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The objective of this pilot study was to examine factors associated with the completion of advance directives (ADs) among patients with hematologic disorders in Korea. Using a descriptive design, patients with largely hematologic malignancies completed the questionnaires, including the Korean-Advance Directive (K-AD) model, which pertains to values, treatment wishes, and proxy appointment. Of 45 patients (aged 48.7 ± 10.7 years, 51.1% men), two-thirds had leukemia (40.0%) and lymphoma (26.7%). "Dying comfortably" was the most frequently selected value (n = 20). Regarding treatment wishes, hospice care was the most desired type (n = 22), whereas aggressive treatments, such as cardiopulmonary resuscitation, were less preferred (n = 3). The patient's spouse was most frequently appointed as a proxy (n = 27). Patients who completed all the 3 components of the K-AD model (51.1%) were less depressed (t = -2.31; P = .028) and more likely to perceive the benefits of the K-AD model (t = 2.07; P = .045), compared with the noncompleters (48.9%). Further, being male (odds ratio [OR], 6.42; P = .031), having higher scores on depressive symptoms (OR, 1.28; P = .016), and perceived barriers (OR, 1.08; P = .040) were associated with lower tendency to complete the K-AD model. These findings support the need for earlier introduction of ADs in hematologic disorders, with consideration of modifiable factors such as depression or barriers to end-of-life care decisions.

Background: Fatigue and depression based on self-report and diagnosis are prevalent in patients with heart failure and adversely affect high rates of hospitalization and emergency department visits, which can impact use of medical services. The relationships of fatigue and depression to use of medical services in patients with preserved and reduced left ventricular ejection fraction (LVEF) may differ., Purpose: We examined the associations of diagnoses of fatigue and depression with use of medical services in patients with preserved and reduced LVEF, controlling for covariates., Methods: Data were collected on fatigue, depression, covariates, and use of medical services. Patients (N = 582) were divided into 2 groups based on LVEF (<40%, reduced LVEF; ≥40%, preserved LVEF). Multiple linear regression analyses were used to analyze the data., Results: A diagnosis of fatigue was a significant factor associated with more use of medical services in the total sample (β = .18, P < .001, R = 54%) and patients with reduced LVEF (β = .13, P = .008, R = 54%) and also preserved LVEF (β = .21, P < .001, R = 54%), controlling for all covariates, but a diagnosis of depression was not., Conclusions: This study demonstrates the important roles of a diagnosis of fatigue in use of medical services. Thus, fatigue needs to be assessed, diagnosed, and managed effectively.

Background: A majority of patients with heart failure (HF) experience HF symptoms. Some literature suggests sex differences in the status of and also factors associated with HF symptoms. However, information on common HF symptom status and factors associated with HF symptoms in male and female patients is scarce., Objectives: The aim of this study was to examine HF symptom status and factors associated with HF symptoms in male and female patients with HF., Methods: Descriptive data on HF symptoms, psychological factors (depressive symptoms and perceived control), sociodemographic factors (age and sex), clinical factors (body mass index, comorbidities, medication, and left ventricular ejection fraction), and a behavioral factor (self-care) were collected in 70 male and 49 female patients with HF. Mann-Whitney U tests, χ tests, and stepwise regression models were used to address the objectives., Results: Fatigue was the most common HF symptom in both sexes, but male patients had less severe HF symptoms, including frequency, severity, and/or distress. In male patients, 2 psychological and 2 clinical factors (comorbidities and use of diuretics) were significantly associated with HF symptoms (adjusted R = 0.669, P < .001), whereas in female patients, only depressive symptoms were significantly associated with HF symptoms (adjusted R = 0.679, P < .001)., Discussion: There were sex differences in HF symptoms and the factors associated with HF symptoms. Clinicians and researchers need to recognize and manage psychological factors in both sexes and clinical factors in male patients by using effective interventions to improve HF symptoms.

Background: In patients with heart failure (HF), high dietary sodium intake is common and associated with HF symptoms, poor health-related quality of life (HRQOL), and high hospitalization rates., Purpose: The aims of this study were to examine the feasibility of a tailored dietary intervention with a practical tool (MyFitnessPal) and to obtain preliminary data about the effects on sodium intake, factors affecting sodium intake (knowledge, skills, experiences, confidence, perceived benefits and barriers, and depressive symptoms), HF symptoms, and HRQOL., Methods: A 6-session intervention was delivered to 11 participants. Paired t tests were used to compare the baseline outcomes with those at 3 months., Results: Participants completed 98% of intervention sessions, and 91% used MyFitnessPal. Sodium intake was reduced, and factors affecting sodium intake, symptoms, and HRQOL were improved (all P < .05)., Conclusion: The intervention was feasible and warrants further research to test the effects of the intervention on the outcomes using larger, heterogeneous samples.

The study aim was to describe the feasibility of conducting a coaching training intervention on use of level of assistance strategies for Certified Nursing Assistants (CNAs) in nursing homes. CNAs received either traditional or coaching training. Feasibility of coaching training was evaluated by determining: acceptability, through use of a Post-Intervention Evaluation Form; fidelity, by adherence to protocol; recruitment and retention, by ease of obtaining the sample and retention rates; and ability to randomize within each home without contamination. CNAs' mean satisfaction score of the coach training was high (4.5 out of 5). Eighteen of 22 comments on the evaluation form were positive. At least six dyads were recruited within the 60-day benchmark in each home. CNA and resident retention rates were 89.47% and 85%, respectively. Eighty-nine percent of intervention group CNAs shared study information, demonstrating contamination. The coaching training intervention is feasible. Findings revealed areas to improve the intervention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Patients with heart failure (HF) have notably poor health-related quality of life (HRQOL). A 5-point improvement in HRQOL is associated with reduction in hospitalization and mortality rates. Heart failure symptoms are associated with poor HRQOL, but little is known about whether changes in HF symptoms lead to changes in HRQOL over time. Therefore, we examined the association of changes in HF symptoms with changes in overall, physical, and emotional aspects of HRQOL over a 12-month period, controlling for typical covariates., Methods: Data on HF symptoms and HRQOL (Minnesota Living Heart Failure questionnaire) were collected from 94 patients with HF (mean age, 58 years; 58.5% female) at baseline and 12-month follow-up. Psychosocial factors (depressive symptoms, perceived control, and social support), behavioral factors (medication adherence and sodium intake), sociodemographic and clinical factors (age, comorbidities, and body mass index), and a physical factor (functional status) were collected at baseline. Multiple and logistic regression analyses were used to analyze the data., Results: In complete models, changes in HF symptoms were associated with changes in the total HRQOL (P < .001) and the physical (P < .001) and emotional (P < .001) aspects of HRQOL over 12 months, controlling for all the factors. Changes in HF symptoms were significantly associated with the likelihood of at least a 5-point improvement in HRQOL (P = .001), controlling for covariates., Conclusions: Improvement in HF symptoms was associated with improvement in HRQOL over 12 months. Thus, development and delivery of interventions that target improvement in HF symptoms may improve HRQOL.

Background: Many patients with heart failure (HF) experience persistent symptoms and poor health-related quality of life (HRQOL). Psychosocial distress is common and adversely affects HF symptoms and HRQOL. A holistic meditation (HOME) intervention that combines mindfulness, compassionate meditation, and self-management may reduce psychosocial distress., Purpose: The aims of this study were to examine the feasibility and acceptability of the HOME intervention in patients with HF and to obtain preliminary data about its effects on psychosocial factors (depressive symptoms, perceived control, and social support), HF symptoms, and HRQOL., Methods: Weekly 90-minute intervention sessions were delivered to 11 patients with HF for 12 weeks. Data on feasibility and acceptability were collected for 12 weeks, and data on psychosocial factors, HF symptoms, and HRQOL were collected at baseline and after the intervention., Results: Eleven of 13 enrolled patients completed all intervention sessions; 2 withdrew because of family health issues. Mean acceptability scores for all sessions ranged from 98% to 100%. In paired t test analyses, perceived control (P = .02, Cohen d = 0.82) and social support (P = .008, Cohen d = 1.00) increased, severity of depressive symptoms (P < .001, Cohen d = 1.54) and HF symptoms (P < .001, Cohen d = 1.91) decreased, and HRQOL was improved (P < .001, Cohen d = 1.82)., Conclusions: The HOME intervention was feasible and acceptable and had positive effects on psychosocial variables, HF symptoms, and HRQOL for patients with HF. Our results indicate that treatment effects should be tested in a larger, controlled clinical trial.

Aim: The purpose of this study was to examine the psychometric properties of the Korean version of the Symptom Status Questionnaire-Heart Failure (SSQ-HF) in patients with heart failure (HF). Specific aims were to examine 1) reliability and item homogeneity, using Cronbach's alpha and item analyses; and 2) validity, using factor analysis and known relationships of depressive symptoms and perceived control to HF symptoms., Background: HF symptoms are among the strongest factors affecting health-related quality of life (HRQOL), and can lead to hospitalization. Therefore, it is important to assess and manage HF symptoms using a reliable and valid instrument. However, there is no such instrument for Korean patients with HF., Methods: Data on HF symptoms, sociodemographic and clinical characteristics, and covariates such as depressive symptoms, perceived control, and self-care maintenance were collected from 119 patients (mean age: 65.0years; 58.8% males). Cronbach's alpha was used to test reliability, and factor analysis and multiple regression analyses were used to test validity., Results: Cronbach's alpha was 0.76, supporting reliability. In factor analysis, a single-factor structure emerged, and the loading coefficients of all items were >0.45, supporting construct validity. In addition, as hypothesized, depressive symptoms and perceived control were significantly associated with HF symptoms, further supporting validity., Conclusions: The reliability and validity of the Korean version of the SSQ-HF were supported among Korean HF patients. Clinicians and researchers can use the SSQ-HF to assess and manage common HF symptoms., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Depressive symptoms and poor health perceptions are predictors of higher hospitalization and mortality rates (heart failure [HF]). However, the association between depressive symptoms and health perceptions as they affect event-free survival outcomes in patients with HF has not been studied. The purpose of this secondary analysis was to determine whether depressive symptoms mediate the relationship between health perceptions and event-free survival in patients with HF. A total of 458 HF patients (61.6 ± 12 years, 55% New York Heart Association Class III/IV) responded to one-item health perception question and completed the Patient Health Questionnaire-9. Event-free survival data were collected for up to 4 years. Multiple regression and Cox proportional hazards regression analysis showed that depressive symptoms mediated the relationship between health perceptions and event-free survival. Decreasing depressive symptoms is essential to improve event-free survival in patients with HF.

The purpose of this study was to examine associations among bone mineral density, osteopenia/osteoporosis, body mass index (BMI), and body composition in patients with heart failure (HF). A total of 119 patients (age = 61 ± 12 years, 65% male) underwent dual-energy X-ray absorptiometry scans to determine bone mineral density and body composition. In multivariable linear regressions, BMI, relative skeletal muscle index (RSMI), and mineral-free lean mass were positively associated with total body bone mineral density. Mineral-free lean mass was most strongly associated with bone mineral density (β = .398). In multivariable logistic regressions, higher BMI, RSMI, and mineral-free lean mass were associated with lower odds for osteopenia/osteoporosis. Fat mass was not associated with total body bone mineral density or osteopenia/osteoporosis. These results suggest that muscle mass may be the important component of body mass associated with bone mineral density in patients with HF.

Background: Poor sleep quality is common and is associated with poor quality of life and health status in patients with heart failure. However, few investigators have focused on the impact of impaired sleep quality on survival in heart failure., Objective: To examine whether self-reported sleep quality is associated with prognosis in patients with heart failure., Methods: The study sample consisted of 204 patients with heart failure. Sleep quality was measured with the Pittsburgh Sleep Quality Index. Poor sleepers were defined as patients with scores greater than 5 on the index. Patients were followed up for a median of 364 days to determine cardiac events (a composite of cardiac death, hospitalizations, or emergency department visits for cardiac reasons). Multivariable Cox proportional hazard regression was used to examine whether poor sleepers were at a higher risk than good sleepers for shorter cardiac event-free survival after covariates were adjusted for., Results: Of 204 patients, 129 (63%) reported poor sleep quality. Poor sleepers were 2.5 times more likely to have a shorter cardiac event-free survival (95% CI, 1.164-5.556) than were good sleepers after covariates were controlled for., Conclusions: Impaired sleep quality was prevalent in patients with heart failure and was associated with poor cardiac event-free survival. Clinicians should assess and manage sleep quality in patients with heart failure to improve outcomes., (©2016 American Association of Critical-Care Nurses.)

Background: Heart failure is associated with high rates of hospitalization and mortality. The majority of patients with heart failure suffer from physical symptoms, and these symptoms are strongly associated with poor health-related quality of life. To improve physical symptoms and health-related quality of life, the modifiable factors associated with physical symptoms need to be examined., Purpose: To examine modifiable psychosocial and behavioral factors associated with physical symptoms and health-related quality of life, and the mediator effects of physical symptoms on the relationships between the modifiable factors and health-related quality of life in patients with heart failure., Methods: Data on potential correlates of physical symptoms (i.e., depressive symptoms, perceived control, social support, medication adherence, sodium intake, and self-care management) were collected from 109 patients with heart failure (mean age 58 ± 14 years, 46% male, 89% New York Heart Association class II/III). Data on physical symptoms (Symptom Status Questionnaire-Heart Failure) and health-related quality of life (Minnesota Living with Heart Failure) also were collected. Simple and multiple regression analyses were used to analyze the data., Results: Among the potential correlates, depressive symptoms and sodium intake were associated with physical symptoms (F=11.63, p<.001), and depressive symptoms and perceived control were associated with health-related quality of life (F=9.917, p<.001). Physical symptoms mediated the relationship between depressive symptoms and health-related quality of life., Conclusion: Improving depressive symptoms and eating the appropriate amount of sodium may be primary intervention targets to improve physical symptoms. To improve health-related quality of life, depressive symptoms as well as physical symptoms need to be managed appropriately., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Depressive symptoms in patients with heart failure can affect the relationship between physical signs and symptoms and inflammation., Objective: To examine the relationship between soluble tumor necrosis factor receptor I and physical signs and symptoms and the effects of depressive symptoms on this relationship in patients with heart failure., Methods: Data on physical signs and symptoms (Symptom Status Questionnaire-Heart Failure), depressive symptoms (Beck Depression Inventory-II), and levels of the receptor (blood samples) were collected from 145 patients with heart failure. Data on the receptor were square root transformed to achieve normality. Patients were divided into 2 groups according to their scores for depressive symptoms (nondepressed <14 and depressed ≥14). Hierarchical multiple regression was used to analyze the data., Results: In the total sample, with controls for covariates, higher levels of the receptor were significantly related to more severe physical signs and symptoms (F = 7.915; P < .001). In subgroup analyses, with controls for covariates, levels of the receptor were significantly related to physical signs and symptoms only in the patients without depression (F = 3.174; P = .005)., Conclusion: Both depressive symptoms and inflammation should be considered along with physical signs and symptoms in patients with heart failure. Further studies are needed to determine the effects of improvement in inflammation on improvement in physical signs and symptoms, with consideration given to the effects of depressive symptoms., (©2014 American Association of Critical-Care Nurses.)

Objectives: To examine the various types of social support associated with physical and depressive symptoms and health-related quality of life (HRQOL) in patients with heart failure (HF) and the mediating effects of symptoms on the relationship between social support and HRQOL., Background: Patients with HF have a high burden of physical and depressive symptoms, along with poor HRQOL. Social support may improve symptoms and HRQOL., Methods: Data on social support (marital status, family relationships, relationships with health care providers, social networks, emotional support, and instrumental support), symptoms, and HRQOL were collected from 71 patients. Hierarchical regression was used to analyze the data., Results: Emotional support was related to all physical and depressive symptoms and HRQOL. Physical and depressive symptoms mediated the relationship between emotional support and HRQOL., Conclusions: Further studies are needed to identify ways to improve emotional support and determine whether the improvement leads to improvements in symptoms and HRQOL., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders., Methods: This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist., Results: The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms., Conclusions: The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Heart failure (HF) is a progressive clinical condition that results in substantial impairment of quality of life (QOL). Helping patients maintain optimal QOL is essential. QOL reflects patients' subjective perceptions about the impact of a clinical condition and its treatment on daily life; however, definitions in the literature vary widely and few reflect the patient's perspective., Purpose: The study explored how patients with HF define and perceive QOL., Methods: Qualitative data were obtained from 14 men and 6 women with HF (mean age 58 +/- 10 years) using semistructured open-ended interviews. The interviews were analyzed using content analysis., Results: Patients with HF defined QOL as their ability to 1) perform desired physical and social activities to meet their and their family's needs; 2) maintain happiness; and 3) engage in fulfilling relationships with others. Patients perceived a variety of factors as positively or negatively affecting QOL: physical (symptoms and good or poor physical status), psychologic (mood and positive or negative perspective), economic (financial status), social (social support and ability for social activities), spiritual, and behavioral (self-care). Patients perceived that HF had a serious impact on QOL, but most evaluated their QOL as good nonetheless., Conclusion: Patients' definition of QOL reflected not only the impact of HF on their daily life but also their active pursuit of happiness. Patients' self-evaluation of QOL reflected the negative impact of HF and patients' altered expectations of what constituted good QOL.

Background: Although self-care may reduce exacerbations of heart failure, reported rates of effective self-care in patients with heart failure are low. Modifiable factors, including psychosocial status, knowledge, and physical factors, are thought to influence heart failure self-care, but little is known about their combined impact on self-care., Objectives: The objective of this study was to identify factors related to self-care behaviors in patients with heart failure., Design: A cross-sectional, correlational study design was used., Participants and Settings: One hundred twenty-two patients (77 men and 45 women, mean age 60+/-12 years old, 66% New York Heart Association functional class III/IV) were recruited from the outpatient clinics of an academic medical center and two community hospitals., Methods: Data on self-care behaviors (Self-Care of Heart Failure Index), depressive symptoms, perceived control, self-care confidence, knowledge, functional status, and social support were collected. Factors related to self-care were examined using hierarchical multiple regression., Results: Mean self-care behavior scores were less than 70 indicating the majority of men and women with HF did not consistently engage in self-care behaviors. Higher self-care confidence and perceived control and better heart failure management knowledge were associated with better self-care (r2=.25, p<.001). Higher perceived control and better knowledge were related to better self-care behaviors in men (r2=.18, p=.001), while higher self-care confidence and poorer functional status were related to better self-care behaviors in women (r2=.35, p<.001)., Conclusion: This study demonstrates the substantial impact of modifiable factors such as confidence in one's self-care abilities, perceived control, and knowledge on self-care behaviors. This study demonstrates that there are gender differences in factors affecting self-care, even though at baseline men and women have similar knowledge levels, physical, psychological, and behavioral status. Effective interventions focusing on modifiable factors and the unique characteristics of men and women should be provided to improve self-care behaviors in patients with heart failure.

Background: Physical symptoms are common and distressing problems for patients with heart failure and may be the strongest predictor of health-related quality of life. Identification of variables predictive of physical symptom status is needed to develop effective interventions to improve health-related quality of life., Methods: A total of 84 patients discharged after being hospitalized for exacerbation of heart failure were followed up for 3 months. The Minnesota Living With Heart Failure Questionnaire and the Dyspnea-Fatigue Index were used to assess health-related quality of life and physical symptom status, respectively. Relationships of health-related quality of life and physical symptom status to baseline demographic, behavioral, biophysiological, and psychological variables were examined with bivariate correlations and stepwise multiple regression analyses., Results: Patients with better physical symptom status and those who worked, were older, and were less anxious at baseline reported better health-related quality of life (F=12.4, P<.001); physical symptom status was the strongest predictor. Patients who had less depression, worked, had higher perceived control, and were younger at baseline reported better physical symptom status (F=14.4, P<.001); depression was the strongest predictor., Conclusions: Physical symptom status is the most important predictor of health-related quality of life, and baseline depression and perceived control are the best predictors of physical symptom status. Interventions targeted to improve psychological status may improve physical symptom status and thereby improve health-related quality of life.

Background: The purpose of this study was to explore factors influencing adherence to the prescribed medical regimen in patients with heart failure (HF)., Methods: A convenience sample of 7 women and 9 men with HF participated in in-depth interviews. The interviews were audio-taped, transcribed, and checked for accuracy. Content analysis strategies were used to analyze the data., Results: The desire to be healthy was the primary motivator in the decision to take medications as prescribed. The process of making connections enhanced medication adherence. Participants connected knowledge of their illness and their symptoms with their medication's effectiveness in decreasing these symptoms. Connections to a health care provider and family enhanced treatment adherence. Participants relied on environmental cues as reminders to take their medications, resulting in a habit of daily medication use., Conclusions: Education that helps clients understand their illness, particular symptoms and how medications help them may be beneficial in promoting adherence. A positive working relationship with the health care provider may result in improved adherence.

Background: Health-related quality of life (HRQOL) in older adults with heart failure may be affected by a variety of variables including aging. It is important to determine the unique impact of heart failure to more effectively improve HRQOL in this population., Objective: The purpose of this study was to compare HRQOL and physical, psychologic, clinical, and sociodemographic status in older adults with and without heart failure., Methods: The HRQOL of 90 older adults with heart failure and 116 healthy older adults was compared. The factors best associated with HRQOL in each group were determined using multiple regression model., Results: HRQOL was substantially worse among older adults with heart failure than among healthy older adults. Older adults with heart failure had more severe physical and emotional symptoms, poorer functional status, and worse health perceptions. Physical symptom status was the strongest predictor of HRQOL in both groups. In addition, in older adults with heart failure, physical symptom status, age, and anxiety were related to HRQOL., Conclusion: The poor HRQOL seen in patients with heart failure is not just a reflection of aging. Comprehensive interventions targeted toward the factors that specifically negatively impact HRQOL are essential in older adults with heart failure.

Background: Patients with end-stage heart failure experience disability, dyspnea, pain, and suffering at the end of life despite progress in treatment approaches. Little is known about the patients with heart failure in hospice and the impact of hospice care on health-related outcomes., Methods and Results: The purposes of this retrospective, descriptive chart review were to (1) describe the characteristics of patients who receive hospice care, (2) identify symptoms most commonly reported by patients with heart failure in hospice during the last 7 days of life, and (3) identify interventions used by hospice nurses to manage the symptoms. The majority of the patients were women, widowed, and white. Median length of stay was 10 days. Nearly 37% of the patients were admitted to hospice during the last week of life. Primary symptoms at admission for hospice care included dyspnea, confusion at least some of the time, and poor appetite. There was no statistically significant difference in symptoms between the day of admission for hospice care and the day of death. Symptom management strategies included oxygen, family reassurance or education, skin care, and patient education. Medications commonly used to relieve symptoms included antianxiety medications, morphine, and/or other narcotics. Although mainstay heart failure drugs had been prescribed for some patients, prescription rates were low and not in line with current guideline recommendations, nor were those medications recorded as being used for symptom management., Conclusion: Further research including prospective study is needed to clearly articulate the impact of hospice care on patients and families affected by heart failure.