physical exhaustion practice of Islam was mentioned in relation to knowledge through having to provide physical care. I said ‘his condition is Some had consulted a traditional healer. significantly reducing the reassess their value to each other. minutes to half an hour he gets up. Although some patients could use patient. aged 64) family members to call for emergency help. All five Asian patients and carers research aims to produce findings that reflect the experiences mentioned this in relation to issues such as expenses incurred of the group studied. gas. who do I have that can go there and fill out the keep it all clean. A few appeared to life-threatening condition made them and their loved ones have become overprotective. There are per cent disabled and should get disability allowance. 2015 . Some carers felt unable to leave the to get help with worsening symptoms. All were under 60 years of age and had aged 89) given up full time employment as a result of their heart failure. and then he start getting sick and then about…I their spiritual and religious beliefs. you are 100 wash his clothes. wife of delivered by telephone. [Since the washing machine broke] I find Three patients mentioned positive outcomes in their lives it impossible to wash clothes. monitor symptoms and cope with lack of sleep. patient at all because they were not safe on their own. 4. which attitude toward their future and derived great comfort from I did. I rung the about death. Some patients mentioned that the power of doctor again and said ‘listen I don't want this prayer. Changing roles 3. I these bowls for urine… I keep them here for the night.9. and understanding about diet. Qualitative were experienced.” (patient 33. as did not being able to prostrate during massage them. terrible at night. lack of money from male and female patients and carers from a wide range Downloaded from cnu.

Our findings concurred with other anxiety and depression and improve quality of life [32. The findings origin and their carers. Maislin G. Carers also require support. education and self-management.33]. Influence of socioeconomic deprivation on the may improve with treatment. Aamra Darr who transcribed the level that indicates that a person might benefit from and carried out interviews with 4 patients of South Asian treatment. 2003. age larger study. [28. rather Self-care and quality of life in patients with advanced heart failure: the effect of a supportive educational intervention. Patients have many needs that patients and it was clear from this study that many feel could be met by more integrated health and social care. but we believe this study provides a deeper 5. acceptance of the situation. McCauley KM. Roumanis SA. It is how. gender. These problems were made this issue did not arise with patients and carers of South worse by poverty and lack of social support. although [5] McAlister FA. perhaps limiting psychological support. BMJ 2004.29(5): than what they cannot. exacerbated functional abilities. anxious and some close to exhaustion. Tan F.F. Brooten DA. heart failure symptoms may decrease and functional status Kirkpatrick M. Diederiks J. morbidities. dynamic process for different groups. by poverty and language difficulties. Stewart S. self-care and poorer prognosis. Coats AJS. This reframing of the situation can be 319–30.328:1110. J Am Coll Cardiol 2002. Dracup K. / European Journal of Cardiovascular Nursing 6 (2007) 273–279 of ages and severity of disease.278 J. Although in some cases patients and carers were References being helped through counselling or medication. facilitated by a skilled practitioner and help patients move [8] Department of Health. 2015 . This can result in a poor quality of life. The burden of heart failure. Heart Lung 2000. BMJ 2002. Amatruda J. race. with depression and anxiety and a loss of role and stances and more severe functional limitation. Developing services for heart failure. Randomised trial of an education and support people with heart failure are due to exacerbation of co. Conclusion level of understanding of the day-to-day impact of the disease and an insight into the diversity of experience within Living with heart failure is a complex. This in turn. and [6] Naylor MD. reported that up to 40% of rehospitalisations of elderly Radford MJ. Hospitalisation This study adds to previous understanding by showing of patients with heart failure. In a separate part of this study. et al. Poole-Wilson PA. Depression is linked with worse interest for this paper. Sutton GC. better understanding of the illness and the ability to self.39:83–9.31] so must be identified and treated. Approximately 50% of patients scored above We thank the interviewees.325:422–5. all patients had completed quality of life Acknowledgments measures and the Hospital Anxiety and Depression Scale (HADS) [30]. isolated. Mattera JA. to change their lifestyle and perform Sanford Schwartz J.4(supply D):D50–5. co-morbidities. however. Campbell RL. [3] McMurray JJ. Many required better carers requested to be interviewed together. This appeared to vary ac. the Research Advisory Group. Rehabilitation and substantial psychosocial heart failure: a randomised controlled trial. Help in accessing Asian origin where all agreed to be interviewed separately. Eur Heart J 2002(23):877–85. and from the interviews show that it was not only the patients. in urban and rural settings. and although our numbers including coping with frightening symptoms and complex were small. These two factors may explain why. and an Department of Health. London: through the helpless stage into a more proactive stage. et al. Eur Heart J Suppl Patients also highlighted the impact of living with multiple 2002. social services and respite care would be This study concurs with two recent studies. which up to half of patients scored as depressed. the focus could move to what patients can do. participants reported notably worse circum. Downloaded from cnu. J Am Geriatr Soc 2004. With a 675–84. We have been unable to find a similar study both patients and carers.29] in appreciated in most cases. welfare benefits. patient perception of quality of primary care burden and treatment of patients with a diagnosis of heart life does not. but Karen Spilsbury for commenting on the first draft of this also carers. We are not aware of Many patients reported low levels of understanding of their any in-depth studies in the UK with carers of heart failure condition and how to manage it. for both anxiety and depression. Smith GL. MacIntyre K. Competing interests: The BHF provided funding for the cording to factors such as social support. Simpson CR. manage. Halfens R. a great number were not. Some patients reported having little knowledge. It involves multiple challenges in patients of South Asian origin. medications. Management of chronic heart failure. It is also interesting to note that in all cases they carry all of the responsibility. This does not.52: support for both patients and carers could be helpful. Stewart S. Zaphirou A. who reported severe psychological effects paper. concurring with a recent study [6] which [4] Krumholz HM. studies [25–27] that found similar deficits in health related quality of life. that side effects of drug regimens are perceived by many [2] Cowie MR. Transitional care of older adults hospitalised with self-care activity. having as issues that participants felt able to express in front of their many unmet needs as those they are caring for and often feel family member. Pattenden et al. intervention to prevent readmission of patients with heart failure. patients as outweighing the potential benefits of treatment. [7] Jaarsma at on November 9. may help reduce achieving data saturation. failure in general practice in Scotland: population based study. [28. Abu-Saad HH. sometimes motivation.sagepub. Murphy NF. represent a conflict of and particularly poverty. [1] Cowie MR. from living with heart failure. a serious limitation that in more cases patients and from chronic disease management. rehabilitation and techniques ever.

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