The Impact of Hospice Care on the Prognosis, Quality of Life, and Emotional Well-being of Patients With Chronic Heart Failure

Abstract

Chronic heart failure (CHF) represents a substantial public health challenge, impacting patients’ emotional well-being, quality of life, and overall prognosis. Palliative care and hospice services are increasingly recognized in managing advanced CHF, yet their evidence-based benefits remain underexplored. This study aimed to assess the influence of hospice care on CHF patient outcomes. A total of 120 inpatients with CHF were randomly assigned to receive either hospice care in addition to standard treatment (experimental group) or standard care alone (control group). Patient assessments included heart function classification, activities of daily living, Minnesota Living With Heart Failure Questionnaire, anxiety scale, and pain assessment. Results demonstrated significant improvements in cardiac function, activities of daily living, anxiety levels, pain scores, and heart failure–related quality of life in the experimental group compared with controls. Reduced anxiety, enhanced emotional well-being, and overall health status improvements were particularly notable postintervention. Hospice care was associated with enhanced functional abilities, emotional well-being, pain management, and overall quality of life for CHF patients. In conclusion, this study underscores hospice care’s positive impact on prognosis, quality of life, and emotional well-being in CHF, emphasizing its potential as a critical component in comprehensive CHF management strategies.

Chronic heart failure (CHF) represents a significant and growing public health burden worldwide, with a prevalence that continues to rise due to an aging population and improved survival following acute cardiovascular events.¹ Despite advancements in pharmacological and device-based therapies, the management of CHF remains complex, often necessitating a multidisciplinary approach to address the diverse needs of patients with this condition.² The impact of CHF extends beyond the physiological manifestations of the disease, encompassing profound implications for patients’ emotional well-being, quality of life, and overall prognosis. As such, there is a critical need to explore novel and comprehensive interventions that address the multifaceted needs of patients with advanced CHF.³

In recent years, there has been increasing recognition of the value of palliative care and hospice services in the management of advanced CHF, with growing evidence supporting the benefits of integrating these services into the standard care of patients with cardiovascular diseases.⁴ The principles of palliative care, which focus on symptom management, advanced care planning, psychosocial support, and end-of-life discussions, align closely with the complex needs of patients with advanced CHF, offering a holistic approach to care that extends beyond traditional disease-focused management.⁵ Furthermore, hospice care, a subset of palliative care designed for patients with a life expectancy of 6 months or less, emphasizes patient-centered support, comfort, and dignity, aiming to maximize quality of life and alleviate suffering for patients and their families during the advanced stages of incurable illnesses.^6-8

Recent studies have highlighted the pivotal role of hospice care in enhancing the outcomes for patients with advanced chronic conditions, including CHF.⁹ A study by Chung et al¹⁰ revealed that patients receiving hospice care had significantly better quality of life, as measured by validated scales, than those under standard care. In terms of emotional well-being, a study by Mossman et al¹¹ demonstrated that patients receiving hospice care reported significantly less anxiety and depression, which persisted even after adjusting for confounding factors such as disease severity and socioeconomic status. Regarding prognosis, although hospice care is typically reserved for patients with a terminal prognosis, emerging evidence suggests that early integration of hospice care may actually improve survival outcomes for some patients with CHF.¹² A study by Giusti et al¹³ found that CHF patients who were enrolled in hospice care earlier had a longer survival time compared with those who entered hospice care in the late stages of their disease. This finding challenges the traditional notion that hospice care is solely focused on end-of-life care and suggests that it may have a broader role in disease management.

Despite the potential benefits of hospice care in the management of CHF, there remains a paucity of robust evidence assessing its impact on patient outcomes, particularly in the context of cardiac function, emotional well-being, activities of daily living (ADLs), pain management, and overall quality of life. Consequently, there is a compelling need for rigorous research that elucidates the potential efficacy of hospice care in addressing the diverse needs of patients with advanced CHF. The present study aimed to fill this gap in the literature by evaluating the impact of hospice care on the prognosis, quality of life, and emotional well-being of patients with CHF.

MATERIALS AND METHODS

Study Design

Patients with CHF in the department of cardiovascular medicine of the tertiary hospital from December 2021 to June 2023 were enrolled and randomly divided into the experimental group and the control group using a computerized random-number generator.

Block randomization with variable block sizes of 4 and 6 was used to maintain balance in the number of participants in each group throughout the recruitment period. This method ensured that the allocation ratio was preserved even if recruitment was halted prematurely. The random allocation sequence was concealed in sequentially numbered, opaque, sealed envelopes. Each envelope contained the group assignment for the next participant to be enrolled. This mechanism prevented researchers and participants from predicting or influencing the allocation sequence until interventions were assigned. The random allocation sequence was generated by an independent statistician not involved in the study’s execution. Participant enrollment and assignment to interventions were carried out by a study coordinator who was blinded to the group assignments until immediately before the intervention began.

Inclusion and Exclusion Criteria

INCLUSION CRITERIA

Patient met CHF diagnostic criteria, and their diagnosis of heart failure was confirmed by imaging and serological examinations¹⁴; had a disease course of at least 1 year; were 50 years or older; and voluntarily signed informed consent forms.

EXCLUSION CRITERIA

Patients were in the acute phase of CHF; had severe pulmonary dysfunction, cerebral infarction, lack of clear consciousness, and limited ability to express themselves; lack self-care abilities or was diagnosed with Alzheimer disease; or had concomitant malignancies.

Intervention Methods

CONTROL GROUP

Standard care for heart failure including disease monitoring, nutritional guidance, adherence to medical prescriptions, prevention and management of complications, and health education was performed at the hospital.

EXPERIMENTAL GROUP

The hospice care intervention was initiated upon the patient’s admission to the hospice unit, following a comprehensive assessment confirming the eligibility criteria. The intervention was delivered over a minimum period of 7 weeks. The care was adjusted according to the patient’s evolving needs and could be extended beyond 7 weeks for patients who required ongoing support. In addition to the standard care provided to the control group, the experimental group received hospice care, including the following:

• 1.Pain management: aromatherapy, music therapy, and companionship by family members;
• 2.Comfort care: single rooms or sharing a ward with patients in less severe condition;
• 3.Sleep care: creating a conducive ward environment with gentle lighting and appropriate room temperature; adjusting monitoring equipment alarm systems and maintaining a quiet environment in accordance with the patient’s condition, minimizing nighttime treatments and diuretic use, and utilizing aromatherapy and music therapy to improve sleep quality;
• 4.Psychological counseling: conducting individualized communication based on the patient’s social and cultural background, understanding the patient’s emotions and concerns, and providing professional psychological counseling to alleviate patient anxiety;
• 5.Spiritual support: providing companionship, empathy, professional symptom control, and appropriately using symbolism, humor, literature, and art to aid in understanding the illness and death;
• 6.End-of-life education: providing emotional support and comfort to patients’ family members and caregivers, helping patients peacefully accept the reality of death, and preventing irrational suicide; and
• 7.Establishing a wish list: assisting terminally ill patients in creating a wish list and completing wish-related tasks with the help of social workers and volunteers.

Observation Indicators

HEART FUNCTION CLASSIFICATION

The New York Heart Association (NYHA) functional classification was used to assess the cardiac function of CHF patients after 7 weeks of care.¹⁵ It categorizes patients into 4 classes based on the symptoms and exercise capacity associated with heart failure. Class I represents no symptoms of heart failure, whereas symptoms progressively worsen from class II to IV. This method provides a simple and rapid assessment of heart function.

ADL SCALE

The Barthel Index was used to assess the ADL of CHF patients after 7 weeks of care by determining self-care abilities. The total score on the Barthel Index categorizes the level of self-care abilities.¹⁶ It evaluates 10 activities including feeding, bathing, grooming, dressing (and undressing), controlling bowel movements, controlling bladder, using the toilet, transferring from bed to chair, walking on level surfaces, and climbing stairs. The scores for each activity are summed to obtain the total score. Based on the total score, self-care abilities are classified into 4 levels: total dependence, moderate dependence, slight dependence, and independence. Total dependence is indicated by a score of ≤40, indicating the need for full assistance; moderate dependence is indicated by a score of 41 to 60, indicating the need for significant assistance; slight dependence is indicated by a score of 61 to 99, indicating the need for limited assistance; and independence is indicated by a score of 100.

MINNESOTA LIVING WITH HEART FAILURE QUESTIONNAIRE

The Minnesota Living With Heart Failure Questionnaire evaluates patients’ physical limitations, emotions, clinical symptoms, and social restrictions in the context of CHF after 7 weeks of care, comprising 21 items categorized into physical, emotional, and overall health statuses. Each item represents the impact of heart failure on the patient’s quality of life, with scores ranging from 0 to 5 for each item and a total score range of 0 to 105. A higher score indicates a lower quality of life. The questionnaire has demonstrated a Cronbach α coefficient of >.75.

ANXIETY ASSESSMENT SCALE

The Zung Self-rating Anxiety Scale (SAS) is utilized to assess the subjective feelings of anxiety experienced by patients after 7 weeks of care.¹⁷ Domestic and international applications have demonstrated that SAS is one of the anxiety self-assessment tools with high reliability and validity. The Zung Self-rating Anxiety Scale comprises 20 items, each rated on a scale of 1 to 4, primarily based on the frequency of symptoms defined in each item. A score of 50 to 59 indicates mild anxiety, 60 to 69 indicates moderate anxiety, and 70 or above indicates severe anxiety.

NUMERIC RATING SCALE FOR PAIN ASSESSMENT

The numeric rating scale (NRS) for pain assessment of CHF patients after 7 weeks of care consists of 11 numbers from 0 to 10. Patients utilize these 11 numbers to describe the intensity of their pain, where a higher number indicates a more severe degree of pain.¹⁸ The scale categorizes pain intensity as follows: 0 for no pain, 1 to 3 for mild pain (pain does not affect sleep), 4 to 6 for moderate pain, 7 to 9 for severe pain (unable to sleep or pain wakes patient from sleep), and 10 for extreme pain. Clinically, it is common to inquire about the level of pain, make a mark, or let the patient themselves indicate the number that best represents their level of pain. This method is widely used in clinical practice.¹⁹ The NRS demonstrates high reliability and validity, is easy to record, and is suitable for clinical patients.

Sample Size

Using G*Power 3.1.9.7 (Heinrich-Heine-Universität Düsseldorf, Germany) to calculate the sample size, select the “means: difference between 2 independent means (2 groups)” option based on t tests, choose an a priori analysis, and set the parameters as follows: 2-tailed mode, effect size d = 0.6, α error probability = .05, power (1 − β error probability) = 0.9, resulting in a minimum sample size of 120 participants for 2 groups. Considering the effectiveness of questionnaire collection, the sample size was increased by 20% to account for dropout rates, leading to a final estimated sample size of 144 hospitalized patients from the cardiology department of a tertiary hospital.

Statistical Analysis

The statistical analysis was conducted using SPSS 22.0 (IBM Corp, Armonk, New York). For continuous data, normality was assessed, and if the data met normal distribution, descriptive statistics were presented as mean ± SD. Independent-sample t test was used for intergroup comparisons, and paired-sample t test for within-group pre-post comparisons. For non–normally distributed data, median (interquartile range) was used for descriptive statistics, with the Wilcoxon rank-sum test for intergroup comparisons and the Wilcoxon signed-rank test for within-group pre-post comparisons. Categorical data were described using frequency and percentage, with intergroup comparisons analyzed using the χ² test. P < .05 was considered statistically significant.

RESULTS

General Data

A total of 144 patients with CHF were enrolled and randomly divided into an experimental group of 72 and a control group of 72 patients. Among these patients, those who could not receive interventions in the hospice unit and those who were lost to follow-up or died during the study were withdrawn from the trial. The dropout rate was 16.67%. Finally, available data of 120 patients were further analyzed in this study (n = 60 for each group) (Figure). There were no significant differences between the control group and the experimental group in terms of age (74.33 ± 11.33 vs 73.07 ± 10.42 years, P = .525), disease course (P = .517), length of hospital stay (8 [7-10] vs 9 [7.5-10] weeks, Z = 0.377, P = .706), or length of survival (13.58 ± 1.06 vs 13.87 ± 1.03 weeks, t = 1.520, P = .131), suggesting that the 2 groups were well-balanced in terms of baseline characteristics (Table 1).

TABLE 1.

Comparison of General Data Between the 2 Groups

Variables	Control Group	Experimental Group	t/Z/χ2	P
Age, y	74.33 ± 11.33	73.07 ± 10.42	0.637	.525
Disease course, mo			4.228	.517
<1	6 (10.00)	3 (5.00)
1-3	5 (8.33)	11 (18.33)
>3	4 (6.67)	6 (10.00)
≥6	5 (8.33)	6 (10.00)
≥12	7 (11.67)	6 (10.00)
≥24	33 (55.00)	28 (46.67)
Length of hospital stay, wk	8 (7-10)	9 (7.5-10)	0.377	.706
Length of survival, wk	13.58 ± 1.06	13.87 ± 1.03	1.520	.131

FIGURE.

Flowchart of patient selection.

Life Indicators

Cardiac function, anxiety, daily living, and pain were evaluated using the NYHA Functional Classification, SAS, Barthel Index, and NRS. After treatment, the experimental group exhibited a statistically significant improvement in cardiac function scores compared with the control group (Z = −6.989, P = .002) (Table 2). The pretreatment and posttreatment comparisons within each group revealed a statistically significant decrease in cardiac function scores in the experimental group (Z = −6.154, P < .001) but not in the control group. Following treatment, the experimental group exhibited a significant reduction in anxiety levels (Z = −6.457, P < .001). Conversely, there was no statistically significant difference in anxiety levels before and after treatment in the control group. The intergroup comparison revealed a significant decrease in anxiety levels in experimental group after treatment (Z = −3.886, P < .001). Following treatment, both the control and experimental groups demonstrated statistically significant improvements in their abilities to perform daily activities (Z = −5.466, P < .001; and Z = −5.666, P < .001). Following treatment, the experimental group showed a statistically significant decrease in pain scores (Z = −3.415, P = .001). However, there was no statistically significant change in pain scores for the control group after treatment. After treatment, the experimental group displayed a significant improvement with P < .0001. These findings suggest that hospice care has a positive impact on cardiac function, anxiety, daily living, and pain in patients with CHF.

TABLE 2.

Comparison of Intergroup and Pretreatment and Posttreatment Life Indicators

Group	Before Treatment	After Treatment	Z	P
Cardiac function
Control group	3 (2.5-3)	3 (2-3)	−1.732	.083
Experimental group	3 (3-3)	2 (1-2)	−6.154	<.001
Z	−0.432	−6.989
P	.666	.002
Anxiety
Control group	45.73 ± 11.89	47 (36.2-52)	−1.414	.157
Experimental group	46.67 ± 13.43	36.5 (29.5-43.5)	−6.457	<.001
t/Z	−0.403	−3.866
P	.688	<.001
Daily living
Control group	80 (70-85)	85 (80-92.5)	−5.466	<.001
Experimental group	85 (65-90)	90 (80-95)	−5.666	<.001
Z	−0.016	−0.687
P	.987	.492
Pain
Control group	2 (0-3)	2 (0-3)	−1.604	.109
Experimental group	1.5 (0-2)	0 (0-1)	−3.415	.001
Z	−1.532	−4.218
P	.126	<.0001

Intergroup and Pretreatment and Posttreatment Heart Failure Quality-of-Life Scores

Quality of life was assessed using the Minnesota Living With Heart Failure Questionnaire. The impact of hospice care on the quality of life of patients with CHF was assessed through a comparison of intergroup and pretreatment and posttreatment heart failure quality-of-life scores (Table 3). Before treatment, the control group had a mean physical condition score of 28.5 (23-36), emotional condition score of 13 (10-16), and overall health status score of 60.5 (51-70), which remained relatively unchanged after treatment. In contrast, the experimental group demonstrated a significant improvement in all aspects of quality of life after treatment, with the physical condition score decreasing to 20 (14-25) (P < .05), emotional condition score decreasing to 9.5 (5-13) (P < .05), and overall health status score decreasing to 43.9 ± 16.16 (P < .05). Notably, there were significant differences between the control and experimental groups after treatment and within the experimental group before and after treatment. These results indicate that hospice care has a substantial positive impact on the quality of life of patients with CHF, particularly in terms of physical and emotional well-being and overall health status.

TABLE 3.

Comparison of Intergroup and Pretreatment and Posttreatment Heart Failure Quality of Life Scores

Group	Time Point	Physical Condition	Emotional Condition	Overall Health Status
Control group	Before treatment	28.5 (23-36)	13 (10-16)	60.5 (51-70)
	After treatment	28 (23-36)	13 (10-16)	60 (50-70)
Experimental group	Before treatment	30 (22.5-34)	12 (8.5-15)	63 (50.5-70.5)
	After treatment	20 (14-25)a,b	9.5 (5-13)a,b	43.9 ± 16.16a,b

Comparison of physical condition, emotional condition, and overall health status within the same group before and after treatment.

^a Significant difference between control group and experimental group after treatment (P < .05).

^b Significant difference within the experimental group before and after treatment (P < .05).

DISCUSSION

Chronic heart failure remains a considerable public health concern globally because of its high prevalence, detrimental effects on patients’ quality of life, and substantial economic burden on health care systems.²⁰ As such, there is a continuous search for effective interventions to improve the prognosis and well-being of patients with CHF. This study aimed to assess the impact of hospice care on the prognosis, quality of life, and emotional well-being of patients with CHF.

One of the key findings of the present study is the significant improvement in cardiac function scores in the experimental group compared with the control group. The NYHA functional classification and improvement in cardiac function scores post–hospice care implementation are crucial indicators of the efficacy of the intervention. The statistically significant improvement in cardiac function in the experimental group suggests that hospice care positively influenced the physiological aspect of CHF management through a multidimensional approach comprising pain management, comfort care, sleep care, psychological counseling, spiritual support, and end-of-life education. This aligns with previous research demonstrating the beneficial effects of holistic care models on cardiac function and symptom management in patients with CHF.²¹

Moreover, hospice care demonstrated a positive impact on the emotional well-being of patients with CHF, as evidenced by the significant reduction in anxiety levels in the experimental group postintervention. Anxiety is a common psychological comorbidity in patients with CHF and is associated with worsened prognostic outcomes and reduced quality of life. The reduction in anxiety levels following hospice care implementation reflects the effectiveness of the intervention in addressing the psychological needs of patients with CHF. Hospice care provides psychosocial support and counseling to address the emotional and psychological impact of CHF.²² Patients with CHF commonly experience anxiety, depression, and existential distress due to the chronic and potentially life-limiting nature of their condition.^23,24 The provision of psychological counseling, spiritual support, and end-of-life education as part of hospice care helps patients cope with the emotional burden of CHF, promoting emotional well-being and resilience.^25,26

The improvement in ADL scores and pain assessment scores in both the control and experimental groups postintervention further supports the positive impact of hospice care on patient well-being. These outcomes indicate that hospice care not only enhances emotional well-being but also contributes to improving functional abilities and pain management in patients with CHF. The multifaceted approach to hospice care, including pain management strategies, sleep care, and comfort care, likely contributed to the observed improvements in ADL and pain assessment scores.^27,28 These findings are consistent with previous studies highlighting the benefits of palliative care interventions in improving physical functioning and symptom management in patients with advanced CHF.²⁹

In addition, the implementation of hospice care demonstrated a substantial positive impact on the quality of life of patients with CHF, particularly in terms of physical and emotional well-being and overall health status.^30,31 The significant improvement in quality-of-life scores following hospice care intervention emphasizes the comprehensive nature of the program in addressing the diverse needs of patients with CHF. Hospice care incorporates advanced care planning and end-of-life discussions, which can alleviate patients’ fears and uncertainties about the future.³² By engaging in open and compassionate conversations about end-of-life care preferences, patients with CHF can experience a sense of control and dignity, reducing anxiety and distress.³³ This approach fosters a supportive environment that empowers patients to make informed choices about their care, leading to improved emotional well-being and quality of life.

The findings of this study have important clinical implications for the management of patients with CHF. Hospice care, through its multidimensional approach, has the potential to enhance patient outcomes and improve the overall quality of care for patients with advanced CHF. The positive impact of hospice care on cardiac function, emotional well-being, ADL, pain management, and quality of life underscores the need to integrate palliative care and hospice services into the standard management of CHF. This approach aligns with current guidelines advocating for the early integration of palliative care in the management of advanced heart failure to improve patient outcomes and enhance overall care delivery.³⁴

Furthermore, the study results highlight the importance of addressing the holistic needs of patients with CHF beyond traditional disease-focused management. The multifaceted nature of hospice care, incorporating psychosocial, spiritual, and physical aspects of care, reflects a patient-centered approach to CHF management. This patient-centered care model has the potential to improve patient satisfaction, enhance symptom management, and optimize overall well-being.

Despite the significant findings of this study, several limitations should be acknowledged. First, the study was conducted at a single center, which may limit the generalizability of the findings to other health care settings. Future multicenter studies are warranted to confirm and extend the current findings. Second, the relatively small sample size may impact the statistical power of the study. Larger-scale studies are needed to further validate the efficacy of hospice care in patients with CHF. In addition, the long-term effects of hospice care on patient outcomes and the potential impact on health care utilization and costs remain to be explored.

CONCLUSION

The results of this study demonstrate that hospice care has a positive impact on the prognosis, quality of life, and emotional well-being of patients with CHF. The multidimensional approach of hospice care, addressing physical, emotional, and psychosocial needs, has the potential to improve patient outcomes and enhance overall care delivery. The integration of hospice care and palliative services into the standard management of CHF is crucial in providing comprehensive, patient-centered care for patients with advanced heart failure. Further research is warranted to validate and extend the current findings and explore the long-term impact of hospice care on patient outcomes and health care utilization.