Category: HEARTe

Mina decides that she wants, as far as possible, to manage her conditions with medications and that she does not wish to have any invasive treatments or interventions. She appreciates that her heart failure and her COPD are not curable and are liable to progress. In NHS Scotland, planning for the future is normally referred to as Advance Care Planning. It involves talking about what you do or do not want to happen to you in the future regarding any care that you might need. The Good Life, Good Death, Good Grief website suggests that issues to think about are:

• granting power of attorney
• thinking about an Anticipatory Care Plan
• talking to your healthcare professional and those important to you about what you want in the future
• thinking about organ donation
• deciding on whether you want a DNACPR order implemented
• any medical treatments that you may not want

Advance care planning is the term most commonly referred to in end of life care, although it does incorporate the writing of wills or “Living Wills” now known as advance directives or advance decisions which can be done by the well person early on in life to plan for what may happen at the end of life. Anticipatory care planning is more commonly applied to support those living with a long term condition to plan for an expected change in health or social status. It also incorporates health improvement and staying well
(Scottish Government, 2010. Anticipatory Care Planning: Frequently Asked Questions).

As suggested by her SPARRA score (46%), Mina, her son and the Heart Failure Nurse draw up an Anticipatory Care Plan. Mina has read through the information on Advance and Anticipatory Care Planning provided by the nurse and knows what is involved.

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Mina and the Heart Failure Nurse agree that Mina and Joe need help and support to enable them both to remain at home for as long as possible. The nurse explains how this might be achieved through an integrated health and social care model of care.

“Health and social care integration is about ensuring that those who use services get the right care and support, whatever their needs, at any point in their care journey.” (Scottish Government, 2015).

The Heart Failure Nurse calls a multidisciplinary team meeting to discuss how Mina and Joe can be offered the care and support that they currently require. Given the complexities involved in providing healthcare for people with multiple conditions, who have a number of different specialist and health & social care professionals involved in their care, it is essential that someone undertakes the role of key co-ordinator. In Mina’s case this is the Heart Failure Nurse. Mina and Joe’s son manages to get time off work and accompanies his mother to the meeting. Following discussion Mina agrees on the following options:

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“People with multiple long term conditions often experience disjointed services that focus on a particular condition in isolation” (Many conditions, One life: Living Well with Multiple Conditions).

It is essential that all the healthcare & social care professionals involved in Mina’s care liaise effectively and work together with her to ensure that her care is person-centred, safe, effective and timely, in line with the ambitions of the Quality Strategy (Scottish Government, 2010).

Reflect on the multidisciplinary management of heart failure patients, with multiple conditions in your area of clinical practice. How effective is communication between the different teams and specialists? How often does everybody involved in the care of a patient meet to discuss management of care?

The Heart Failure Nurse assesses Mina using a number of validated assessment tools (see additional information below). He notes the following observations.

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The heart failure nurse identifies two priorities of care for Mina. These are to:

• reduce fluid retention and, thus, relieve Mina’s oedema and dyspnoea
• support Mina with personal care and food preparation

SIGN 147 – Management of chronic heart failure (2016) [.pdf] recommends that patients with heart failure and clinical signs or symptoms of fluid overload or congestion should be considered for diuretic therapy. The aim is to reduce fluid retention without overtreating and causing dehydration or renal dysfunction. Mina is already taking a loop diuretic and the heart failure nurse increases the dosage.

The nurse liaises with the local social work team and an emergency care team is organised to help both Mina and Joe with personal care and support Mina with meal preparation, for a limited period of time. This will allow time for the multidisciplinary care team to meet and consider Mina’s long term care options. The heart failure nurse agrees to visit Mina again in a couple of days, to assess her response to the diuretic therapy and to check how she is feeling now that she is getting some help in the home.

Mina recently visited her GP and was prescribed increased diuretics for her breathlessness and oedema. The Heart Failure Nurse comes to do a follow-up visit to assess whether the drugs have been effective. He has visited several times in the past and knows the family well.

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Like Sandy, Mina has a number of health conditions which impact on her heart failure. Again, these include both cardiac and non-cardiac conditions.

Cardiac conditions

Aortic Stenosis

Aortic stenosis is a narrowing of the aortic valve opening in the heart. It becomes increasingly common with age, as the calcium deposits and scarring which occur with age damage the valve and restrict the amount of blood flowing through it. The left ventricle of the heart has to work harder to pump blood through the narrowed valve into the aorta, causing the wall of the ventricle to thicken. This thickened ventricular wall takes up more space, leaving less room to accommodate the amount of blood required to supply the body and, eventually, leading to heart failure. As the number of elderly people in the population increases, so too does the prevalence of aortic stenosis as a cause of heart failure.

Left Ventricular Systolic Dysfunction

Mina has a moderate degree of left ventricle systolic dysfuncion (LVSD), probably caused by her aortic stenosis. LVSD is where decreased contractility of the heart leads to a decrease in cardiac output. The left ventricle becomes enlarged and dilated, meaning that it is less able to contract strongly enough to pump blood out and around the body. The end result is sodium retention and fluid overload.

Mitral Valve Regurgitation

Mitral valve regurgitation (also known as incompetence) occurs when the mitral valve does not close properly. When the valve does not seal effectively, this allows blood to flow in two directions during contractions. Some blood flows through into the ventricle and some flows back into the left atrium. Increased blood volume and pressure in the left atrium can cause increased pressure in the pulmonary veins and cause pulmonary congestion. If the regurgitation is severe, it can cause the heart to enlarge in an effort to maintain forward flow of the blood, resulting in heart failure.

Pulmonary Hypertension

Pulmonary congestion leads to low oxygen levels in the alveoli of the lungs. This causes the pulmonary arteries to constrict, increasing the pressure within the vessels. If the pressure in the pulmonary arteries rises to a sufficiently high level, the result is secondary pulmonary hypertension. The right side of the heart has to work harder to push blood through the pulmonary arteries into the lungs. Over time, the right ventricle becomes thickened and enlarged, leading to a deterioration in the heart’s pumping mechanism and resulting in heart failure.

Non-cardiac conditions

Chronic Obstructive Airways Disease

Chronic Obstructive Airways Disease (COPD) is characterised by persistent respiratory symptoms and airflow limitations. These are normally due to abnormalities in the airway or the alveoli, usually caused by significant exposure to noxious particles or gases, such as those found in cigarette smoke. (Although Mina does not smoke now, she was a heavy smoker for many years.) COPD is irreversible and progressive, causing many of the same symptoms as heart failure. It is a common comorbidity with heart failure and, like heart failure, the risk of developing COPD increases with age. A survey of primary care patients in Scotland found that 23.8% of patients with heart failure also had COPD (Hawkins et al, 2010). It appears that COPD patients are at higher risk of developing heart failure and other cardiovascular conditions due to a shared pathogenic mechanism, associated with low-grade systemic inflammation.

Depression

There are known major links between cardiac disease and depression. Mina has suffered from severe depression in the past and such depression is now known to be a risk factor for cardiac disease. Depression has been associated with a four fold increase in the risk of heart disease, even when other risk factors, such as smoking, are controlled. The links between the two are bidirectional, with the impact of heart failure and the lifestyle changes it involves, frequently leading to a person becoming depressed.

In Mina’s case, the presence of other conditions in addition to her heart failure makes diagnosis and treatment more difficult and complex, as her multiple conditions share many of the same signs and symptoms. The existence of multiple conditions presents challenges for management, particularly in relation to drug therapy.