Lakhasly

Nursing Care of Elders with Heart Diseases 1.Specific therapeutic interventions for heart failure, of course, involve treatment of the underlying cause or triggering mechanism, but the current emphasis is on pharmacologic therapy to improve cardiac performance with specific neurohormonal agents and non-pharmacologic therapy to reduce symptoms and staging periodic exacerbations.An extensive review by Cintron and Hernandez of pain assessment and treatment in elderly patients with HF highlights the lack of data on effective pain treatments in this patient group and emphasizes the importance of diagnosing the cause and characteristics of pain to establish an appropriate treatment plan.Importance of Nursing Care for Elders with Heart Diseases The preface and first chapter of strategies for improved survival in heart failure indicated that heart failure is a common, costly, disabling, and deadly condition and asked for bestowing it greater public health attention.Aspects of Nursing Care for Elders with Heart Diseases The nursing care for elderly with heart diseases involves managing symptoms and pain, promoting healthy lifestyle changes, assisting with activities of daily living, and educating patients and families.Prevalence of pain in elders with HF appears to be higher than in the general population and can often be attributed to coexisting diseases such as arthritis, renal disease, and previous surgeries and procedures.As stated previously, elderly patients with heart disease suffer from differing levels of fatigue, which is a problematic difficulty because many activities of daily living (ADL's) require a moderate amount of energy expenditure.Medication is focused on cardiac conditions, so medications often prescribed for heart conditions are anticoagulants, cholesterol-lowering drugs, anti-angina drugs, beta-blockers, ACE inhibitors, and diuretics.Despite the common knowledge that prevention is easier and ultimately more cost-effective than treatment, the statistical evidence that reducing risk factors in elderly individuals will prolong survival and improve quality of life is less compelling than it is for younger persons.The physical symptoms of weakness, fatigue, and impaired concentration can mimic the symptoms of depression, and the mood disturbance resulting from these symptoms may be mistaken for a primary affective disorder.A recent article by Toback (2008) stressed the importance of medication reconciliation in elderly patients during care transitions, as discrepancies in the medication regimens and misuse are recognized as common causes of patient deterioration during care transitions.This knowledge deficit study, led by Chung and others (2004) from an acute medical elderly ward in Hong Kong, tested the hypothesis that a nurse-led educational program would decrease drug-related readmission within 6 months.Ideally, the nurse's ongoing assessment will allow for early detection of complications, thus preventing further morbidity and mortality in the elder with heart disease.Although in the study, palliative care did not lead to improvement in patient and family satisfaction compared with standard care, in-depth interviews revealed the highly complex and often subtle ways in which patient satisfaction can be influenced by symptoms and their severity, the experience of comfort and relief, and the personal and social significance of unwanted events and changes in health status.Dyspnea can be attributed to various underlying conditions and the sensation itself is subjective, often making it hard to establish a precise mechanism of symptom production.According to the World Health Organization, adherence is quite low for medications prescribed for chronic diseases, and it is widely reported that in the United States, the percentage of adherence for medication regimens is lower than 50%.Weight loss, smoking cessation, dietary changes, and adherence to an exercise regimen are all interventions that can positively affect the elder's cardiac status and overall well-being.Depression has been shown to be an independent risk factor for the development of coronary artery disease and is associated with increased morbidity and mortality in individuals with heart disease.It is essential that patients with heart disease have their emotional well-being optimized, as improvement in emotional state has been associated with better general health, reduction in symptom severity, and improved exercise capacity.It contributes to poor quality of life, decreased functional capacity, depression, anxiety, social isolation, and increased health care utilization.This will enable the nurse to provide individualized, patient-centered care aiming to alleviate the bothersome symptoms and will foster optimal communication between patient and nurse.However, the relief of symptoms must be balanced with the avoidance of adverse effects caused by excessive diuresis and relative hypovolemia, such as renal failure and hyperkalemia.Symptom relief and maintenance of functional capacity are the primary goals of HF therapy.1.1.1.2.1.3.2.2.1.2.2.2.3.

Nursing Care of Elders with Heart Diseases

1. Importance of Nursing Care for Elders with Heart Diseases
   The preface and first chapter of strategies for improved survival in heart failure indicated that heart failure is a common, costly, disabling, and deadly condition and asked for bestowing it greater public health attention. A central thrust of the task force has been to assert that the prevention and treatment of this condition should be firmly based on a broad detailed understanding of its epidemiology and burden to the population. This is part of the re-branding and re-definition of heart failure to the main context of both short-term and long-term links to excess in disability and death. This references the high mortality and morbidity of the condition as above. In outpatient chronic heart failure, quality of life is poor and is comparable to that seen in major high mortality cancers. Exemplified in the final result by the clear marginal benefit of survival in the CHARM-added trial leading to early cessation of the study at interim analysis. High-quality, accurately focused chronic care nursing is indicated throughout the spectrum of patient types.
   Old age is the process of declining physical and mental capacity, but what is most serious and heavy is the change from home to hospital for treatment. Therefore, the goals of care for older patients with heart failure are to relieve symptoms and improve brain reward over the long term with signs of improved health. Specific therapeutic interventions for heart failure, of course, involve treatment of the underlying cause or triggering mechanism, but the current emphasis is on pharmacologic therapy to improve cardiac performance with specific neurohormonal agents and non-pharmacologic therapy to reduce symptoms and staging periodic exacerbations. Both use the practical guideline for specific treatments directed at functional abnormalities in individual patients. The prime mover in the treatment of heart failure is the quality of nursing care.
   1.1. Ensuring proper medication administration
   High rates of polypharmacy can lead to confusion and accidental omission of the right doses for specific drugs. Often, the patient is unable to afford buying the medications. Stockpiling is an unsafe practice but is common in cases when the patient has difficulty understanding the directions of the drug regimen and has been prescribed the same type of drug from different doctors. In some cases, the patient simply deems that the medications are not necessary for the way they are feeling. Failure to adhere to medications may not be mentioned to the physician and the patient, and as a result, the nurse may not even be aware of what drugs are actually being taken. This issue has great relevance to the field of nursing, as identification and prevention of these issues are steps to ensure that patients are getting the best out of their drug therapies.
   The first step for providing medication is to administer medication. If the patient is not taking medication, then clearly the concept of providing medication is irrelevant. However, the issue of non-adherence to medication regimens is common, particularly in elders with chronic conditions. According to the World Health Organization, adherence is quite low for medications prescribed for chronic diseases, and it is widely reported that in the United States, the percentage of adherence for medication regimens is lower than 50%. Adherence is a multifaceted issue encompassing social, economic, and healthcare system aspects, and there are many reasons why patients do not adhere to their medication regimens.
   Readmission is costly and undesirable, especially for heart failure patients, so administering the right medications at home is crucial and can prevent deterioration in patients' health. A recent article by Toback (2008) stressed the importance of medication reconciliation in elderly patients during care transitions, as discrepancies in the medication regimens and misuse are recognized as common causes of patient deterioration during care transitions. The duration and severity of deterioration are often unknown, and in any case, the deterioration can cause irreparable damage to the patient's health, so prevention is absolutely necessary. It is during care transitions that elders with heart conditions are particularly vulnerable, especially during hospital discharge. Nurses providing discharge planning functions should take an active role in ensuring that the right medications will be administered to the patient.
   This knowledge deficit study, led by Chung and others (2004) from an acute medical elderly ward in Hong Kong, tested the hypothesis that a nurse-led educational program would decrease drug-related readmission within 6 months. A total of 200 patients were recruited to an intervention and control group. At 6 months, the patients who received the educational program had a significantly lower drug-related readmission. This, for example, shows that medication education for patients can be effective for nurses to manage patients' drug adherence at the home level.
   Medication is focused on cardiac conditions, so medications often prescribed for heart conditions are anticoagulants, cholesterol-lowering drugs, anti-angina drugs, beta-blockers, ACE inhibitors, and diuretics. A wide knowledge of medication is needed for the nurse to educate the patient and also to assess the effectiveness of the drugs.
   1.2. Monitoring vital signs regularly
   This will allow the nurse to note changes in the patient's clinical status and determine the effectiveness of the current medical interventions. For example, a drop in blood pressure and an increase in heart rate in a patient with decompensated heart failure would indicate a need for an increase in the dose of intravenous diuretics. Alternatively, a transient fever in a patient with endocarditis could signal an embolic phenomenon. In both cases, the nurse's findings would prompt an immediate consultation with the patient's physician and implementation of new orders. Ideally, the nurse's ongoing assessment will allow for early detection of complications, thus preventing further morbidity and mortality in the elder with heart disease.
   Despite the common knowledge that prevention is easier and ultimately more cost-effective than treatment, the statistical evidence that reducing risk factors in elderly individuals will prolong survival and improve quality of life is less compelling than it is for younger persons. Thus, at times the nurse caring for an elder with heart disease will be in the role of health educator, promoting behaviour change that will enhance the patient's cardiovascular health. Weight loss, smoking cessation, dietary changes, and adherence to an exercise regimen are all interventions that can positively affect the elder's cardiac status and overall well-being. The nurse's ability to monitor and support the patient's attempts at behavioural change will greatly influence the success of these endeavours.
   1.3. Providing emotional support to patients and their families
   The most common psychological reaction to heart disease in the elderly is depression. Depression may occur with or without anxiety symptoms and may range from moderate to severe. The cause of depression is multifactorial and involves a complex interaction of physical, psychosocial, and somatic conditions. The physical symptoms of weakness, fatigue, and impaired concentration can mimic the symptoms of depression, and the mood disturbance resulting from these symptoms may be mistaken for a primary affective disorder. Depression has been shown to be an independent risk factor for the development of coronary artery disease and is associated with increased morbidity and mortality in individuals with heart disease. The mortality rate at 5 years has been reported to be twice as high in patients with major depressive disorder compared to those without depression. It is essential that patients with heart disease have their emotional well-being optimized, as improvement in emotional state has been associated with better general health, reduction in symptom severity, and improved exercise capacity.
   Illness generally imparts a feeling of helplessness and dependency in patients. Heart disease - being a chronic and terminal illness - may frequently lead to increased anxiety due to the fear of impending death. This may result in various psychological disorders among patients, particularly depression. Another reason for depression in patients with heart disease is the prohibitory lifestyle that is frequently recommended. Elderly patients, in particular, may feel isolated and cut off from relatives, friends, and regular activities. The fear, anxiety, and depression may also extend to the patient's family members. In severe cases, caregiver stress overload may lead to deterioration of the patient's condition.


2. Aspects of Care Provided by Nurses
   2.1. Assisting with activities of daily living
   2.2. Educating patients on self-care measures
   2.3. Collaborating with other healthcare professionals for comprehensive care
   2.4. Implementing preventive measures to reduce complications


3. Challenges Faced by Nurses in Caring for Elders with Heart Diseases
   3.1. Managing multiple comorbidities
   3.2. Addressing communication barriers with elderly patients
   3.3. Ensuring medication adherence in a complex medication regimen


4. Aspects of Nursing Care for Elders with Heart Diseases
   The nursing care for elderly with heart diseases involves managing symptoms and pain, promoting healthy lifestyle changes, assisting with activities of daily living, and educating patients and families. Pain is a common and significant problem in elderly patients suffering from heart failure and other cardiac disorders. It contributes to poor quality of life, decreased functional capacity, depression, anxiety, social isolation, and increased health care utilization. The nurse can directly impact the patient's pain by monitoring, assessing, and managing pain through both pharmacologic and non-pharmacologic approaches. The nurse should be knowledgeable about non-pharmacologic therapies and be able to teach those techniques to the patient and family. These techniques include relaxation therapy, imagery, cognitive-behavioral therapy, and complementary and alternative therapies such as massage and acupuncture. It is essential that the nurse has a good understanding of local and systemic symptoms associated with heart failure because substantial symptom burden is predictive of poor quality of life, hospitalization, and death. This will enable the nurse to provide individualized, patient-centered care aiming to alleviate the bothersome symptoms and will foster optimal communication between patient and nurse.
   2.1. Managing Symptoms and Pain
   Pain management in elders with heart disease is an important issue that has received relatively little focus compared with symptom relief through management of disease progression. Prevalence of pain in elders with HF appears to be higher than in the general population and can often be attributed to coexisting diseases such as arthritis, renal disease, and previous surgeries and procedures. It is also known that elders with ischemic heart disease may have chest pain at rest which can be stable and controlled with medication, or unstable indicating that urgent invasive procedures such as angioplasty or surgery may be necessary to alleviate the symptoms. An extensive review by Cintron and Hernandez of pain assessment and treatment in elderly patients with HF highlights the lack of data on effective pain treatments in this patient group and emphasizes the importance of diagnosing the cause and characteristics of pain to establish an appropriate treatment plan.
   Relief of symptoms in terminally ill patients with heart disease through palliative care can be achieved through many methods. According to the National Institute of Health (NIH), palliative care is a comprehensive approach to treating human suffering, and not just a specific treatment modality. Phase 1 of the SUPPORT study showed that compared to traditional care, palliative treatment led to significant improvement in some symptoms of patients with HF, but there was inconclusive evidence on patient and family satisfaction with care. Although in the study, palliative care did not lead to improvement in patient and family satisfaction compared with standard care, in-depth interviews revealed the highly complex and often subtle ways in which patient satisfaction can be influenced by symptoms and their severity, the experience of comfort and relief, and the personal and social significance of unwanted events and changes in health status. This suggests that although it may not be directly evaluated, palliative care can significantly improve patients' experiences of their illness.
   Symptoms associated with heart failure (HF) are one of the main reasons why elders seek medical attention. Symptom relief and maintenance of functional capacity are the primary goals of HF therapy. Symptoms of HF such as dyspnea, fatigue, and peripheral edema are considered relatively difficult to manage due to their unspecific nature. Dyspnea can be attributed to various underlying conditions and the sensation itself is subjective, often making it hard to establish a precise mechanism of symptom production. Despite this, many symptoms associated with HF are caused by fluid and sodium retention. Addressing this through increasing doses of diuretics can provide effective relief of symptoms and reduced morbidity in HF patients. However, the relief of symptoms must be balanced with the avoidance of adverse effects caused by excessive diuresis and relative hypovolemia, such as renal failure and hyperkalemia. Accordingly, patients and their symptoms must be closely monitored during changes in dose of diuretic or other medications. In general, the use of a symptom-guided approach can be more effective than the routine increase of medication dose.
   2.2. Promoting Healthy Lifestyle Changes
   The success of lifestyle changes heavily depends on the will of the elders. People who do not have the willingness to change will only waste the effort and cost of therapy. The goal of behavior change in elders is to help them understand that the changes are important and must be done immediately, and to help them replace their bad habits with healthier ones. Elders who change their behavior after understanding the importance of maintaining their health will obtain better results compared to those who change because they feel pressured to do so. Success in achieving these results is possible because they are given the opportunity to choose, and this opportunity will not arise unless they have the will to change.
   In order to assist the elders who suffer from cardiovascular disease, changes in lifestyle are needed to enhance their quality of life. The encouragement for this change should be delivered by every member of the healthcare team in order to give the elders the opportunity to choose and improve their quality of life through behavior changes. The healthcare team should explain to the elders that the heart diseases they suffer from cannot be cured and will become worse if they do not try to change their lifestyle. The lifestyle changes explained here include stopping smoking, regular exercise, healthy eating, and stress reduction.
   2.3. Assisting with Activities of Daily Living
   One cross-sectional study has looked at specific task performance as it related to life satisfaction in elder men with chronic cardiac disease. It measured patient perceived task importance and the patient's ability to perform associated tasks. Researchers noted that although patients were able to do most self-care and home management tasks, they had difficulty with higher energy expenditure leisure and social activities. These tasks are of high importance to life satisfaction and independently living elders, so it is crucial to assess guided progress or changes to alternative activities.
   The effects of heart disease can lead to increased fatigue, which can lead to elders limiting or completely avoiding certain activities out of fear symptoms will worsen. These limitations disrupt normal daily routines and may cause the elder to need to set new goals for adjusted independence levels. Dependence is necessary when an elder cannot complete a task safely, and speculation of task safety is relative to symptom severity and perceived capabilities.
   In the lifespan perspective, most self-care independence changes are often attributable to heart disease progression. As stated previously, elderly patients with heart disease suffer from differing levels of fatigue, which is a problematic difficulty because many activities of daily living (ADL's) require a moderate amount of energy expenditure. The most basic needs include maintaining adequate food and fluid intake, as well as continence management. Fatigue may lead to the elder taking "shortcuts" in meal preparation, a situation that further jeopardizes nutrition.
   2.4. Educating Patients and Families
   Family support can influence elder's participation in rehabilitation. This underscores the need to involve the patient and family as a unit when planning secondary prevention strategies.
   Patient education is an essential component of secondary prevention. Elders who have had a cardiac event can benefit from rehabilitation programs to improve quality of life and to reduce the risk of further heart problems. A systematic review found that participation in cardiac rehabilitation program was beneficial for older adults and was associated with a survival advantage at the end of the intervention.
   Elders with heart disease often have multiple chronic conditions. Self-care is necessary in order to maintain health and to prevent further functional decline. Elders with heart failure may experience atypical symptoms or may misinterpret the symptoms as a normal part of aging. They need to be taught to recognize early symptoms of heart failure exacerbation with an action plan of what to do when symptoms occur.
   Elderly patients and caregivers need to receive clear and understandable information because they are expected to take responsibility for implementing complex regimens of care. Lifelong learning is essential for elders with heart disease and their families faced with rapid changes in the healthcare environment. Education to promote self-care and to effectively participate in cardiac rehabilitation involves collaborative partnerships between patients, families, and healthcare professionals.


5. Challenges in Nursing Care for Elders with Heart Diseases
   3.1. Dealing with Multiple Coexisting Conditions
   3.2. Addressing Communication Barriers
   3.3. Managing Complex Medication Regimens


6. Challenges in Nursing Care for Elders with Heart Diseases
   Heart Failure (HF) and chronic disease management is based around a partnership between the patient and healthcare provider, aimed at better maintenance of stability through early identification and treatment of changes in patient health status. This often requires elucidation of recent changes in signs/symptoms to baseline or subjective reports which may be difficult in diagnosing exacerbation of heart failure in a patient with comorbid conditions. Annual surveys and qualitative studies of older adults with comorbid chronic conditions suggest that they are more likely to experience problems in daily life, more likely to encounter a medical error, and when asked, frequently report that they believe their primary care to be uncoordinated. They may require frequent changes in the healthcare options they receive and have greater transition between ambulatory and home or institutional care, making it harder to achieve stability. This is pertinent to the current era of the COVID-19 pandemic which has been a rollercoaster for many older adults with chronic conditions due to repeated hospitalization and frequency of changes in urgency and care options. Lastly, elders with comorbid chronic conditions often have complex medication regimens and treatment plans. Although efforts to simplify treatments are ongoing, many conditions have evidence-based treatments that may conflict with those of other conditions and medications; a phenomenon described as treatment burden.
   Due to increasing problems and complexity of care, it has been identified that caring for older adults with multimorbidity - the coexistence of two or more chronic conditions - is a substantial challenge in the 21st century. The existence of multimorbidity among elders with heart failure poses a complex puzzle with no easy solution. The chronicity, complexity, and uncertainty of this patient population manifest through the individual and the system that is designed to help them. Multimorbidity complicates priority setting, decision-making, and treatment intended to prevent specific health failures, and the interactions between conditions have health state and cost implications. Moreover, elders suffering from one or more of these chronic illnesses have diverse long-term care needs, which may not be met due to gaps in the continuum of care.
   3.1. Multimorbidity and Complex Care Needs
   Complex care needs in elders with heart disease are related to two main concurrent health states: frailty and disability, whose symptoms and syndromes overlap and interact. Frailty is a state of increased vulnerability to poor resolution of homeostasis after a minor stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. Disability is difficulty or dependency in performing tasks or activities in specific domains or life-centered dimensions. The complex interactions between frailty and disability and their impact on health outcomes for elders with heart diseases are best explained by the concept of likelihood of benefit or the trade-off between quantity and quality of life. This provides a framework for decision making regarding treatments or interventions in the setting of uncertain outcomes. The aim of any care aiming to improve or maintain function or quality of life in an elder with heart disease should be to minimize decrease in function, independence, and quality of life and delay progression to terminal events or disability and dependency in care. This is achieved by effective management of symptoms and prevention of the onset of new conditions. An understanding of the patients' care preferences and goals is crucial in determining the best course of action at any point in time.
   Multimorbidity is the coexistence of two or more chronic conditions and has become the new face of chronic illness in aging populations. It is particularly common in elders with heart disease and is frequently the rule rather than the exception. Multimorbidity compels a move away from a disease-specific model of care to a patient-centered approach which respects the patients' goals and care preferences. An overarching consideration in multimorbidity is the potential for the total burden of treatment to become unmanageable. The benefits of each treatment or intervention need to be carefully weighed up and there is often a need to prioritize which conditions, symptoms, or goals to focus on with finite time and resources. The WHO has highlighted that one of the essential needs for a person-centered care approach is for health systems to orientate services around the patient. This requires an integrated and coordinated approach to care from the patients' perspective across a system or pathway of care.
   3.2. Communication and Language Barriers
   Poor communication is a significant barrier to providing effective nursing care to the elderly with heart failure. Therefore, it is not surprising that it is one of the most frequently mentioned problems in the literature on elderly people with chronic diseases. Communication has been defined as the exchange of information (which may be spoken or written), the meaningful understanding of what is exchanged, and a two-way process between the individual and the healthcare professional. Effective communication is a vital part of the nursing process and the basis for building a therapeutic relationship that is central to nursing care and management. It is needed to assess and understand patients' needs and problems, to help patients understand their health status, to encourage trust and involvement in decision-making, to educate, and to provide support to patients and their families. These are all essential components of care for elderly people with chronic diseases, but ones which are often compromised due to poor communication caused by language difficulties.
   The most obvious of these is difficulty in speaking/understanding the host language of the country in which the patient is receiving healthcare. In Europe, this problem is compounded by the increasing numbers of elderly migrants from Eastern Europe and the growing numbers of refugees and asylum seekers from diverse ethnic backgrounds. A recent review of European nurses' experiences of caring for patients from different cultures suggests that the language barrier is a major source of stress for both the nurse and patient and frequently leads to the use of family members or unqualified interpreters to translate sensitive information about healthcare and treatments. This represents a serious risk to patient safety and informed consent and can compound feelings of social exclusion and powerlessness for the patient. It is becoming increasingly recognized that language-congruent professional interpreters are required to ensure safe and effective care, but this service is rarely available due to funding and resource constraints.
   3.3. Emotional and Psychological Support
   Emotional and psychological health is an integral part of holistic wellness in the elderly. An acute or chronic disease may affect an elder's emotional state as one copes with changes in their physical health. It is imperative to assess emotional and psychological status on a continual basis as close to all interactions with the elderly will have some bearing on their psychological state. Anxiety, depression, and fear are common responses to the diagnosis of heart disease. Elders may be fearful of the unknown and what is in store for them in the future. They may associate heart disease with immediate death and be overwhelmed with a sense of helplessness. This can be compounded with erratic lifestyle changes, numerous doctor visits, and hospitalizations. Depressive symptoms in the elderly are often overlooked as they may be seen as a normal part of the aging process and a reaction to systemic losses. It has been estimated that 5-10% of elderly adults are depressed, and depression in those who have a chronic illness is said to be as high as 20%. Nurses must be aware of risk factors and changes in behavior that may lead to the diagnosis of depression. The existence of depression will hinder an elder's adherence to treatment and lifestyle changes. Measures should be taken to ensure the elder receives a psychiatric assessment and treatment. Anxiety and depression both have negative effects on recovery and/or slowing the progression of heart disease. Studies have shown that treating depression may improve outcomes in heart disease.
   3.4. Ethical Considerations in End-of-Life Care
   The case for palliative and hospice care for heart failure patients is steadily growing, and it is important to try and identify those patients who may benefit from end-of-life care services, as well as to provide an appropriate care package.
   The transition to palliative therapies can be difficult enough for patients to accept when they have an understanding of the prognosis, and it is usually the case that patients are optimistic and do not wish to focus on end-of-life care. At this current time, the needs of patients with heart failure in relation to palliative care are unknown, and there is a growing disparity between the greater availability of hospice services for cancer patients. The enrollment of heart failure patients to hospice services has increased over time; however, the length of stay is still shorter than cancer patients, and the prognosis related to specific hospice interventions is unclear.
   Advanced care planning is an important process that allows a competent individual to make decisions on what care they would like to receive if they were to become physically incapable in the future and unable to make decisions. This often involves the use of a legal document known as a living will or durable power of attorney for healthcare. This can sometimes be challenging for family members to accept and may cause conflict if they do not agree with the decisions made.
   It is well documented that people with life-limiting diseases such as heart failure often undergo numerous invasive procedures and treatments at the end of life as an attempt to prolong life. When the patient reaches a point where curative treatments are no longer effective or the patient is getting little benefit, there needs to be a transition from curative treatments to more of a palliative approach. This discussion should be led by the healthcare provider and should happen when the patient is relatively stable, as opposed to waiting for a critical event to occur.
   Societal attitudes to death and dying have been subject to considerable change over the past century, and it is part of the human condition that such change will continue. As people's attitudes and dispositions change over time, so too will attitudes towards death and dying. In the past, death was regarded as more of a public event and was 'expected', whereas in today's society, death is more likely to be hidden away and not spoken about, with people trying almost anything to stave it off.


7. Strategies for Overcoming Challenges in Nursing Care
   4.1. Interdisciplinary Collaboration
   4.2. Cultural Competence in Care Delivery
   4.3. Self-Care for Nurses
   4.4. Continuous Professional Development


8. Strategies for Enhancing Nursing Care for Elders with Heart Diseases
   Always learning, always growing. Nurses working with elders with heart failure should continually update their knowledge and clinical skills related to caring for elders with chronic illnesses. The prevalence of co-morbid conditions in elders with heart failure increases the complexity of their care. Understanding the clinical protocols and guidelines for managing co-morbid conditions will improve the elders' health outcomes. Health care is increasingly being provided in a technology-rich environment. Nurses should become proficient in using technology to facilitate their elders' health. For example, using blood glucose monitors for elders with diabetes or teaching elders with arthritis how to use assistive devices to facilitate independence. Technology can also be harnessed to improve elders' safety, for example, providing emergency response systems for elders at risk for falls or using special mattress overlays to prevent pressure sores among elders with functional limitations. Although learning can take place through self-study or on the job, more structured educational programs can result in better patient outcomes. In order to promote the highest standards of care for elders with heart failure, nurses require access to specialty education and training in heart failure care. This can occur through academic detailing programs, attending conferences or courses, or achieving formal certification in heart failure care. High quality care for elders with heart failure is also contingent on an adequate nursing workforce to meet their complex care needs. Therefore, it is imperative to develop career paths and mentoring programs in heart failure care to attract and retain a competent nursing workforce for the rapidly growing population of elders with heart failure.
   Another important strategy to enhance nursing care for elders with heart failure is to promote interdisciplinary collaboration and teamwork. The unique care needs of elders with heart failure often exceed the capacity of individual practitioners or single disciplinary teams. Improving the coordination of care for elders with heart failure requires collaboration between a range of health professionals, as well as between health providers and informal caregivers. Interdisciplinary collaboration can improve the quality of holistic care provided to elders with heart failure and reduce hospitalizations. For example, a recent study showed that elders with heart failure who received care from a nurse practitioner-physician clinical management team were less likely to be hospitalized and had higher survival rates compared to those receiving care from a primary care physician alone. However, this collaboration would require a more highly skilled nursing workforce and changes in health care policy and reimbursement to allow nurses to practice to the full extent of their education and training.
   4.1. Continuous professional development and training
   The Nursing and Midwifery Board of Australia has made it mandatory for nurses to develop a portfolio that links with their National competency standards. The portfolio, while not meeting a defined requirement for learning needs analysis, could be a useful tool in aiding the nurse to identify their learning needs and then structure their learning to address their identified needs. This would be useful in directing nurses to formal learning opportunities which they could then link to improving their competency and patient outcomes.
   For informal learning to be worthwhile, it should be directed towards identified learning needs. Assessment of learning needs for the individual and the organization is paramount in order to direct nurses to learning that is relevant and meets the needs of the organization and the patients. An individual could carry out a log of learning activities, identifying what was learned, how it has improved their practice and patient outcomes. This would be especially useful for reflective learning.
   Continuous professional development and training enable nurses to keep abreast with the fast-changing healthcare environment. Professional development is essential for nurses to increase their competence, improve the quality of care, and build capacity to meet the changing needs of the patients. There are various ways of continuing professional development, namely through formal education, attending seminars, workshops, conferences, professional reading, and being involved in research.
   4.2. Utilizing technology for remote monitoring and telehealth
   Remote monitoring is a new technology that has been developed to monitor the conditions of heart failure patients at home. It provides updated information as to the patient's condition, can be used to anticipate changes in condition, and can prevent the need for hospital admission. Remote monitoring can take many forms, from monitoring weight and symptoms that are entered by the patient into an online diary, to devices that will automatically transmit information from the patient to their healthcare provider. One such example is a study done using a CardioMEMS device, which is a sensor implanted into the patient's pulmonary artery that detects changes in pressure – an indication of worsening heart failure. The sensor sends pressure readings to a monitoring device that can be reviewed by the patient's healthcare provider. In the study, patients that had the device had a 37% reduction in hospitalizations related to heart failure within the first year, compared to those with similar severity of heart failure who did not have the device. Lastly, the healthcare provider to patient ratio is greatly reduced using these mechanisms, as one provider can potentially monitor the condition of hundreds of patients from a single computer. This type of monitoring is the first step to being able to prevent heart failure readmissions and can reduce the burdens on both the patient and the healthcare system.
   Telehealth is the use of phone or video conferences to provide medical consultation or follow-up with patients at a location that is more convenient than an office or clinic, such as the patient's home. This can be especially useful to heart failure patients, as it can allow for communication with the patient's healthcare provider without the need for the patient to travel, which can often cause an increase in symptoms. High-risk HF patients that were part of a telehealth study done in Canada showed a 56% reduction in combined hospital admissions and emergency room visits, compared to similar patients that did not participate in the study. Telephone follow-up and care coordination initiated by a nurse has also been shown to reduce mortality or hospitalization in HF patients post-discharge after an admission for decompensated heart failure. This indicates that telehealth can be a very effective tool when combined with care provided by a nurse or other members of the healthcare team. An increasingly globalized society with more access to technology and devices means that these types of interventions will only increase in prevalence.
   4.3. Promoting interdisciplinary collaboration and teamwork
   Continuous attempts have been made to enhance collaboration between members of the healthcare team to provide high-quality patient care. Effective interpersonal communication is the foundation of teamwork and is essential to promote collaboration. Nurses need to work in unison with other healthcare professionals and patients to protect the interests of clients and comprehensively understand the situation before determining the course of action. This, in turn, will lead to better assessment and evaluation of patients, improved team decision making, and task fulfillment. The role of the nurse in the healthcare team is to act as an advocate for clients to ensure the best possible care. Shared understanding among team members can prevent misconceptions about the roles of each healthcare professional and enhance the nurse's ability to advocate for both the client and nursing as a profession. Long-term promotion of collaboration and teamwork will require changes to nursing education and medical/nursing hierarchies. It is important for future nurses and other healthcare professionals to understand that they are part of a team all working towards a common goal.
   4.4. Advocating for patient-centered care and shared decision-making
   A recent consensus statement on quality care for heart failure calls for a shift from a provider-centric to a patient-centric model of care and outlines specific recommendations for achieving this goal. Key recommendations include the use of shared decision-making at the transition points between acute and post-acute care and in advanced heart failure, a focus on palliative care and the timely involvement of hospice for patients at the end of life, and facilitation of patient self-management by providing the necessary education and support and by aligning care plans with patient goals. To accomplish these recommendations, major changes must occur in healthcare systems and provider attitudes, and there must be active involvement of patients and their families.
   Advocating for patient-centered care and shared decision making is a vital strategy for patients with chronic heart failure. Despite recent gains in evidence-based management of heart failure, there remains a gap between what scientific evidence recommends and the care that many patients receive. Standard medical care, including nursing, tends to be physician-driven, with a focus on disease management rather than effective patient self-management. Many patients feel that their preferences and values are not actively considered in treatment decisions, resulting in a lack of treatment congruence with patient goals. A recent observational study showed that elderly adults often receive cardiovascular medications with the explicit purpose of prolonging life rather than relieving symptoms, even though they have limited life expectancy or would prefer a palliative approach. Awareness of the impact of underlying geriatric syndromes and the presence of functional limitations on the complexity of health status, as well as acknowledgment of between-patient variability in life expectancy and the absence of a straightforward relationship between disease severity and choice of treatment, should lead to care plans that are tailored to individual patients.