Timely Interventions to Enable and Reach Patients With Heart Failure, and Their Caregivers With Palliative Care

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• Patients:
  • have cognitive impairment (e.g., dementia)
  • have severe, untreated, active mental illness (e.g., major depressive disorder)
  • have ventricular assist device implant.
  • have non-reversible hearing or visual loss or
  • are active drug abuser or
  • already known to a palliative care service.
• Caregivers who meet any of the exclusion criteria at baseline will be ineligible for the study:
  • have cognitive impairment (e.g., dementia) or
  • have severe, untreated, active mental illness (e.g., major depressive disorder)
  • have non-reversible hearing or visual loss.
  • are active drug abuser or
  • are a domestic helper for the patient

• Patients:
  • 21 years or older and
  • able to communicate in English/Chinese/Malay and
  • be of stage C or D heart failure, as defined by American College of Cardiology/American Heart Association (ACC/AHA) classification system and
  • have functional limitation of New York Heart Association (NYHA) functional status of at least 2 or more and
  • be deemed by their cardiologist's clinical judgement to have an expected prognosis of at least 6 months survival, and
  • have had a heart failure related hospitalization event (e.g. symptomatic decompensated heart failure) within 6 months prior to recruitment and
  • have a phone that allows telecommunication.
• Caregivers must meet all the following inclusion criteria to be eligible for the study :
  • direct, unpaid, family caregiver of the patient;
  • self-reported by the patient to be the main person to be either:
  • responsible for up to 4 hours a day of caregiving tasks
  • and/or decision maker/spokesperson with the medical team
  • Caregiver may or may not live in the same residence as the patient.
  • Caregivers must be 21 years and above.
  • Able to communicate in English/Chinese/Malay.