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

Inclusion criteria

• 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.

Exclusion criteria

• 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