Chronic Heart Failure Management: Recommendations for John's Care

This report provides recommendations for the management of John's chronic heart failure (CHF), based on a review of three research articles. The report first summarizes the key findings of each article, including studies on end-of-life discussions, psychological interventions (CBT, motivational interviewing), and exercise rehabilitation programs for CHF patients. The report then synthesizes these findings to formulate specific recommendations for John's future care, including a mental health care plan incorporating CBT and motivational interviewing, discussions about end-of-life wishes, and participation in an exercise rehabilitation program. The report emphasizes the importance of building positive therapeutic relationships with the multidisciplinary care team to improve adherence to the care plan. The report concludes by highlighting the benefits of early interventions and the importance of a holistic approach to CHF management, incorporating physical, psychological, and end-of-life care considerations. The report references studies that support the recommendations, emphasizing the benefits of exercise, psychological interventions, and early end-of-life discussions.

Part one
Im, J., Mak, S., Upshur, R., Steinberg, L., & Kuluski, K. (2019). 'The Future is
Probably Now': Understanding of illness, uncertainty and end‐of‐life
discussions in older adults with heart failure and family caregivers. Health
Expectations, 22(6), 1331-1340. https://doi.org/10.1111/hex.12980
An interpretive description qualitative study of adults with heart failure (HF)
and their family caregivers. The aim of the study was to investigate patients’ and their
caregivers’ understanding of HF, their moments of uncertainty, and their knowledge,
understanding, and experiences with end-of-life discussions. 12 patients and seven
family caregivers were selected from an outpatient clinic in Canada, the selection
criteria included; patients who were older than 65 years with advanced HF or older
than 80 years and were being treated by the HF clinic, not awaiting a transplant, not
under specialist palliative care, English speaking, and able to provide informed
consent. The lead author conducted hour long interviews with the participants where
they were asked open-ended question on the following categories: goals of care, end-
of-life discussion, and understanding of illness. The transcripts from the interview
were reviewed and the answers to the questions were categorised. The study found
that the participants’ understanding of HF was shaped by their experiences with the
illness, symptoms, self-care routines, and hospitalisations, as well as their ability to
adapt to challenges cause by HF. Majority of participants were knowledgeable
regarding management of their disease, yet restricted in their comprehension of the
potential consequences of HF. Majority of participants had not yet participated in end-
of-life discussions, with an inability to connect the manifestations of HF with the
progression of illness leading towards the end-of-life. The study was limited by the
fact that the sample size for carers was small, as well as the fact that the data was

gained by only what the participants chose to share. Given the sensitivity of the topics
covered, some information may have been withheld. Overall, majority of participants
had not engaged in end-of-life discussions and further research is needed to determine
the impact of early end-of-life care discussions for patients’ with HF and their
caregivers.
Jiang, Y., Shorey, S., Seah, B., Chan, W. X., Tam, W. W. S., & Wang, W. (2018).
The effectiveness of psychological interventions on self-care, psychological
and health outcomes in patients with chronic heart failure—A systematic
review and meta-analysis. International Journal of Nursing Studies, 78, 16-25.
https://doi.org/https://doi.org/10.1016/j.ijnurstu.2017.08.006
A systematic review and meta-analysis with the aim of evaluating the
effectiveness of randomised control trials that use psychological theory or methods on
anxiety and depression levels, self-care behaviours, physical function, and health
related quality of life (HRQoL). The interventions used to assess the effectiveness
included; psychotherapy, stress management, motivational interviewing, and/or
therapeutic or nondirective supportive counselling. A thorough literature search of
English studies conducted between January 2006 and December 2016 was preformed
using CINAHL, Cochrane Library, EMBASE, PubMed, PsycINFO, Scopus, Web of
Science, and ProQuest Dissertations and Theses. The trials were reviewed by the
primary author in order to determine eligibility and were then critically appraised
based on the Cochrane Collaboration Tool. 29 articles were included in this systemic
review, comprising of 25 studies with 3837 participants. The outcome measures of
this review include self-care behaviours, anxiety and depression levels, HRQoL, and
physical function. The review found that psychological interventions improve HRQoL
at three months post follow-up. There was no significant effect on the participants’

anxiety level and physical function. Cognitive behavioural therapy (CBT) did show to
improve depression levels and a positive, but short term, effect was shown on self-
care. The review was limited by the fact that only English studies were included and
the sample size of some of the studies were relatively small. Overall, psychological
interventions on self-care and HRQoL in HF patients without clinical depression and
cognitive impairment, produces a beneficial effect.
Miller, S., Mandrusiak, A., & Adsett, J. (2018). Getting to the Heart of the Matter:
What is the Landscape of Exercise Rehabilitation for People With Heart
Failure in Australia? Heart, Lung & Circulation, 27(11), 1350-1356.
https://doi.org/10.1016/j.hlc.2017.08.016
A cross-sectional survey of public, private and community health services
across Australia, examining the quantity and features of services that provide exercise
rehabilitation for people with HF. The study aims to provide an update to information
regarding exercise rehabilitation services for people with HF in Australia and identify
perceived barriers for organisations to provide these services. In order to locate
eligible participants, researchers used the Cardiac Rehabilitation Program Directory.
457 services were then contacted for participation, of those, 334 responded. The
online program, Survey Monkey, was used to conduct the survey and gather
responses. The survey comprised of 24 questions, including the following sections;
service descriptors, perceived barriers, program characteristics, and exercise training
characteristics. An Excel spreadsheet was used in order to store the responses. The
principal researcher then summarised and analysed the responses to the questions.
Further qualitative data was provided by the thematic analysis of free text comments.
Out of the 334 respondents, 251 reported to provide a group-based supervised
exercise rehabilitation program for people with HF. Services that were unable to

provide exercise programs identified the following organisational barriers; insufficient
funding, clinical resources, and staffing. A majority (81%) of the services that
reported patients were unable to access appropriate exercise guidance were located
remotely. The exercise programs reported were found to follow the current best-
practice guidelines.
Part two
The first article chosen in response to the management of John’s chronic heart
failure (CHF) was The Future is Probably Now. The article was chosen as it explores
the benefits of discussing end-of-life care with patients’ with HF and their caregivers.
Im et al. (2019) discusses the way in which patients and caregivers may perceive
hospital admissions and subsequent discharges as a normalised routine part of
managing HF. There is then a false sense of recovery following discharge, rather than
the understanding of the gradual downwards trajectory of the illness and increased
threat of mortality (Im et al., 2019). Stocker et al. (2017) found that people with HF
prefer to approach the maintenance and management of their disease day-to-day, as
opposed to viewing it as a terminal illness. This can lead to caregivers being
unprepared for death (Stacey et al., 2018) and patients end-of-life wishes may not be
met due to lack of prior discussion (Im et al., 2019). The main, author of the article
was, at the time of writing, a Master's candidate in a health services research
programme, having been mentored by the senior author for the past three years (Im et
al., 2019). The senior author is experienced in qualitative research and is currently
leading a research programme regarding the experience of various vulnerable
populations and their caregivers (Im et al., 2019). This determines that the author is
knowledgeable in the topic of qualitative research, and has the support of an expert in
the field. The article outlined clear outcome measures and methods with the findings

being relevant to John’s case. The article was published in the Health Expectations
journal which holds an impact factor of 2.847. Based on this information, this article
is a reliable source of information and is able to provide recommendations for best
practice guidelines.
The second chosen article in response to John’s case was The effectiveness of
psychological interventions on self-care, psychological and health outcomes in
patients with CHF. The article was chosen as it finds that CBT and psychological
interventions improve depression levels, HRQoL, and self-care habits. Cajanding
(2016) found that nurse-led CBT significantly improved the mood, self-esteem, and
HRQoL in patients living with HF. In the chosen article, motivational interviewing
was also determined to have great positive effect on the patients self-esteem (Jiang et
al., 2018). Creber et al. (2016) also reported a significant improvement in self-care
management with the use of motivational interviews. The article was written by
nursing students at the National University of Singapore. They used a plethora of
databases to search for eligible articles and critically appraised them using the
Cochrane Collaboration Tool. The article outlined clear outcome measures and
methods with the findings being relevant to John’s case. The article was published in
the International Journal of Nursing Studies, which has an impact factor of 3.57.
Based on these findings, this article is a reliable source of information and can be used
in line with best practice guidelines.
Lastly, the third article chosen was Getting to the Heart of the Matter: What is
the Landscape of Exercise Rehabilitation for People With Heart Failure in Australia?.
This article was chosen as it outlines the quantity and features of services that provide
exercise rehabilitation for people with HF. Long et al. (2019) found that exercise-
based cardiac rehabilitation programs improve HRQoL, reduce hospital admissions,

and reduce mortality in the long term. In Australia, there are approximately 158 000
CHF related hospital admissions per year, with an expected yearly healthcare cost of
$3.1 billion (Chen et al., 2017). The article outlined clear outcome measures and
methods, with the findings being relevant to John’s case. The study has shown the
benefits of providing a exercise rehabilitation program for patients with HF, while
also touching on some barriers that may be faced. This can be used by clinicians to
help identify current barriers, as the benefits are clearly shown. It has also found that
current providers are following best practice guidelines in regards to their exercise
programs. This study was published in the Heart, Lung & Circulation journal, which
has an impact factor of 2.078. Based on the proven quality of this article, it is a
reliable source and should be used by clinicians in order to provide care for patients
with CHF, according to best practice guidelines.
Part three
In regards to John’s future care, the following recommendations are made.
Firstly, a mental health care plan should be arrange for John in order for him to
engage in CBT, motivational interviews, and other psychological interventions.
Motivational interviewing allows a structured approach, recognising the patient as the
central role in their care, and the importance of positive relationships with healthcare
providers (Hannah & Cheng, 2020). Nurse-led CBT programs should be
implemented, as has shown an increase in mood, self-esteem and HRQoL (Cajanding,
2016). It will also be beneficial to talk with John and his family caregiver about end-
of-life care and what John’s wishes may be. Discussing end-of-life decisions early on
can allow John’s treatment team to alter his plan of care in relation to his wishes.
People who avoid these discussions until later down the track may find that they are
unaware of all treatment options, and therefore find their wishes are not adequately

achieved (Cortez, Maynard, & Campbell, 2019). In addition, it would be beneficial
for John to participate in a exercise rehabilitation program. Exercise programs are
proven to increase functional status and HRQoL, as well as reducing rehospitalisation
rates (O’Brien & Hunter, 2017). Finally, John will greatly benefit from building
positive therapeutic relationships with the multidisciplinary team providing his care.
This will increase the likelihood of John’s adherence to his care plan (Hannah &
Cheng, 2020).

References
Cajanding, R. J. (2016). The effectiveness of a nurse-led cognitive-behavioral therapy
on the quality of life, self-esteem and mood among filipino patients living with
heart failure: a randomized controlled trial. Applied Nursing Research, 31, 86-
93. https://doi.org/10.1016/j.apnr.2016.01.002
Chen, L., Booley, S., Keates, A. K., & Stewart, S. (2017). Snapshot of heart failure in
Australia. Retrieved from
https://www.acu.edu.au/-/media/feature/pagecontent/richtext/about-acu/news-
and-events/heart-failure-burden-report.pdf?
la=en&hash=8A53AE5BB0B50E213C0E49673F1C38C4
Cortez, D., Maynard, D. W., & Campbell, T. C. (2019) Creating space to discuss end-
of-life issues in cancer care. Patient Education and Counseling, 102(2), 216-
222. https://doi.org/10.1016/j.pec.2018.07.002
Creber, R. M., Patey, M., Lee, C. S., Kuan, A., Jurgens, C., & Riegel, B. (2016).
Motivational interviewing to improve self-care for patients with chronic heart
failure: MITI-HF randomized controlled trial. Patient Education and
Counseling, 99(2), 256-264. https://doi.org/10.1016/j.pec.2015.08.031
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Im, J., Mak, S., Upshur, R., Steinberg, L., & Kuluski, K. (2019). 'The Future is
Probably Now': Understanding of illness, uncertainty and end‐of‐life

discussions in older adults with heart failure and family caregivers. Health
Expectations, 22(6), 1331-1340. https://doi.org/10.1111/hex.12980
Jiang, Y., Shorey, S., Seah, B., Chan, W. X., Tam, W. W. S., & Wang, W. (2018).
The effectiveness of psychological interventions on self-care, psychological
and health outcomes in patients with chronic heart failure—A systematic
review and meta-analysis. International Journal of Nursing Studies, 78, 16-25.
https://doi.org/https://doi.org/10.1016/j.ijnurstu.2017.08.006
Long, L., Mordi, I. R., Bridges, C., Sagar, V. A., Davies, E. J., Coats, A. J. S., Dalal,
H., Rees, K., Singh, S. J., & Taylor, R. S. (2019) Exercise‐based cardiac
rehabilitation for adults with heart failure. Cochrane Database of Systematic
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Miller, S., Mandrusiak, A., & Adsett, J. (2018). Getting to the Heart of the Matter:
What is the Landscape of Exercise Rehabilitation for People With Heart
Failure in Australia? Heart, Lung & Circulation, 27(11), 1350-1356.
https://doi.org/10.1016/j.hlc.2017.08.016
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