Recent eLetters

We would like to thank Drs Satchithananda, Hookey and Sister Ingram for their interest in our editorial. We welcome this opportunity to respond. We framed our discussion in the setting of left ventricular systolic dysfunction as this is where the robust evidence base for heart failure therapy has evolved. The evidence base for effective therapy for the clinical syndrome of heart failure with preserved systolic function (HFpSF) is much weaker, with very few randomised controlled clinical trials (RCTs). However, we accept that the symptomatic burden and mortality risk for those with HFpSF is comparable, and loop diuretic therapy for the associated dyspnoea and congestion is no less applicable to that clinical cohort. Indeed, differentiating between such sub- populations may be largely irrelevant as many heart failure patients exhibit demonstrable abnormalities of both systolic and diastolic function.

While there are differences in the assignment of weighting in terms of the class of recommendation and hierarchy of evidence on the conventional use of loop diuretics over the range of acute and chronic heart failure treatment guidelines, and RCTs may be hard to justify ethically, we have an experiential repository of about 40 years of clinical practice with the use of oral and intravenous furosemide across the clinical spectrum of heart failure. Accumulation of this experience underpins clinical judgement and is consistent with the development of so called 'tacit knowledge' which has been proposed as fundamental to evidence base development 1.

Certainly, individualising patients' dosing regimens with appropriate clinical monitoring is mandated for this therapy to be effective and safe, irrespective of the route of furosemide administration as demonstrated in Diuretic Optimization Strategies Evaluation (DOSE) trial 2. The successful use of this approach specifically for the prescription of subcutaneous (SC) furosemide was apparent in the Scarborough study cited in our editorial in which a wide dosing range was employed 3. This study also demonstrated the effectiveness of multidisciplinary team working, widely accepted as beneficial across the entire heart failure disease trajectory, and no less relevant at the end of life 4. Indeed, the recently published NICE heart failure quality standards require such an approach, integrating the complementary clinical skills of both heart failure and palliative care professionals to support those with moderate to severe heart failure 5.

The main driver behind our editorial was concern about the largely empirical adoption of SC furosemide by the palliative care community for the treatment of patients dying with heart failure as the primary terminal illness or as a comorbidity without addressing the need for systematic assessment of effectiveness or clinical risk. This use of SC furosemide for some of the sickest heart failure patients challenges the accepted treatment paradigm, but also provides opportunity for formal clinical evaluation, and we welcome the authors' potential contribution to development of the evidence base for this form of therapy.

James M Beattie

Department of Cardiology, Heart of England NHS Foundation Trust, Birmingham, UK; National Clinical Advisor, NHS Improvement.

Miriam J Johnson

Hull York Medical School, University of Hull; St Catherine's Hospice, Scarborough, UK.

References

1. Thornton T. Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement. Philos Ethics Humanit Med. 2006 1:2

2. Felker GM, Lee KL, Bull DA. et al, Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364:797-805

3. Zacharias H, Raw J, Nunn A. et al. Is there a role for subcutaneous furosemide in the community and hospice management of end- stage heart failure? Palliat Med 2011,25: 658-63.

4. Ryder M, Beattie JM, O'Hanlon R. et al. Multidisciplinary heart failure management and end of life care. Curr Opin Support Pall Care 2011, 5: 317-21.

5. NHS National Institute for Health and Clinical Excellence. Heart failure quality standard, June 2011. Available from http://www.nice.org.uk/guidance/qualitystandards/chronicheartfailure/home.jsp

(accessed 4 Apr 2012).

Conflict of Interest:

None declared

The introduction of a novel scheme in Weston-super-Mare described by Abel et al.,[1] which utilises a health care mentor to assist palliative care patients identify supportive networks within their communities and seeks to foster the development of compassionate community networks is to be congratulated. While the scheme is undoubtedly innovative in a palliative care setting a comparable model was initiated in a generalist community health care setting in Scotland almost a decade ago. The WHO Europe Family Health Nursing Pilot in Scotland[2] was supported by the delivery of an educational programme by the University of Stirling from 2001-2005. The pilot was part of a wider European initiative developed from the recommendations of HEALTH 21.[3] Assessment and documentation used by nursing staff in the pilot was based on the Calgary Family Assessment Model [4] and included the use of genograms and ecomaps. There have been several published evaluations of the Family Health Nursing Pilot and a conceptual model of Family Centred Health Care developed.[2,5,6,7] Congruent with compassionate communities the emphasis of this model is to shift the focus from an individual to a community perspective. Whilst it is clear that the authors view the use of health care mentors as only the first step in developing autonomous community networks, they may perhaps draw parallels from the Family Health Nurse Pilot to facilitate development of their current scheme in Weston-super-Mare. 1.Abel J, Bowra J, Walter T, Howarth G. Compassionate community networks: supporting home dying. BMJ Support Palliat Care 2011; 1:129-133. 2. Scottish Executive. The WHO Europe Family Health Nursing Pilot in Scotland Final Report. Edinburgh: Scottish Executive 2006. 3. World Health Organisation (WHO). Europe HEALTH21: Health for all in the 21st Century. Copenhagen: WHO Europe 1998. 4. Wright L, Leahey M. Nurses and Families: a guide to family assessment and Intervention. Third edition. Philadelphia: FA Davis Company 2000. 5. MacDuff C, West BJM. An evaluation of the first year of family health nursing practice in Scotland. International Journal of Nursing Studies 2005; 42:47-59 6. Murray I. Family Health Nurse Project--An Education Program of the World Health Organization : The University of Stirling Experience Journal of Family Nursing 2008;14(4):469-485 7. Parfitt B A, Cornish F, Whyte L, Van Hooren M. Family Centred Health Care: The Contribution of Family Health Nurses. An Evaluation of the Family Health Nurse Role, Phase 2: School of Nursing, Midwifery and Community Health, Glasgow Caledonian University 2006.

Conflict of Interest:

I am employed by the University of Stirling but I was not a member of the institution during the Family Health Nurse Pilot.

We read with interest the article by Harper et al in the last edition of this journal (2011;1:306-309). By establishing a correlation between infant mortality and the increased mortality risk of the parents, the article speaks, albeit indirectly, to the possible links between emotional and physical states - a topic of important and growing interest. However, two points present themselves about the authors' analysis - the first is statistical, the second conceptual.

Harper et al are direct about possible confounding factors for which they were unable to control but which may nullify any causal link implied by the statistical correlation they identify (p308). However, given their use of census data, there is one possible confounding factor that they might have controlled for - age of parent at the time of birth. Harper et al imply that the small difference in mean age between the comparison and control group means age should not raise concern. However, if parent and infant mortality are more likely among both older and younger parents, the difference in mean age might be minimal or invisible, even though the casual implications of the chi-squared correlation would be weakened. Previous research suggests that such a two-sided confounding factor may exist for age. Young births, such as teenage pregnancies, have been linked to worse outcomes for both mother and child (see, for example, citations in Wellings and Kaye, 1999). Births to older parents are similarly more likely to face complications and older parents would naturally be closer to average life expectancies.

The results presented by the authors point towards this possibility. The 'bereaved' group manifests a wider range of ages than the 'control' group. The effect is most significant in the English data - the smallest difference in standard deviations exists for the 1981-1991 cohort, which is between 8.4 and 5.7. Since the English data manifest a higher relative risk, it is worth exploring whether age may be such a confounding factor. Year of birth might also be included in the analysis, to control for the possibility that both infant and parent mortality risks may be shifting over time.

The second concern is a conceptual one. If a ceteris paribus causal link exists between the death of one's children and an increased mortality risk for parents, it seems likely that this is linked to the trauma caused by the loss of a loved one. But emotional bonds are not all equal - on average, they might be expected to become stronger over time. From this perspective, the average relative risk of parent mortality after a miscarriage should be lower than death in childbirth, which would be lower in turn than death in early infancy and the death of a young child.

The Dutch study (Li et al, 2003) referenced by Harper et al bears out this principle - the relative risk of parent mortality in their study is higher for a child dying aged between 1 and 11 months than a child dying at less than one month. The analysis by Harper et al can be extended to explore this hypothesis. Parents suffering stillbirths and infant mortalities are currently combined into a single category - by splitting the two groups, differences might be observed. The accidental inclusion of parents whose child dies aged older than one in the 'non-bereaved' group would bias effects downward, but differences may still be observable.

For the Scottish data, ethical non-identification reasons and small sample sizes prevented such subgroup analysis (p307). However, the small sample size resulted by design - the choice of 20 birthdays or 5.3% of the population. Had the authors chosen a larger set of birthdays, it may have been ethically possible to analyse the two subgroups in greater detail. No such restriction applied to the English data.

The authors are to be congratulated on their research and we agree with them that further statistical and case study work is required. We hope that the suggestions are amenable to straightforward exploration on similar datasets to those used by the authors.

Dr Wing Chu, ST1 Doctor in Palliative Care; Christian Percy, Statistical Consultant

References Wellings, K. and Kane, R. (1999), 'Trends in teenage pregnancy in England and Wales: how can we explain them', J R Soc Med 1999;92:277-282

Conflict of Interest:

None declared