Case scenario: A 70-year-old man has been admitted to a cardiology unit after recently being diagnosed with acute left ventricular failure. This gentleman had a myocardial infarction four years ago but has recently noted he gets short of breath at night and on climbing the stairs.
Introduction
Severe and / or chronic disease conditions are usually associated with psychological co-morbidities that arise as a result of the disease burden as has been published in the literature for many decades (Schneiderman N, 2004; Carrol et al, 1993; Dracup et al, 1992; Mayou et al, 1991; Hecker et al, 1989; Lahdensuoa et al. 1989; Walden et al, 1994; Kuhn et al, 1998). Even more than the psychological impact on the individual patient, different chronic illnesses have been shown, to varying extents, to have a negative impact on the psychological health of the families of affected patients (Holmes and Deb, 2003). As a result, there is a need to provide psychological support to patients and their families and, ideally, all health care professionals should be trained in empathic communication skills to be prepared to handle these situations as they arise with patients.
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The limited consultation time that physicians are usually able to spend with individual patients makes it impossible for them to carry out detailed patient counselling and obtain relevant non-medical patient information towards achieving total holistic health. As such, nurses are often best placed and in a logical position to have most extensive interactions with patients than any other health care professionals. The specialist nurse is in an ideal position to do this as she has the ability and is presented with the opportunity to focus on both the clinical needs and the educational and supportive needs of the patient and their family (Dahl and Penque, 2000).
Accordingly, the role of nurses in clinical practice often extends beyond traditional clinical management to include patient counselling, monitoring, and providing psychosocial support to both the patient and his / her close family members. The objective of this assignment is to analyse and evaluate the expected altered physiology, and the potential social and psychological complications that the abovementioned patient might be faced with as a result of the newly diagnosed left ventricular failure. This assignment will also look at the physical and psychological consequences of suffering from a heart failure, as well as the indispensable role of the nurse in providing support to such a patient and his / her relatives.
Left ventricular failure
Left ventricular failure or left heart failure, as the term suggests, refers to heart failure in which the left ventricle fails to contract forcefully enough to maintain a normal cardiac output and peripheral perfusion (Mosby’s Medical Dictionary 2009). Acute left ventricular failure usually manifests as pulmonary oedema and congestion due to increased pressure in the pulmonary capillaries.
There are myriad possible causes of left ventricular failure, which could include: most commonly ischaemic heart disease, systemic hypertension, mitral and aortic valve disease and various cardiomyopathies (He et al, 2001; Baldasseroni et al, 2002). From the patient’s medical history, the cause of this acute episode is likely the myocardial infarction (i.e. ischaemic heart disease), which he suffered four years ago. The occurrence of acute heart failure is most common in the setting of acute myocardial infarction, which is associated with extensive loss of ventricular muscle – in this case, left ventricular muscle. It has been shown that previous experiences of myocardial ischaemia, especially if recurrent, constitute a significant risk factor for the severity of left ventricular dysfunction and, ultimately, heart failure (Gheorghiade & Bonow, 1998).
The patient is showing a few classic symptoms of heart failure – essential features of heart failure (criteria 1 and 2) include breathlessness or dyspnoea especially on exertion, fatigue and ankle swelling (Kumar and Clark, 6th edition, 2005). Although not a formal diagnostic measure, the fact that our patient only complains of breathlessness on exertion may be indicative of the less severe disease as breathlessness at rest is usually associated with more severe disease. It appears that the patient is also experiencing paroxysmal nocturnal dyspnoea, another key symptom of heart failure, which describes a sudden fit of breathlessness at night.
Left-sided heart failure can involve failure of the forward or backward function. Forward dysfunction is more commonly associated with poor systemic circulation (symptoms could include confusion and dizziness), while problems with the backward function is more likely to cause congestion of the pulmonary system and respiratory-related symptoms, like our patient is showing.
Pathophysiology of left ventricular failure
Acute left ventricular failure in isolation is a serious illness that could potentially change the patient’s life course. In addition, however, we need to consider the further consequences of the disease on the heart function and general physiology of the affected patient.
With conditions like a myocardial infarction, the efficiency of the cardiac muscle is compromised, due to the damage or overloading. These functional changes associated with myocardial infarction and, eventually, heart failure lead to significant structural and functional changes in the patient’s heart, which ultimately cause reduced cardiac output and an increased strain on the heart.
For example, left ventricular failure causes a decrease in stroke volume as a result of systolic and / or diastolic failure. The condition also leads to a considerable reduction in the patient’s cardiac output, which is likely responsible for the symptom of exercise intolerance that is frequently seen with afflicted patients. In the case of our patient, this is evident in the breathlessness he experiences on climbing stairs. This leads to hypotension and tachycardia, with a fast but weak pulse rate, when the heart attempts to compensate for the reduced cardiac output and reduced arterial blood pressure.
Conversely, the blood pressure in the lungs is raised as the heart fails to adequately pump out the blood which flows to it from the lungs, and causes a very frightening life-threatening emergency condition known as pulmonary oedema (Kumar and Clark, 6th edition, 2005). Pulmonary oedema occurs when the pulmonary pressure rises and forces fluid filtration out of the capillaries and into the interstitial space or, worse, into the alveoli (Kumar and Clark, 6th edition, 2005).
Thus, the impact of left ventricular failure cannot be overemphasised. It is important to consider the feelings of the patient and the relative impact of the condition on their quality of life and ensure that adequate support is provided as necessary.
Social and psychological consequences associated with left ventricular failure
Patients with heart failure frequently show significant impairment of all the measured aspects of physical and mental health, as well as reduction in physical functioning. This impairment appears to be correlated with severity of disease, i.e. patients with more severe heart failure by the HYHA classification tend to show significantly worse impairment and Short-Form 36 (SF-36) score (Hobbs et al, 2002). The physical health burden was also shown to be significantly greater than that suffered in other serious common chronic disorders, whether cardiac or other systems, e.g. chronic lung disease and arthritis.
Patients diagnosed with any form of heart disease often experience emotional distress due to the life-threatening nature of their disease and are often faced with functional impairments that may influence quality of life. Some of the key manifestations of the psychological impact of heart disease are depression, anxiety, social isolation, health status, and Type D personality (Pederson et al, 2009).
The reported prevalence statistics of depression in patients with heart failure varies considerably across the different studies, which use different methodologies, different patient types (e.g. out- or inpatients), and different depression assessment scales. The broad range varies from 13% (Murberg et al, 1998) to 48% (Gottlieb et al, 2004). It is estimated that the prevalence of depression in patients with heart failure is approximately 100 cases per 1000 persons over the age of 65 years old (McMurray and Stewart, 2000). By this estimate, the age and medical history of our patient makes him more susceptible to depression and possibly other psychological disorders than the general population.
In a study by Ramasamy et al in 2006, the investigators strove to identify psychological and social factors that are significantly correlated with dyspnoea in patients with heart failure. Using the dyspnoea scale to measure patients’ breathlessness and the Hospital Anxiety and Depression Scale to assess specific psychological disorders like anxiety and depression, the investigators showed that there was a significant correlative relationship between dyspnoea associated with heart failure and depression, fatigue, and overall health perception. It is worth noting that while the study was relatively small (N = 67), the patient sample was representative of the population and also showed similar characteristics to our patient. The sample was predominantly male with a mean age of 65.38 ± 14.05 years.
In a larger study (N = 1,848) of patients who had had a myocardial infarction 2 years ago, left ventricular dysfunction was found to be significantly related to physical function (p = 0.021); social dysfunction (p = 0.014); psychological well-being 9p = 0.042); and perceived health status (p = 0.024) (Coyne et al, 2000). Increasing age, like in our patient, was found to be predictive of poorer outcomes in most cases. Similarly, the presence of co-morbidities was associated with worse outcomes across all dimensions. Although our patient’s brief history does not mention any co-morbidities, it is quite likely that, given his age and medical history, our patient may have other related disease conditions such as diabetes mellitus and hypercholesterolaemia, which would increase his risk of experiencing psychological distress.
Importantly, depression in patients with heart failure is strongly associated with increased morbidity and mortality (Barefoot and Schroll, 1996; Frasure-Smith et al, 1995; Frasure-Smith et al, 2000; Lesperance et al, 2002). It is interesting to note the apparent two-way correlation between heart failure and depression. Clearly heart failure, as with other chronic conditions, is a proven risk factor for developing psychological conditions. On the other hand, there is also evidence to show that there is an increased risk of cardiac events in patients who are suffering from depression (Joynt et al, 2004; Musselman et al, 1998; Nair et al, 1999).
With this close relationship between cardiac and psychological disorders, there appears to be an integration of physiological and psychological factors in cardiovascular health. Four pathological patterns that occur in depressed patients correspond strongly to the pathogenesis of heart failure (Thomas et al, 2008), and these are outlined below:
Neurohormonal activation
Hypercoagulability
Autonomic neurocardiac dysfunction
Cytokine cascade
In addition, these two conditions (depression and heart failure) also have some clinical features in common, which often cloud the diagnostic process in both cases – this provides further evidence supporting the link between heart failure and psychological disorders. As an example, both heart failure and depression are often associated with poor physical function, low mood, anhedonia – a loss of interest in pleasurable activities, lack of appetite, weight loss / gain, hypersomina, insomnia and other common symptoms. Other symptoms of depression such as feeling worthless, inability to concentrate, and thoughts of dying can also be caused by the poor quality of life that is typically characteristic of heart failure (Juenger et al, 2002; Hobbs et al, 2002).
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There is also the consideration of social disorders that frequently occur in heart failure. Social isolation is a common occurrence in patients with heart failure (Murberg and Bru, 2001). It is important to recognise this as a noteworthy complication in these patients. Results of a small study of 119 clinically stable patients with symptomatic heart failure suggested that social isolation might be a significant predictor for mortality (Murberg and Bru, 2001). Similarly, a larger study, which closely examined the psychosocial characteristics of patients with heart disease, also found that patients with limited or non-existent social networks had a higher risk of mortality (Brummett et al, 2001).
In studies that strive to evaluate the effect of heart failure on patients’ quality of life, some of the other issues that are reported by these patients include: anxiety, hostility, reduced activities of daily living, inability to work and disruption of work roles, disruption of social interaction with friends and family, and reduced sexual activity and satisfaction (Grady 1993; Konstam et al, 1996).
Thus it is clear that diseases such as heart failure can considerably impact of patients’ quality of life – it is important to adopt a holistic care approach that integrates physical as well psychological and emotional treatment and support in patient management protocols.
Nursing management of patients with left ventricular failure
According to Thomas et al (2008), biological, psychological, and social aspects of morbidity and mortality in heart failure can be integrated in a holistic model. It is undoubtedly important for all health care professionals involved in the care of patients with heart failure to be conversant in the psychological aspects of the disease as this plays a major role in the affected patients’ lives. The management of heart failure should include symptom relief, prevention of further heart failure progression, and quality of life improvement (Riegel et al, 2000); in addition, heart failure treatment should strive to incorporate appropriate pharmacological interventions as well as lifestyle management, which could include risk factor reduction, dietary changes, exercise and education and counselling.
In terms of manpower resource, one possible strategy in heart failure management is to adopt a nurse-directed multidisciplinary plan of care that would incorporate intensive education, detailed drug plan analysis, planning for early discharge and long-term follow up while the patient is back at home (Rich et al, 1995). These patients are in dire need of close clinical management and empathic encouragement to help identify and successfully manage their symptoms. Evidence supports the theory that having regular contact with a heath care team that is dedicated to management of their chronic disease gives patients increased confidence that can help foster self management and improve the patient’s quality of life (Fonarow et al, 1997).
The traditional clinical roles of the specialist nurse in the care of patients with heart failure would logically include education and counselling to ensure that the patient has a full understanding of their disease and drug treatment. This counselling would also educate the patient about the benefits of relevant lifestyle modifications such as smoking cessation, dietary modifications, maintaining an appropriate level of daily activity, and healthy emotional coping strategies. All this information should be repeated at subsequent patient visits to ensure patients’ understanding. Another key role for the nurse is to strive to involve the patient’s family members in the agreed plan of care. It is crucial to ensure that the patient and his / her family receive appropriate education, support and assistance to help them understand and cope effectively with the situation (Weinberger and Kenny, 2000). Nurse support in heart failure patients has been shown to be of benefit to the patients (Deaton, 2000). In particular, the need for extensive patient education to ensure that the patient understands his / her condition, the need to be adherent with prescribed medication and, probably most importantly, is able to recognise warning signs and take appropriate action, cannot be overemphasised (Beattie, 2000).
Following discharge, there is a need for the specialist nurse to maintain continued contact with the patient through follow-up calls and individualised support strategies according to the specific needs of the patient and family. These calls or visits would present an ideal opportunity to assess that the patient’s adherence to prescribed therapy – both pharmacological and non-pharmacological. This type of emotional support is also a predictor of cardiovascular events – patients that do not receive emotional support after suffering a heart failure are more likely to suffer further cardiovascular events in the year immediately following discharge compared with patients who have received adequate emotional support (Krumholz et al, 1997).
Another reason why home visits by nurses are very useful to these patients is the simple convenience that it offers to patients. The common symptoms of heart failure, such as breathlessness and fatigue, often limit the patients’ physical functionality especially outside of their homes and having to make clinic visits could be quite tasking. Home care is proven to be of significant benefits in cardiac patients (Goodwin, 1999).
Also, nurse-provided social support can help improve the quality of life of patients with heart failure and alleviate any depressive symptoms, anxiety or other psychological disorders (Thomas et al, 2008). A lack of social support is directly proportional to higher depression and low remission of depression in patients with heart failure (Koenig, 1998; Murberg and Bru, 2001; Holahan et al, 1995). Nurses can optimise this available evidence base to ensure that patients with heart failure under their care are provided with social support that is individualised to the patient’s needs. It would also be the role of the nurse to educate the patient’s family members and / or care givers on the importance of social support in these patients and on simple steps to take in their daily life to provide this support effectively (Thomas et al, 2008). Possibly simply being aware of this association between social support and its impact on depression will motivate nurses to incorporate social assessment and support (e.g. through cardiac support groups) in the management of heart failure patients (Thomas et al, 2008).
In a sub analysis of the same study by Murberg and Bru, the investigators evaluated the effects of avoidance coping styles on the mortality risk in patients with symptomatic congestive heart failure. The results showed that behavioural disengagement was significantly associated with an increased risk of mortality in this vulnerable group of patients. This conclusion has practical implications for all health care professionals who get involved the pathway of care of patients with heart failure and highlights once again the need to go beyond physical treatment and traditional support. In conclusion from their findings, Murberg and Bru recommended that counselling and support to equip patients with active coping skills could be beneficial in helping patients manage their disease, improve their prognosis and increase the quality of life (Murberg and Bru 2001; Murberg et al, 2004).
It is important that heart failure is recognised as a terminal disease, and that the severity of the disease is fully appreciated and communicated to the affected patients. It appears that a majority of affected patients underestimate their condition and do not even realise the palliative nature of their condition (McCarthy et al, 1996). The simple reason for this is that physicians do not communicate this information clearly to the patients (Stewart and Blue, 2001). Understandably, these would be difficult conversations to have with patients and their families but, nevertheless, the terminal process of the disease should be discussed with the patients and their family members for optimal outcomes.
Nursing requirements for providing effective patient management and support
The task to inform patients and families about their disease therefore usually falls to nurses, who are clearly in a logical position to address this, due to the traditional existing nurse-patient relationships. However, there are certain skills that need to be developed and training to be provided to equip nurses to effectively carry out this role.
The nurse-patient relationship is usually a very human connection, which “humanises healthcare”, and combines the compassion, knowledge and experience of nurses with the patient’s medical experience (Stein-Parbury J, 2009). Nurses need to have good interpersonal communication and relationship-building skills. Furthermore, the role that nurses would have to take in the management of our patient necessitates that the specialist nurse have advanced interpersonal skills to competently communicate with the patient on a therapeutic and personal level.
In developing the interpersonal skills and empathic communication skills that are necessary to be able to have those difficult conversations with patients and their families, i.e. breaking bad news, patient counselling, and ensuring proper understanding of all recommendations and prescriptions, there are some key considerations that should be mastered (Stein-Parbury J, 2009):
Focus, intensity and perspective: this is a key point of differentiation between personal and professional relationships. In fact, the focus, intensity and perspective can be different from one particular of nurse-patient interaction to another. As an example, the intensity would be markedly different when counselling a patient regarding lifestyle modifications and therapy, compared with breaking bad news to patients’ families
Professional boundaries: although, the relationship between nurse and patient can be quite a close one, it is always important to maintain some level of professional boundaries without coming across as being distant from the patient and their experiences. Another element of professional boundaries revolve around the concept of ‘Fitness to Practice’, and recognising what tasks might be outside the scope of nursing practice
Overinvolvement: there is a risk of becoming overinvolved with patients, and this should be avoided as it could easily compromise the nurse’s professional role and sense of control, and could make the nurse less focused and therefore less useful to the patient
Mutual verses unilateral relationships: in most cases, the ideal relationship should be a mutual one, where there is a shared sense of responsibility, commitment and control. There are situations, however, that may require unilateral decisions without consulting the patients, e.g. in cases of emergencies when urgent responses are warranted
Dislike between patient and nurse: it is perhaps unrealistic to presume that nurses will take a natural liking to all their patients, and vice versa. Whatever the case, nurses must not allow their dislike for a particular patient to interfere with the care they provide. There is a skill to attain here – nurses need to come to a realisation that it is their responsibility to care for their patients, irrespective of whether they actually like the particular patient
Interpersonal skills and empathic communication skills should be an integral part of the nursing training curriculum as these skills are fundamental to the role that nurses play in patient management, especially in cases like our patient who is suffering from a serious life-threatening condition.
Conclusion
Left ventricular heart failure in itself is a serious problem, which is further exacerbated by psychological and social complications that significantly reduce patients’ quality of life. Nurses should be an integral part of the multidisciplinary management team as they can have unrivalled input in educating, coaching monitoring and, importantly, supporting patients and their families towards achieving optimal outcomes.
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