PROFESSIONAL ISSUES
Chronic heart failure nursing: integrated
multidisciplinary care
Emma Jane Brennan
H
eart failure (HF) is ‘a complex clinical syndrome
of symptoms and signs that suggest the
efficiency of the heart as a pump is impaired’
(The National Institute for Health and Care
Excellence (NICE), 2010). Approximately
900 000 people in the UK have HF, with prevalence rates
rising due to an ageing population and increased survival from
cardiovascular events (NICE, 2010; Conrad et al, 2018). It is
a progressive condition for which there is currently no cure;
mortality rates are high and hospital admissions are frequent
(NICE, 2010; Ponikowski et al, 2016). Patient and family burden
is great owing to poor patient prognosis and reduced quality of
life (QoL) (Jeon et al, 2010).The condition has been described
as a present day global epidemic (Cowie, 2017). In the UK, the
number of people living with HF increased by 23% between
2002 and 2014 (Conrad et al, 2018).The financial implications
of HF are vast: an estimated 1–2% of the NHS budget is spent
on heart failure, with 60–70% of this related to the costs of
hospitalisation (Braunschweig et al, 2011).
With the correct treatment and care structures in place, the
outcomes and experiences of people living with HF can be
improved (Stromberg, 2003; McAlister et al, 2004; Price, 2012;
Takeda et al, 2012). Management consists of pharmacological,
interventional and holistic care to ensure optimal treatment
(NICE, 2010; Ponikowski et al, 2016). In recent years, chronic
HF management has taken on a nurse-led multidisciplinary
team (MDT) approach (Jaarsma and van Veldhuisen, 2008;
NICE, 2016; Powell et al, 2010). Community-based disease
management programmes to support HF patients are generally
well established throughout the UK; however, their structure
and content often vary greatly from service to service (All Party
Parliamentary Group (APPG), 2016). This article examines
integrated nurse-led chronic HF care management, with
reference to the evidence and guidelines.
Nurse-led heart failure services
Evidence-based guidelines for the diagnosis, treatment and
management of HF aid effective and safe practice (NICE, 2010;
Ponikowski et al, 2016).Therefore, many people living with HF
© 2018 MA Healthcare Ltd
Emma Jane Brennan, Heart Failure Specialist Nurse, Whittington
Health NHS Trust, London, emma.brennan1@nhs.net
Accepted for publication: June 2018
British Journal of Nursing, 2018, Vol 27, No 12681
ABSTRACT
Heart failure is a condition that is increasing in prevalence in the UK, with
high patient mortality rates and frequent hospital admissions. Nurse-led
heart failure services help to improve patient outcomes through aiding
pharmacological, interventional and holistic care. Heart failure management
teams that work to support patients can vary greatly from service to service.
This article discusses the evidence and guidelines supporting an integrated
multidisciplinary approach to chronic heart failure nursing care.
Key words: ■ Heart failure  ■ Heart failure specialist nurses 
■ Integrated care  ■ Multidisciplinary team  ■ Heart failure services
receive excellent care with access to well established and expert
services comprised of dedicated HF teams. However, there is
still an inconsistency in HF services throughout the UK based
on varying local commissioning in the field (APPG, 2016).
The APPG report on Heart Disease (APPG, 2016) launched
an inquiry into the diagnosis, treatment and care for people
living with HF in the UK. It outlined 10 recommendations for
HF services related to improving diagnosis; information and
support for patients; integrated management; MDT working;
exercise-based rehabilitation; palliative care and advanced care
planning.The report identified a need to ascertain the number,
location and qualifications of heart failure specialist nurses
(HFSNs) in the country and to ensure that the workforce is
sufficient to meet demand (APPG, 2016). It also recognised
the role of HFSNs in delivering a multidisciplinary, integrated
approach to care (APPG, 2016).
Structured and integrated HF services in the UK are not
a novel concept. Between 2004 and 2007, the British Heart
Foundation (BHF), in conjunction with the Big Lottery Fund,
trialled a community-based HF programme led by HFSNs.
In England, 76 HFSNs posts were established across 26 NHS
primary care organisations, and nurse-led community and
home-based HF services were delivered to 15 000 patients.
Results showed a 35% reduction in all-cause hospital admissions
and cost savings of £1826 per patient cared for by the HFSN.
This study demonstrated that HFSNs based in primary care play
a crucial role in managing and supporting HF patients (BHF,
2008). A significant number of randomised trials of nurse-led
interventions in heart failure have shown that HFSNs have the
potential to make a substantial impact on the overall burden
of HF in reducing mortality, limiting costly admissions and
improving patient QoL on an individual basis (Blue et al, 2001;
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 Table 1. Types of heart failure by European Society of
Cardiology (ESC) classification
Type of heart failure Ejection fraction (EF)
Heart failure with reduced EF (HFrEF) <40%
Heart failure with mid-range EF (HFmrEF) 40–49%
Heart failure with preserved EF (HFpEF) ≥50%
Source: ESC 2016—Ponikowski et al, 2016
Table 2. New York Heart Association functional classification of heart failure
Class I No limitation of physical activity. Ordinary physical activity does not
cause fatigue, breathlessness or palpitation
Class II Slight limitation of physical activity. Comfortable at rest, but ordinary
physical activity results in fatigue, breathlessness or palpitation
Class III Marked limitation of physical activity. Comfortable at rest, less than
ordinary activity causes fatigue, breathlessness or palpitation
Class IV Unable to carry on any physical activity without discomfort. Symptoms
at rest may be present. If any physical activity is undertaken,
discomfort increases
Source: ESC 2016—Ponikowski et al, 2016
Stromberg, 2003;Thompson et al, 2005; Sisk et al, 2006;Takeda
et al, 2012).
In addition to identifying and responding to patient
deterioration, nurse-led HF services improve health outcomes
by implementing recommended pharmacotherapy, increasing
adherence to self-management strategies, facilitating patient
education and coordinating care (Grange, 2005; Price, 2012;
Güder et al, 2015;Young, 2017).
HF is a condition that frequently warrants complex nursing
and medical treatment, and patients under the care of an HFSN
are less likely to be hospitalised (Stewart and Blue, 2004; BHF,
2008). Specialist HF nurses exemplify modern nursing roles
with in-depth knowledge and proficiency in their specialty
(Thompson et al, 2008). HFSNs often care for elderly, frail
and high risk patients, therefore the role requires experience
and decision-making skills, as well as the ability to work in
an autonomous capacity (Stewart and Blue, 2004; Blue and
McMurray, 2005). Grange (2005) maintained that HFSNs
possess a wealth of expertise in patient management and
support in both pharmacological and non-pharmacological
care. Effectively managing HF patients requires clinical expertise
and decision-making ability, in order to act on examination
findings and blood chemistry results, know how and when to
adjust and titrate medication, understand when to seek advice
from cardiologists or admit patients to hospital, and when to
involve other MDT team members, such as social services,
physiotherapists or palliative care (Blue and McMurray, 2005).
To achieve high standards of care, HFSNs often have
extensive cardiac nursing backgrounds and advanced skills,
such as physical assessment and history taking, prescribing,
lifestyle and behaviour change training, palliative care training,
difficult conversations training, and have they will completed
heart failure courses at university (Grange, 2005; BHF, 2015).
In addition, many HFSNs are educated to Master’s level and
682
contribute to teaching and research within their field of practice
(Scottish Heart Failure Nurse Forum, 2013).
Early diagnosis and care planning
Early diagnosis is key to ensuring evidence-based treatment is
implemented in a timely fashion. All people with a suspected
diagnosis of HF should have natriuretic peptide (NP) blood tests
and, based on the results of this, an echocardiogram and specialist
assessment by a cardiologist should be requested (NICE, 2010).
If the patient has had a myocardial infarction or the serum levels
of NP are high, the echocardiogram and specialist assessment
must be carried out within 2 weeks (NICE, 2010) (Figure 1).
The first step in establishing patient treatment needs is making
sure that there is an understanding of the type and aetiology of
the HF, as this will help determine the appropriate medication
regimes; interventional and surgical options (such as cardiac
resynchronisation therapy, implantable cardioverter defibrillators,
left ventricular assist devices or heart transplantation); or the
lifestyle changes to be considered (Ponikowski et al, 2016)
(Table 1 and Table 2). An agreed plan of care can then be
implemented with structured follow-up reviews based on
individual patient requirements (Walker et al, 2011).An HF care
plan often covers a holistic patient assessment and will include
uptitration of medications, follow-up review information and
other services as necessary (Ponikowski et al, 2016). Following
specialist diagnosis, the HFSN can assist in ensuring that care
in their local area is evidence-based and individualised to suit
each patient’s needs. They can also promote communication
between primary and secondary care to facilitate cohesive HF
care (Jolly, 2002).
Medication optimisation
Several effective medication therapies have been proven to
reduce morbidity and mortality in patients with HF with
reduced ejection fraction, and, as such, their use is recommended
in the guidelines for treatment. These medications include:
angiotensin converting enzyme (ACE) inhibitors, angiotensin
receptor blockers (ARBs), beta blockers, mineralocorticoid
receptor antagonists (MRA), angiotensin receptor-neprilysin
inhibitors (ARNIs), ivabradine and digoxin (Ponikowski et
al, 2016). A nitrate and hydralazine combination can also be
used in some patients (Ponikowski et al, 2016). For all HF
patients with congestion, management of fluid volume status
is fundamental to controlling symptoms and improving QoL
(Stewart and Blue, 2004; Wetmore et al, 2013). Loop diuretics
are the first-line agent for diuresis because of their powerful
effects in the ascending loop of Henle. HF symptoms are reduced
through use of loop diuretics; however, no benefit on mortality
has been identified with their use (Wetmore et al, 2013). A
combination of loop and thiazide diuretics or metolazone can
also help to improve diuresis in patients with congestion where
loop diuretics alone are not effective due to their synergistic
© 2018 MA Healthcare Ltd
effect (McKenzie, 2003).
One of the challenges in HF management is achieving and
monitoring medication doses that have led to positive patient
outcomes in clinical trials (Wetmore et al, 2013). HF patients
are generally older, many are frail with multiple complex
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 PROFESSIONAL ISSUES

Take a detailed history and perform a clinical examination

Previous MI No previous MI

Within 2 Measure serum

weeks natriuretic peptides

Specialist assessment and Within 2 High Raised

Doppler echocardiography weeks levels levels
Within 6 weeks

Abnormality consistent No clear Consider measuring serum natriuretic Normal

with heart failure abnormality peptides if levels not known levels

Raised levels
Assess severity, aetiology, precipitating factors,
type of cardiac dysfunction, correctable causes
Investigate other diagnosis

Heart failure due to Heart failure with

Other cardiac left ventricular systolic preserved ejection Heart failure unlikely,
abnormality dysfunction fraction other diagnosis

Serum natriuretic peptides

High levels: BNP > 400 pg/ml (116 pmol/L) or NTproBNP > 2000 pg/ml (236 pmol/L)
Raised levels: BNP > 100–400 pg/ml (29-116 pmol/L) or NTproBNP 400–2000 pg/ml (47–236 pmo/L)
Normal levels: BNP < 100 pg/ml (29 pmol/L) or NTproBNP < 400 pg/ml (47 pmol/L)

Figure 1. Heart failure patient pathway (National Clinical Guideline Centre for Acute and Chronic Conditions, 2010)

comorbidities such as diabetes, renal disease and respiratory
disease, and prescribing in this patient group can be challenging
and complex (McKenzie and Cowley, 2003; Nuttall and Rutt-
Howard, 2016).Therefore, practices to ensure the safe initiation
and optimisation of medication must be adhered to (Nursing
and Midwifery Council (NMC), 2006; Beckwith and Franklin,
2011; Nuttall and Rutt-Howard, 2016). Drug treatment in HF
with reduced ejection fraction is largely based on a combination
of medications that are incrementally titrated up towards the
optimum dosage until maximum benefit is achieved (BHF,
2008). This process may take several months and requires a
collaborative effort between the patient and nurse (Stewart and
Blue, 2004;Wetmore et al, 2013). As no treatment has yet been
shown to reduce morbidity or mortality for people with HF
preserved ejection fraction or HF mid-range ejection fraction,
drug therapy is usually targeted at symptom relief, such as
reducing congestion through the use of diuretics along with
the management of comorbidities (Ponikowski et al, 2016).
Experience and training in caring for patients with HF and
managing their medications is crucial for health professionals
© 2018 MA Healthcare Ltd
their use, is important (Beckwith and Franklin, 2011; Nuttall
and Rutt-Howard, 2016). Particular attention should be paid
to HF patient tolerance of the medication and dosing, review
of renal function, blood pressure, heart rate and fluid volume
status, and potential medication side effects should be evaluated
at regular follow-up reviews of 1–2 weekly intervals during
medication titration (Stewart and Blue, 2004; Nuttall and Rutt-
Howard, 2016). While promoting the optimisation of key HF
medications, HFSNs should also be aware of drugs that should
be avoided in HF and over-the-counter medications that may
have an adverse effect on their symptoms and prognosis (Bakai
et al, 2015). Clear explanation of medications accompanied by
written instruction, regular patient review and monitoring can
assist in ensuring medication adherence and reducing adverse
drug reactions and drug interactions (Kairuz et al, 2008; Nuttall
and Rutt-Howard, 2016).
Self-care and symptom recognition
A central element to nurse-led HF management programmes
is patient self-care. Patients frequently seek advice about self-

caring for individuals with the condition (Stewart and Blue,
2004). Hence, HFSNs are generally well placed to initiate and
uptitrate patient medications (Stewart and Blue, 2004; Kirk,
2007). An understanding of the action of the drug therapy
recommended in HF, as well as specific contraindications in
management strategies and lifestyle changes when in contact
with specialised HF services (Jaarsma et al, 2006).The practice
of self-care has been associated with decreased morbidity
and mortality and improved QoL, and guidelines on HF
management frequently stress its importance (Schnell-Hoehn

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 Box 1. Multidisciplinary team in heart failure
■■ Cardiologists
■■ Heart failure specialist nurses
■■ General practitioners
■■ Pharmacists
■■ Chronic conditions management nurses
■■ Cardiac rehabilitation
■■ Cardiac diagnostic teams
■■ Rapid response and frailty teams
■■ Palliative care teams
■■ Social services
■■ Physiotherapists
■■ Occupational therapists
■■ Psychological services
■■ Dietitians
et al, 2009; NICE, 2010; Ponikowski et al, 2016). In HF, self-care
refers to the behaviours adopted by patients to maintain their
health, and the decisions they make in response to worsening
HF symptoms (Riegel et al, 2009). It is a process that involves
adherence to pharmacological treatments, consumption of a
low-salt diet, smoking cessation, limited alcohol consumption,
daily monitoring of body weight, as well as assessing for signs
or symptoms of HF decompensation and responding to these
in an appropriate manner (Riegel et al, 2009).
HF is a chronic condition that requires substantial decision-
making to encourage positive health practices (self-care
maintenance) and behaviours to manage the signs and symptoms
of the condition (self-care management) (Riegel et al, 2011). It
is an important undertaking for which a good understanding of
the illness and its treatment is necessary (White et al, 2014).The
development of patient skills in early recognition, monitoring and
management of signs and symptoms have also been recognised as
important for effective self-care (Clark et al, 2009; Riegel et al,
2011; Clark et al, 2014). Riegel et al (2011) identify a gradient
in HF self-care behaviours ranging from novice to inconsistent
to expert, with knowledge of HF and its lifestyle implications
at the core of patient success. Clark et al (2009) suggested that
factors associated with poor HF self-care are a lack of knowledge
and misconceptions surrounding HF treatment, depression, day-
time sleepiness and limited family support.
Understanding patient needs is crucial in facilitating self-
care. Dickson and Riegel (2009) carried out a meta-analysis to
investigate which self-care skills patients with HF thought they
should have and how they developed such skills. In this study, a
re-examination of three mixed-methods HF studies focusing on
the theme of self-care were analysed (n=85). Results indicated
that both tactical and situational skills are needed by patients
with HF to adhere to prescribed medication, diet, exercise,
symptom-monitoring and symptom-management practices. In
order to incorporate HF self-care skills into daily life, patients
684
required time, practice and support from family and friends.
It was also demonstrated that knowledge was foundational to
self-care, but was not in itself enough (Dickson and Riegel,
2009). HF teams can facilitate self-care through adopting
personalised care, tailoring information and education to suit
different patient needs and by supporting their journey towards
self-care management (Jaarsma et al, 2006; Dickson and Riegel
2009; Powell et al, 2010).
Integrated discharge planning and
multidisciplinary team care
The role of HFSNs is also crucial in caring for patients who have
recently been discharged from hospital. In the high-risk period
following discharge, guidelines stipulate that all patients with a
diagnosis of HF should have a follow-up clinical assessment by
a HF specialist within 2 weeks (NICE, 2010; Ponikowski et al,
2016). Early follow-up from a specialist HF team is associated
with reduced mortality and fewer hospitalisations (Lee et
al, 2010; Muzzarelli et al, 2010; McAlister et al, 2016). The
latest national HF audit, commissioned by the Health Quality
Improvement Partnership, outlined that mortality at 30 days
and 1 year was lower for those seen by a HFSN or receiving
cardiology follow-up (National Institute for Cardiovascular
Outcomes Research (NICOR), 2017).
In order to meet early follow-up criteria after discharge to
drive improved patient outcomes, communication between
acute and community HF teams is important. Hospital and
community healthcare services often work independently,
which can lead to reduced communication and fragmentation
of care across the sectors (Doos et al, 2015).Therefore, discharge
planning for patients with HF should begin early in the acute
phase to ensure integrated care planning and continuity of
care (Ponikowski et al, 2016). Patients and, if they wish, their
families or carers should also be involved in the discharge
process (Ponikowski et al, 2016). Measures aimed at increased
communication and MDT care can help to improve the
discharge process (Riley and Masters, 2016).
HF guidelines recommend that an MDT approach to care
should be adopted by specialist teams (NICE, 2010; Ponikowski et
al, 2016). HF MDTs in the UK are often made up of cardiologists,
HFSN, GPs and pharmacists, with outreach into diagnostics,
cardiac rehabilitation, chronic conditions management nurses,
rapid response and frailty teams, palliative care teams, social
services, physiotherapists, occupational therapists, psychological
services, dietitians and other specialist services (McDonagh,
2005; Ponikowski et al, 2016; Riley and Masters, 2016) (Box 1).
An organised system of specialist HF care can lead to improved
QoL and survival in patients with the condition (Jaarsma, 2005).
A meta-analysis of randomised controlled trials carried out by
McAlister et al (2004) highlights the effectiveness of MDT
strategies for HF patients. Data from 29 trials (n=5039) were
pooled and results indicated that MDT care in HF is associated
© 2018 MA Healthcare Ltd
with a 27% reduction in HF hospitalisation rates and a 43%
reduction in total number of HF hospitalisations. Furthermore,
where these strategies included specialised follow-up by an
MDT team, all-cause mortality was reduced by approximately
one-quarter (McAlister et al, 2004).
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In order to facilitate seamless MDT care between the community
and hospital settings, Blue and McMurray (2005) suggested
weekly MDT meetings to ensure optimal communication and
shared planning of HF care, particularly for challenging cases.
However, as services differ throughout the country, this may not
be standard practice. Rotational HFSN posts between community
and hospital may help to improve channels of communication
and MDT working; a similar approach is for community HFSNs
to undertake weekly visits to inpatients and attend weekly MDT
meetings with the acute hospital team (Riley and Masters, 2016;
Sussex Community NHS Foundation Trust, 2018).
Jaarsma (2005) emphasised that MDT care in HF involving
several professionals with their own expertise is important in
ensuring the delivery of evidence-based care. Jolly (2002)
maintained that HFSN should coordinate individually tailored
care for patients involving other members of the MDT when
necessary, as HFSN often have established relationships with
their patients, enabling them to understand their unique care
needs. A review of 25 (n=5292) trials by Takeda et al (2012)
indicated that case management interventions led by an HFSN
reduces HF hospital readmissions at 12 months, all-cause
readmissions and all-cause mortality. Clinical risk indicators,
such as psychosocial factors, high frailty scoring and issues
related to mobility, can help to indicate which interprofessional
service might be most effective for which person (Jaarsma
2005;Vidán et al, 2014; Ponikowski et al, 2016). People with a
high frailty score may benefit from closer contact with the HF
specialist team, with more frequent follow-up and monitoring
and individualised self-care support (Ponikowski et al, 2016).
Cardiac rehabilitation
Supervised exercise training is advised for people with stable
chronic HF, regardless of left ventricular ejection fraction
(NICE, 2010; Ponikowski et al, 2016). Specific training designed
for patients with HF can be incorporated within a cardiac
rehabilitation programme, which is usually delivered by specialist
nurses or physiotherapists with support from exercise therapists,
and overseen by an experienced clinician with a special interest
in cardiac rehabilitation (NICE, 2010; British Association for
Cardiovascular Prevention and Rehabilitation (BACPR), 2017).
The classes typically involve weekly attendance at group sessions
for 8 weeks (BACPR, 2017). Supervised exercise training,
psychological support and education are the core components
of comprehensive rehabilitation programmes, which focus on
optimising cardiovascular risk reduction, fostering healthy
behaviours and promoting an active lifestyle (Balady et al, 2007;
NICE, 2010). Cardiac rehabilitation exercise training often
includes intensity, frequency and duration with a view towards
progression. However, components can also be adjusted to suit
patient needs (O’Connor et al, 2009).
The health benefits of exercise-based cardiac rehabilitation
have been widely recognised, with patient outcomes including
© 2018 MA Healthcare Ltd
reduced hospitalisations and improvement in exercise tolerance,
functional capacity and QoL (O’Connor et al, 2009; Downing
and Balady, 2011;Taylor et al, 2014). A systematic review of 33
trials (n=4740) concluded that exercise training reduced the
rate of overall and HF-specific hospitalisation and improved
British Journal of Nursing, 2018, Vol 27, No 12685
PROFESSIONAL ISSUES
patient QoL, with a trend towards reducing patient mortality
in the longer term (> 1 year) (Taylor et al, 2014). Furthermore,
the National HF Audit (NICOR, 2017) reported that referral
to cardiac rehabilitation was associated with improved survival
at 1 year.
Cardiac rehabilitation programmes can also help reduce
patient uncertainty and anxiety related to HF by facilitating
better management of the condition through providing
information about the syndrome and encouraging lifestyle
changes to reduce the risks of further heart problems (NICE,
2010; BACPR, 2017). Unfortunately, referral to cardiac
rehabilitation services is suboptimal, with less than 20% of
HF patients participating in cardiac rehabilitation programmes
according to a European survey (Bjarnason-Wehrens et al,
2010). Furthermore, figures from the National HF Audit suggest
that approximately 7–18% of patients with HF are referred to
cardiac rehabilitation, with higher rates of referral coming from
cardiology wards compared with general wards (NICOR, 2017).
Good channels of communication between secondary and
primary care post-discharge can aid patient uptake of cardiac
rehabilitation and optimise secondary prevention (Dalal, 2003).
It is of vital importance that people are given the opportunity
to benefit from structured exercise programmes and, as such,
they should be offered to all suitable HF patients.
Palliative care
The palliative care needs of patients and carers should be
identified, assessed and managed at the earliest opportunity by
the HF team (Ponikowski et al, 2016). Palliative care is a holistic,
symptom-based approach to care that can improve QoL for
both patients and their caregivers (Adler et al, 2009; Ghashghaei
et al, 2016). It can complement traditional care and enhance
symptom relief, patient–caregiver communication, emotional
support, and medical decision-making (LeMond and Allen,
2011; Evangelista et al, 2012).
Goodlin (2009) maintained that palliative treatment must be
provided concurrently with evidence-based, disease-modifying
interventions in comprehensive HF care. Brännström and
Boman (2014) carried out a randomised controlled trial to
evaluate the effects of a palliative care and HF intervention on
symptom burden, QoL and HF functional classes compared with
usual HF care. Patients in the intervention group (n=36) were
offered a multidisciplinary care approach involving collaboration
between specialists in palliative and HF care, which addressed
aspects such as physical and social symptoms and psychosocial
support.The control group received usual HF care from GPs or
doctors and/or the nurse‐led HF clinic (n=36).All HF patients
included in the trial were considered optimally treated with HF
medication. Results indicated that a person-centred, integrated
palliative HF care model has the potential to improve QoL
and morbidity substantially in patients with severe chronic HF
(Brännström and Boman 2014).
Where appropriate, end-of-life HF care should include
discussing stopping medication that does not have an immediate
effect on symptom management and addressing resuscitation
status, as well as the deactivation of implanted defibrillators
(Hauptman et al, 2008;Adler et al, 2009; Ponikowski et al, 2016;
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KEY POINTS
■■ Heart failure (HF) is a condition that is increasing in prevalence in the UK,
with high patient mortality rates and frequent hospital admissions
■■ There is an inconsistency in HF services throughout the UK based on
varying local commissioning within the field
■■ Nurse-led heart failure services help improve patient outcomes through
aiding pharmacological, interventional and holistic care
■■ An integrated approach to chronic HF nursing care can help improve
patient outcomes
■■ Timely diagnosis, access to appropriate treatment, early follow-up post-
hospital discharge, cardiac rehabilitation and palliative care support should
be prioritised in all patients with HF
Young, 2017). In specific cases, specialist palliative care services
can assist the HF team in dealing with challenging symptoms,
initiating end-of-life conversations and advanced care planning
(Hauptman et al, 2008;Adler et al, 2009;Young, 2017). However,
despite a growing body of evidence supporting the integration
of palliative care into advanced HF management, palliative
therapies remain underused in this patient group (Adler et al,
2009; LeMond and Allen, 2011).
A sensitive approach to communication and decision-making
between health professionals and patients about therapies,
devices and prognosis should be incorporated into HF care
and may require revision at turning points in the patient’s
condition (Goodlin, 2009; Jaarsma et al, 2009). HFSNs are in
a unique position to identify when a patient requires palliative
care support, because, due to the chronic nature of the condition,
they often develop long-term relationships with patients and
their families (Glogowska et al, 2015).
The illness trajectory of each person varies. However, most
HF patients will go through three phases: a relatively stable
chronic disease management phase; one or more secondary
phases of decline, often requiring hospital care and a variety
of supportive strategies; and a terminal phase of deterioration
(Murray et al, 2007). Although palliative care discussions
are recommended early in the disease trajectory, inadequate
initiation of these conversations means that, in practice, these
discussions are often tied to end-of-life care (Hupcey et al, 2009).
As prognostication is difficult to accurately predict, certain
patient triggers can help ascertain when palliative care
discussions should take place or be revisited. These include
multiple episodes of HF decompensation within 6 months
despite optimal tolerated therapy, malignant arrhythmias, signs
of cardiac cachexia, chronic poor QoL and New York Heart
Association (NYHA) class IV symptoms (Jaarsma et al, 2009).
The BHF and the National Council of Palliative Care (2014)
have produced a ‘Difficult Conversations’ guide based on
conversations with HF patients, which aims to support people
caring for patients with HF in how to open up dialogue about
end-of-life wishes and preferences.
As palliative care is a multidisciplinary approach to care, a
support system that covers many issues faced during illness and
bereavement can be provided to patients with HF (McIlvennan
and Allen, 2016). HF patients often fear suffering at the end of
686
their lives and are concerned with symptom relief, such as the
control of pain and dyspnoea, as well as loss of independence and
maintaining dignity (Gott et al, 2008; Strömberg and Jaarsma,
2008). Individualised palliative care offered through symptom
management and advanced care planning can help patients feel
supported through the ups and downs in their condition and
evoke feelings of security; it is therefore an integral element in
good HF care (Brännström et al, 2006).
Conclusion
The rising prevalence rates of HF in recent years has prompted
comprehensive guidelines for the care of patients with the
condition. Specialised HF management teams assist in the
diagnosis, treatment and long-term care planning of patients.
An integrated approach to chronic HF nursing care can help
to improve patient outcomes and is strongly recommended
in the literature. HF specialist nurses are in a unique position
to help achieve service integration and maintain evidence-
based practice for their patients. This can be accomplished
by ensuring HF services are unified with individualised HF
patient care and MDT involvement.Timely diagnosis, access to
appropriate treatment, early follow-up post-hospital discharge,
cardiac rehabilitation and palliative care support should be
prioritised in all patients with HF.  BJN
Declaration of interest: none
Adler ED, Goldfinger JZ, Kalman J et al. Palliative care in the treatment of
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org/10.1161/circulationaha.109.869123
All Party Parliamentary Group. Focus on heart failure: 10 recommendations
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CPD reflective questions
■■ What experience do you have of the inconsistencies in care received by heart failure patients, and what can be done
to address these?
© 2018 MA Healthcare Ltd
■■ What can you do to ensure the timely diagnosis and care planning of heart failure patients?
■■ What changes can you make to improve referral rates of heart failure patients to cardiac rehabilitation programmes?
■■ How can you identify when a patient requires palliative care support?
British Journal of Nursing, 2018, Vol 27, No 12687
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