Journal of General Internal Medicine

, Volume 24, Issue 5, pp 592–598 | Cite as

Symptom Burden, Depression, and Spiritual Well-Being: A Comparison of Heart Failure and Advanced Cancer Patients

  • David B. Bekelman
  • John S. Rumsfeld
  • Edward P. Havranek
  • Traci E. Yamashita
  • Evelyn Hutt
  • Sheldon H. Gottlieb
  • Sydney M. Dy
  • Jean S. Kutner
Original Article



A lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer.


We examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients.


This was a cross-sectional study.


Sixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer.


Symptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being scale).


Overall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction ≤30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer.


Patients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.


heart failure quality of life palliative symptoms spirituality depression 



This study was funded by the Johns Hopkins Center for Complementary and Alternative Medicine; the Johns Hopkins General Clinical Research Center; and the National Center for Complimentary and Alternative Medicine, NIH. Dr. Bekelman is supported by the University of Colorado-Denver Mordecai Palliative Care Pilot Grants Fund and the University of Colorado-Denver Hartford/Jahnigen Division of Geriatrics Center of Excellence in Geriatric Medicine. Part of this manuscript was presented at the American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Conference in Baltimore, Maryland, May 2008 and the Society for General Internal Medicine 31st Annual Meeting in Pittsburgh, Pennsylvania, April 2008.

Conflict of Interest

None of the authors have any potential conflicts of interest. The funders did not have a role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; nor in preparation, review, or approval of the manuscript.


  1. 1.
    MacIntyre K, Capewell S, Stewart S, et al. Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995. Circulation. 2000;102(10):1126–31.PubMedGoogle Scholar
  2. 2.
    Krumholz HM, Parent EM, Tu N, et al. Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med. 1997;157(1):99–104.PubMedCrossRefGoogle Scholar
  3. 3.
    Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail. 2001;3(3):315–22.PubMedCrossRefGoogle Scholar
  4. 4.
    Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs. 2005;4(3):198–206.PubMedCrossRefGoogle Scholar
  5. 5.
    Bekelman DB, Havranek EP, Becker DM, et al. Symptoms, depression, and quality of life in patients with heart failure. J Card Fail. 2007;13(8):643–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Rumsfeld JS, Havranek E, Masoudi FA, et al. Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol. 2003;42(10):1811–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48(8):1527–37.PubMedCrossRefGoogle Scholar
  8. 8.
    Talback M, Stenbeck M, Rosen M, Barlow L, Glimelius B. Cancer survival in Sweden 1960–1998–developments across four decades. Acta Oncol. 2003;42(7):637–59.PubMedCrossRefGoogle Scholar
  9. 9.
    Tishelman C, Petersson LM, Degner LF, Sprangers MA. Symptom prevalence, intensity, and distress in patients with inoperable lung cancer in relation to time of death. J Clin Oncol. 2007;25(34):5381–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Labori KJ, Hjermstad MJ, Wester T, Buanes T, Loge JH. Symptom profiles and palliative care in advanced pancreatic cancer: a prospective study. Support Care Cancer. 2006;14(11):1126–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Muller-Nordhorn J, Roll S, Bohmig M, et al. Health-related quality of life in patients with pancreatic cancer. Digestion. 2006;74(2):118–25.PubMedCrossRefGoogle Scholar
  12. 12.
    Morrison RS, Meier DE. Clinical practice. Palliative care. N Engl J Med. 2004;350(25):2582–90.PubMedCrossRefGoogle Scholar
  13. 13.
    Riegel B, Moser DK, Powell M, Rector TS, Havranek EP. Nonpharmacologic care by heart failure experts. J Card Fail. 2006;12(2):149–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ. 2002;325(7370):929.PubMedCrossRefGoogle Scholar
  15. 15.
    Murray SA, Kendall M, Boyd K, Worth A, Benton TF. Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliat Med. 2004;18(1):39–45.PubMedCrossRefGoogle Scholar
  16. 16.
    Horne G, Payne S. Removing the boundaries: palliative care for patients with heart failure. Palliat Med. 2004;18(4):291–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Bekelman DB, Dy SM, Becker DM, et al. Spiritual well-being and depression in patients with heart failure. J Gen Intern Med. 2007;22(4):470–7.PubMedCrossRefGoogle Scholar
  18. 18.
    National Comprehensive Cancer Network I. The NCCN Clinical Practice Guidelines in Oncology. Available at Accessed February 5, 2009.
  19. 19.
    Chang VT, Hwang SS, Feuerman M, Kasimis BS, Thaler HT. The memorial symptom assessment scale short form (MSAS-SF). Cancer. 2000;89(5):1162–71.PubMedCrossRefGoogle Scholar
  20. 20.
    Tranmer JE, Heyland D, Dudgeon D, Groll D, Squires-Graham M, Coulson K. Measuring the symptom experience of seriously ill cancer and noncancer hospitalized patients near the end of life with the memorial symptom assessment scale. J Pain Symptom Manage. 2003;25(5):420–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Yesavage JA, Sheikh JI. Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clinical Gerontology. 1986;6:165–73.CrossRefGoogle Scholar
  22. 22.
    Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24(4):709–11.PubMedGoogle Scholar
  23. 23.
    Whooley MA, Browner WS. Association between depressive symptoms and mortality in older women. Study of Osteoporotic Fractures Research Group. Arch Intern Med. 1998;158(19):2129–35.PubMedCrossRefGoogle Scholar
  24. 24.
    Weintraub D, Saboe K, Stern MB. Effect of age on geriatric depression scale performance in Parkinson’s disease. Mov Disord. 2007;22(9):1331–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Ferraro FR, Chelminski I. Preliminary normative data on the Geriatric Depression Scale-Short Form (GDS-SF) in a young adult sample. J Clin Psychol. 1996;52(4):443–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Rule BG, Harvey HZ, Dobbs AR. Reliability of the geriatric depression scale for younger adults. Clinical Gerontologist. 1989;9:37–43.CrossRefGoogle Scholar
  27. 27.
    Arthur A, Jagger C, Lindesay J, Graham C, Clarke M. Using an annual over-75 health check to screen for depression: validation of the short Geriatric Depression Scale (GDS15) within general practice. Int J Geriatr Psychiatry. 1999;14(6):431–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Peterman AH, Fitchett G, Brady MJ, Hernandez L, Cella D. Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy–Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med. 2002;24(1):49–58.PubMedCrossRefGoogle Scholar
  29. 29.
    McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet. 2003;361(9369):1603–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Green CP, Porter CB, Bresnahan DR, Spertus JA. Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure. J Am Coll Cardiol. 2000;35(5):1245–55.PubMedCrossRefGoogle Scholar
  31. 31.
    Spertus J, Peterson E, Conard MW, et al. Monitoring clinical changes in patients with heart failure: a comparison of methods. Am Heart J. 2005;150(4):707–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Heidenreich PA, Spertus JA, Jones PG, et al. Health status identifies heart failure outpatients at risk for hospitalization or death. J Am Coll Cardiol. 2006;47(4):752–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Walke LM, Gallo WT, Tinetti ME, Fried TR. The burden of symptoms among community-dwelling older persons with advanced chronic disease. Arch Intern Med. 2004;164(21):2321–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Berard RM, Boermeester F, Viljoen G. Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management. Psychooncology. 1998;7(2):112–20.PubMedCrossRefGoogle Scholar
  35. 35.
    Murray SA, Kendall M, Grant E, Boyd K, Barclay S, Sheikh A. Patterns of social, psychological, and spiritual decline toward the end of life in lung cancer and heart failure. J Pain Symptom Manage. 2007;34(4):393–402.PubMedCrossRefGoogle Scholar
  36. 36.
    Masoudi FA, Rumsfeld JS, Havranek EP, et al. Age, functional capacity, and health-related quality of life in patients with heart failure. J Card Fail. 2004;10(5):368–73.PubMedCrossRefGoogle Scholar
  37. 37.
    Hauptman PJ, Havranek EP. Integrating palliative care into heart failure care. Arch Intern Med. 2005;165(4):374–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Goodlin SJ, Hauptman PJ, Arnold R, et al. Consensus statement: Palliative and supportive care in advanced heart failure. J Card Fail. 2004;10(3):200–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Pantilat SZ, Steimle AE. Palliative care for patients with heart failure. JAMA. 2004;291(20):2476–82.PubMedCrossRefGoogle Scholar
  40. 40.
    Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to update the 2001 Guidelines for the evaluation and management of heart failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112(12):e154–e235.PubMedCrossRefGoogle Scholar
  41. 41.
    Addington-Hall JM, Gibbs JS. Heart failure now on the palliative care agenda. Palliat Med. 2000;14(5):361–2.PubMedCrossRefGoogle Scholar
  42. 42.
    Athavale NV. Palliative care is an important aspect of heart failure management. Age Ageing. 2003;32(1):117–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Gibbs JS, McCoy AS, Gibbs LM, Rogers AE, Addington-Hall JM. Living with and dying from heart failure: the role of palliative care. Heart. 2002;88(Suppl 2):ii36–9.PubMedGoogle Scholar
  44. 44.
    Gottlieb SH. Palliative care in heart failure. Heart. 2003;3(8):326–35.Google Scholar
  45. 45.
    Lewis C, Stephens B. Improving palliative care provision for patients with heart failure. Br J Nurs. 2005;14(10):563–7.PubMedGoogle Scholar
  46. 46.
    Stewart S, McMurray JJ. Palliative care for heart failure. BMJ. 2002; 325(7370):915–6.PubMedCrossRefGoogle Scholar
  47. 47.
    Ward C. The need for palliative care in the management of heart failure. Heart. 2002;87(3):294–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Woodend AK. What’s new in palliative care for patients with heart failure? Can J Cardiovasc Nurs. 2005;15(2):3–4.Google Scholar
  49. 49.
    Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to update the 2001 Guidelines for the evaluation and management of heart failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112(12):e154–235.PubMedCrossRefGoogle Scholar
  50. 50.
    Field MJ, Cassel CK, ed. Approaching Death: Improving Care at the End of Life. Washington, D.C.: National Academy Press; 1997.Google Scholar
  51. 51.
    Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350(21):2140–50.PubMedCrossRefGoogle Scholar
  52. 52.
    Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352(15):1539–49.PubMedCrossRefGoogle Scholar
  53. 53.
    Dalal S, Del Fabbro E, Bruera E. Symptom control in palliative care–Part I: oncology as a paradigmatic example. J Palliat Med. 2006;9(2):391–408.PubMedCrossRefGoogle Scholar
  54. 54.
    Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care–Part III: dyspnea and delirium. J Palliat Med. 2006;9(2):422–36.PubMedCrossRefGoogle Scholar
  55. 55.
    Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care–Part II: cachexia/anorexia and fatigue. J Palliat Med. 2006;9(2):409–21.PubMedCrossRefGoogle Scholar
  56. 56.
    Higginson IJ, Finlay I, Goodwin DM, et al. Do hospital-based palliative teams improve care for patients or families at the end of life? J Pain Symptom Manage. 2002;23(2):96–106.PubMedCrossRefGoogle Scholar
  57. 57.
    Glassman AH, O’Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288(6):701–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Gottlieb SS, Kop WJ, Thomas SA, et al. A double-blind placebo-controlled pilot study of controlled-release paroxetine on depression and quality of life in chronic heart failure. Am Heart J. 2007;153(5):868–73.PubMedCrossRefGoogle Scholar
  59. 59.
    Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA. 2003;289(23):3106–116.PubMedCrossRefGoogle Scholar
  60. 60.
    Coulehan JL, Platt FW, Egener B, et al. “Let me see if i have this right…": words that help build empathy. Ann Intern Med. 2001;135(3):221–7.PubMedGoogle Scholar
  61. 61.
    Reynolds CF III, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med. 2006;354(11):1130–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45.PubMedCrossRefGoogle Scholar
  63. 63.
    Havranek EP, Masoudi FA, Westfall KA, Wolfe P, Ordin DL, Krumholz HM. Spectrum of heart failure in older patients: results from the National Heart Failure project. Am Heart J. 2002;143(3):412–7.PubMedCrossRefGoogle Scholar
  64. 64.
    Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med. 1999;159(15):1803–6.PubMedCrossRefGoogle Scholar
  65. 65.
    Brady MJ, Peterman AH, Fitchett G, Mo M, Cella D. A case for including spirituality in quality of life measurement in oncology. Psychooncology. 1999;8(5):417–28.PubMedCrossRefGoogle Scholar
  66. 66.
    Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol. 2005;23(24):5520–5.PubMedCrossRefGoogle Scholar
  67. 67.
    Breitbart W. Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer. 2002;10(4):272–80.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • David B. Bekelman
    • 1
  • John S. Rumsfeld
    • 1
    • 2
  • Edward P. Havranek
    • 1
    • 3
  • Traci E. Yamashita
    • 1
  • Evelyn Hutt
    • 1
    • 2
  • Sheldon H. Gottlieb
    • 4
  • Sydney M. Dy
    • 5
  • Jean S. Kutner
    • 1
  1. 1.Department of MedicineUniversity of Colorado Denver School of MedicineAuroraUSA
  2. 2.Department of Veterans Affairs Medical CenterEastern Colorado Health Care SystemDenverUSA
  3. 3.Department of MedicineDenver Health Medical CenterDenverUSA
  4. 4.Department of MedicineJohns Hopkins Bayview Medical CenterBaltimoreUSA
  5. 5.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA

Personalised recommendations