"I've spent the past 10 years as a salmon swimming upstream, educating and informing healthcare professionals about palliative management for advanced heart failure patients," explained Erin Donaho, BSN, RN, heart failure clinician at St. Luke's Episcopal Hospital, home of the Texas Heart Institute, Houston. "Nurses offer palliative management of this condition by aggressively addressing symptoms through effective partnerships with patients and families. We need to acknowledge how powerful palliative management is and understand how wonderful that it's in the hands of professional nurses."

Palliative Care

Donaho joined the institute's Heart Failure Center a decade ago when her father was dying of heart failure.

"I had worked a year as a heart failure nurse, but my dad was managed at the end of life by hospice staff who treated him as if he had terminal cancer," she recalled. "His lungs were filling up with fluid, yet they gave him subq Ativan for his anxiety and sublingual Roxanol (morphine) for his pain. What he really needed was a diuretic, but they didn't understand symptom management for advanced heart failure."

Although he was an astute man with a doctoral degree, Donaho's dad didn't receive a clear message from his caregivers at the end of life. "One day he turned to me and said, 'What am I dying from?'" Donaho recalled. "I told him, 'Dad, it's your heart,' and he responded, 'I thought I had cancer.' It was heartbreaking to hear that, but I reinforced his diagnosis of advanced heart failure. He then told me, 'You go on and do a good job taking care of people with heart failure' - and I've done just that."

Even today, there is a great deal of misunderstanding about the term heart failure. "Patients come to us scared to death after receiving that diagnosis," Donaho said. "When I tell them this is a chronic terminal disease, the response is, 'Whoa, wait a minute!' But then I let them know my job is to keep them on the planet for as long as possible and help them manage their symptoms in a way that allows them to keep doing what they enjoy.

"Any time you aggressively treat heart failure symptoms and are engaged with the patient using the best clinical practices to treat them, you are providing palliative care to those who are not candidates for heart transplants or [left ventricular assist devices]," Donaho explained. "This is where nursing is headed as a profession; we are the experts in managing chronic disease and there will continue to be a growing need for that expertise in the years to come."

Designing Your Own Career

Donaho is a proponent of thoughtful career planning for nurses.

"I'm living proof nurses really can map out their careers if they take the time to figure out what they want to do," she noted. "I began by asking myself, 'Where does a new nurse go to learn about the heart?' and chose to begin in the open-heart recovery room at St. Luke's over 20 years ago. I stayed there for 5 years before moving to the cardiac cath lab to learn more about the 3-D heart. I assisted interventional cardiology for a year, then went to the Texas Heart Institute's department of cardiology research. In 1998, one of the clinical nurse specialists called to ask me if I wanted to be part of the heart failure team, and I've been here ever since."

After earning her master's in nursing next year, Donaho will embark on the next phase of her career.

"I'm looking at options like opening nurse-run heart failure clinics as part of the Texas Heart Institute system," she said. "I've started my own company called Heart Failure Solutions to teach hospice staff about palliative care of advanced heart failure patients, and have developed modules about advanced heart failure management for the hospice nurse and am finishing modules for home care nurses. These class IV heart failure patients want to be at home, not in the hospital, and we need quality nurses out there assessing them, intervening and communicating with folks like us when things are going wrong."

Donaho also spends time as a consultant for a national pacemaker company, one of seven hand-picked mentors teaching nurses around the country about new technology to measure filling pressures and provide better care for patients with difficult-to-manage heart failure.

"This new generation of nurses will hopefully understand the world is their oyster and they can impact healthcare not only in the hospital, but across the spectrum, by creating their own careers or even becoming entrepreneurs," she said. "I didn't understand that early on in my career, and I only wish someone had told me sooner."

Sandy Keefe is a frequent contributor to ADVANCE.