Table 3.
Domains of supportive care and team members involved in early & late phases of heart failure progression
| DOMAINS | EARLY PHASE | LATE PHASE | TEAM MEMBERS |
|---|---|---|---|
| Physical Well-being | Life-prolonging Heart Failure Therapies (Medications, Interventional Procedures) | Physician, Advanced Practice Provider (APP)*, Pharmacist | |
| Symptom Management (Pain, Dyspnea, Fatigue, Insomnia, Anorexia, Pruritus, Side Effects of Treatments/Interventions) | Physician, APP, Pain Specialist, Palliative Care Specialist (PCS), Pulmonologist, Respiratory Therapist, Pharmacist, Physical & Occupational Therapy (PT/OT) | ||
| Complementary & Alternative Medicine (as desired by the patient) | Acupuncturist, Clinical Art Therapist, Message Therapist, Yoga Instructor | ||
| Exercise/Weight Control/Nutrition | Rehabilitation/Strengthening | Physiatrist, PT/OT, Nutritionist | |
| Psychosocial Support | Quality of Life | ALL Team Members | |
| Community Resources (Insurance, Financial Aid, Support Groups) | Community Resources (Transportation, Home Care, Hospice) | Social Work, Case Management (SW/CM), Home Health, Support Group Facilitator, Hospice Team | |
| Spirituality | Chaplain | ||
| Depression, Anxiety | Physician, APP, Psychiatrist, Psychologist, Pharmacist, Chaplain, PCS, Support Group | ||
| Emotional Support, Coping | Loss of Control, Autonomy, Legacy Building | ||
| Communication | Appoint Team Liaison | Maintain Open, Trusting Relationship (“Meet patients where they are”) | Physician, APP, Caregiver, Team Liaison, PCS, Psychologist, Psychiatrist |
| Continuity of Care | |||
| Shared-decision Making, Assess Goals of Care | |||
| Disease Understanding | Prognostic Understanding (As patient wishes to know) | ||
| Addressing Fears & Concerns | |||
| Advance Care Planning | Legal (Advance directives—including living wills, appointment of alternate decision maker [health care power of attorney]) | Legal (Reassess Preferences and Goals of Care Frequently) | Physician, APP, SW/CM, PCS, Caregiver |
| Difficult Issues (Choosing a Place of Death; Avoiding Prolonged Suffering; Code status, Considering Hospice; De-escalation of Care; Preferences for Rehospitalization, Device Deactivation | Physician, APP, PCS, Caregiver, Hospice | ||
| Education | Self-management/Self-care (Adherence to Medication, Diet; Exercise) | Physician, APP, Pharmacist, Dietician, Physiatrist, PT/OT | |
| Understanding heart failure and the implications of the diagnosis | Understanding Unpredictable Course | Physician, APP | |
| Knowledge of Potentially Life-limiting Nature of Illness | |||
| Caregiver Focus | Preserve/Foster Relationships, Caregiver Agreement with/Acceptance of Patient Preferences | Caregiver | |
| Prevention of Caregiver Fatigue and Burnout | SW/CM, Support Group, Psychologist, Psychiatrist | ||
| Avoid Leaving Financial Burdens | Caregiver, SW/CM | ||
| Bereavement Support | Caregiver, Psychologist, Psychiatrist, SW/CM, Chaplain | ||
*
“Advanced Practice Provider” refers to nurse practitioners or physician assistants