Heart failure is an increasingly prevalent chronic condition which causes substantial morbidity and mortality, placing an increasing economic burden on health care. Hospitalizations as a result of heart failure are projected to increase considerably over the next two decades. A robust restructuring of existing heart failure treatment models in the UK is needed to enable an integrated seamless transition of care across the community, primary care and hospital networks. This has to be achieved with the patient as a partner in health care as a part of a multidisciplinary approach. This uses innovative strategies such as ambulatory treatment (including intravenous diuretics, remote and telemonitoring) as well as shifting heart failure treatment to the community and to patients' homes. This article analyses the existing evidence for ambulatory management of acute decompensated heart failure and looks at future strategies for restructuring care.

Learning ObjectivesAfter reading this chapter and completing the learning activities, the reader will be able to: Describe cardiac conditions classed as acquired and hereditary structural heart disease  Discuss the relationship between rheumatic heart disease and valvular disease  Identify the most common forms of cardiomyopathy and their causes  Discuss the role of the nurse in a multidisciplinary team caring for patients with structural heart disease  Identify sources of information for patients with strutural heart disease and their families.

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e20544 Background: Despite their poor prognosis, few cancer patients have advanced care directives (ACD). Most often, ACD is discussed in an inpatient setting, when the patient is acutely ill and often nearing the end of life. Timely and thoughtful discussion would be better accomplished for both the patient and the family before such hospitalization. Methods: Interviews were done in 108 outpatients in an ambulatory chemotherapy center. A questionnaire noted whether ACD was executed or not, demographics (including education, religion and insurance status), performance status, characteristics of their cancer, and family status. All patients without ACD were counseled on the importance of ACD. The presence of an ACD was documented at each visit. Statistical comparison of patients with and without ACD at each visit was done. Results: The following variables were significantly associated with having an ACD at the first visit. Patients living alone could not be included in the logistic regression model, as none had advanced directives. However ACD execution differed significantly in patients living alone, compared with those living with family (0/33 vs 15/75; p=0.005). An additional 42 patients executed an ACD by the third visit. At the third visit, only living with family vs living alone remained significantly associated with having ACD. [OR=3.17 95% CI: 1.34, 7.50; p=0.009]. Conclusions: The following findings are noteworthy. Only 15/108 (14%) cancer outpatients had ACD. This disturbingly low rate increased to 55/108 (51%) after physician- initiated discussion. The following characteristics predicted not having ACD before intervention: younger age, absence of metastasis, better performance status, lower education status and living alone. After several physician interventions, only living alone remained a significant barrier to ACD execution by cancer outpatients. These results provide new insights and strategies to encourage improved advanced directive execution. [Table: see text] No significant financial relationships to disclose.