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Main Findings: :

Main Findings: Can a supportive palliative care approach be encompassed within the existing HFSN ’ s role? Can patients be identified earlier despite an uncertain and unpredictable disease trajectory? Are the supportive palliative care needs of patients and their caregivers being met within the existing HFSNS?

Recommendations::

Recommendations: Holistic Assessment using evidence based assessment tools is required to encourage a shift away from the disease focus Proactive identification of high risk patients HFSN should co-ordinate care in collaboration with other health and social care providers Information gathering should include disease specific details and supplementary information around the wider holistic assessment & significant conversations around anticipatory care planning encompassing the gold standard tools such as (ACP. GSF, LCP, e-PCS) A patient centred approach to care will identify not only those patients who are at higher risk of dying but will also identify those who die whilst still being optimised or who die suddenly. Education and training to support all HCP ’ s is required and needs to be sustained. Systems that encourage person centred assessment within the acute settings to ensure appropriate goals of care are implemented and that multiple prolonged/terminal hospitalisation is avoided whenever possible is urgently required.

Future Direction::

Future Direction: Although extending palliative care to non-malignant conditions features significantly on the political health and social care agenda, the evidence as to how we can deliver this change in clinical practice is still in its early stages. The findings within this project support that the experience of persons living with heart failure the disease is as equally important as the clinical outcomes themselves.

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How can we address the need?

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