Faculty Publications (HBMCoNM)

Permanent URI for this collectionhttps://repository.mbru.ac.ae/handle/1/634

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Breastfeeding transition in Oman: A generation shift or a product of social development? A qualitative study on three generations of Omani mothers
(Public Library of Science (PLoS), 2025-04-17) Khalaf, Atika
Background: Exclusive breastfeeding is essential for infant health, yet its practice varies across generations and cultures. Although the health benefits of breastfeeding have been well known for decades, the utilization of infant formula feeding worldwide and in Oman, in particular, continues to rise, most likely as a result of a lack of social support and the time limit faced by working mothers. Little is known about the factors affecting Omani mothers’ breastfeeding experiences and practices. Therefore, this study aims to gain an in-depth understanding of the experiences of breastfeeding practices among three generations of Omani mothers. Methods: This qualitative study investigated exclusive breastfeeding practices among three generations of Omani mothers. Participants were recruited using a selective approach followed by a snowball technique, resulting in a total of 50 women, which included 17 first-generation mothers, 18 grandmothers, and 15 great-grandmothers. Participants were characterized by varying ages and socio-demographic backgrounds. Semi-structured face-to-face interviews were conducted in Arabic, and data collection continued until data saturation was reached. Data were analyzed using qualitative content analysis methodology, ensuring robustness and credibility. Results: The analysis yielded two main categories reflecting the mothers’ experiences, three representing the grandmothers’ experiences, and two concerning the great-grandmothers’ experiences. While overarching themes like the significance of breastfeeding emerged across all generations, disparities were seen concerning challenges, beliefs, and support systems. Mothers highlighted contemporary hurdles such as work-life balance and societal pressures, whereas grandmothers emphasized inherited practices and cultural norms. Great-grandmothers reflected on the evolution of societal and familial dynamics impacting breastfeeding traditions. Despite these differences, a shared commitment to breastfeeding and recognition of its importance for maternal and child well-being was evident across generations. Conclusion: The findings underscore the importance of societal support, healthcare provider education, and workplace policies in promoting exclusive breastfeeding. Targeted interventions are needed to address barriers to breastfeeding and empower women to make informed feeding choices. By addressing these challenges, societal institutions can contribute to achieving higher rates of exclusive breastfeeding and improve maternal and child health outcomes in Oman.
Cancer Cachexia in Clinical Practice: A Review of Treatment Barriers Among Cancer Patients
(Wiley, 2025-01) Alsharawneh, Anas; Ricardo Santiago Gomez
Background: Cancer cachexia is a multifactorial syndrome that affects patients’ quality of life and survival. It accounts for over 20% of cancer deaths. Despite its high incidence, there is no evidence-based standard of care for managing it. Early detection and management require preventative measures and multimodal therapy. Aim: The purpose of this study was to conduct an in-depth review of the literature on cancer cachexia and its barriers for effective assessment and management. Methods: The literature review was conducted through various electronic databases to identify studies published on cancer cachexia and its barriers for effective assessment and management of cancer cachexia. Results: The review indicated that barriers for effective assessment and management of cancer cachexia were on three levels: patients, health workers, and organizations. Also, there is a knowledge gap in understanding, assessing, and managing cancer cachexia among healthcare workers, patients, and family members. Conclusion: The research indicates that patients, family members, and healthcare professionals lack sufficient knowledge about how to identify, assess, and treat cancer cachexia. This gap has a lot of important barriers, both modifiable and nonmodifiable. Patients, healthcare professionals, and organizations are the three levels of those barriers.
Empathy, the scientific clinical gaze and contemporary practice: a critical reflection
(BMJ, 2025-09-18) Khalaf, Atika
This review essay critically examines a modern manifestation of the scientific clinical gaze, drawing upon Michel Foucault's foundational concepts. Using a Swedish medical case involving cultural bias and delayed diagnosis, the essay questions the strengths and vulnerabilities of the clinical gaze, highlighting its susceptibility to subjective distortions despite aspirations toward scientific objectivity. It situates this analysis within broader critiques of the sociopolitical entanglement of medicine, emphasising how implicit bias, institutional norms and power structures continue to influence clinical practice. The discussion further integrates recent scholarship from narrative medicine, cultural competence and reflexivity studies to propose an enriched model of clinical engagement. By advocating for the incorporation of empathy, narrative competence and reflexive awareness into clinical training and practice, the essay outlines strategies to mitigate the epistemic violence historically associated with the clinical gaze. These recommendations aim to advance medical humanities scholarship, foster more equitable healthcare delivery and prepare future practitioners for ethically attuned and culturally sensitive patient care. Through this critical reflection, the essay contributes to ongoing debates regarding the rehumanisation of modern medicine.
Stratifying atherosclerotic cardiovascular disease by SMuRF burden in a Middle-Eastern country: A multiregistry study of demographics, comorbidities, and therapeutic trends
(Public Library of Science (PLoS), 2025-09-22) Al Nsair, Nezam; Rizik M. H. Al-Sayyed
Background: Atherosclerotic cardiovascular disease (ASCVD) is a growing public health challenge in the Middle East, driven by increasing rates of obesity, diabetes, and hypertension. However, limited region-specific data exist on the distribution and impact of Standard Modifiable Risk Factors (SMuRFs) among affected individuals. Most available evidence is derived from Western populations, which may not reflect the unique demographic, cultural, and epidemiological profiles of Middle Eastern communities. Objective: This study aims to compare demographic profiles, clinical presentations, comorbidities, and pharmacologic management among Middle Eastern patients with ASCVD, stratified by SMuRF burden: SMuRF-less (no risk factors), 1–2 SMuRFs, and 3–4 SMuRFs. The goal is to identify clinically relevant differences across these groups and address the significant gap in region-specific data on ASCVD risk factors and outcomes. Methods: Data were pooled from six established cardiovascular registries and the Jordan SMuRF-less patient study. Baseline characteristics, cardiovascular risk profiles, comorbidities, use of secondary prevention therapies, and one-year outcomes were analyzed across the three SMuRF categories. Results: Among 5,540 patients, the group with 3–4 SMuRFs exhibited the highest prevalence of hypertension (88.9%), diabetes (35.4%), smoking (54.0%), and a family history of cardiovascular disease (39.3%). This group also showed increased rates of chronic kidney disease (7.3%) and heart failure (15.1%). Statin, aspirin, and beta-blocker use increased in parallel with SMuRF burden. Key lipid profiles deteriorated with increasing SMuRFs, with the highest LDL cholesterol observed in patients with 1–2 SMuRFs. Conclusions: This study provides valuable insight into the clinical characteristics and management patterns of Middle Eastern patients with atherosclerotic cardiovascular disease (ASCVD), stratified according to the burden of standard modifiable risk factors (SMuRFs). An increased SMuRF burden was associated with a higher prevalence of comorbid conditions, including hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, and heart failure. Utilizing data from six regional registries, this study represents the first comprehensive, region-specific analysis of the role of modifiable risk factors in this population. The findings underscore the critical need for individualized, risk-based prevention and management strategies to mitigate the rising burden of ASCVD across the Middle East.
Two Surveys, 16 Years Apart: Comparing Traditional and Complementary Medicine Use by Children With Cancer in Jordan
(2025-12) Alsharawneh, Anas
Background: Traditional and complementary medicine (T&CM) is commonly used by children with cancer alongside conventional treatments. However, data on its use in Jordan remain limited. This study aimed to assess the current prevalence, types, motivations, and disclosure rates of T&CM use in Jordan, and to compare these findings with those from the original 2008 study conducted in the same setting.
Digital Disruption: Investigating the Effects of Nighttime Technology Use on Researchers’ Sleep Quality and Psychological Wellbeing
(IEEE, 2025-07-08) AbuRuz, Mohannad
This study investigates the effects of nighttime technology use on researchers’ sleep quality and psychological wellbeing at the University of Sharjah, UAE. Utilizing a descriptive qualitative research design, the study engaged participants through semi-structured interviews to explore their perspectives on nighttime technology use. Thematic analysis of the interview data revealed three main emergent themes: (1) "Risk and Protective Factors of Nighttime Technology Use and Sleep Disturbances," (2) "Technostress and Psychological Wellbeing," and (3) "Protective Strategies: Researchers’ Perspectives." The findings offer some insights into the effects of nighttime technology use on researchers’ sleep quality and psychological wellbeing. These insights can help develop programs aimed at improving work-life balance for researchers, emphasizing the importance of mental health and self-care in high-pressure academic environments.
Exploring clinical empathy among maternal healthcare providers in Zambia: Does the heart meet the mind? Insights from a qualitative study
(SAGE Publications, 2025-10-15) Khalaf, Atika
Empathy is crucial for enhancing interpersonal interactions in healthcare. While provider empathy improves health outcomes, studies focused on this concept in Zambia are limited. This qualitative study utilized a hermeneutic phenomenological approach, employing qualitative content analysis as the analysis method, to explore clinical empathy through the perspectives of 14 maternal healthcare providers recruited via purposive and snowball sampling. Participants varied in age, experience, and professional roles. The study identified three primary themes: (1) the multifaceted nature of empathy in maternal healthcare, (2) dual aspects of empathy—patient care and professional boundaries, and (3) contextual dynamics—balancing challenges in maternal empathy. Findings highlight that while empathy enhances patient experiences, providers often struggle to maintain emotional boundaries. The study highlights the need for targeted training programs in strengthening empathy in clinical practice and recommends further research on culturally specific expressions of empathy in healthcare settings.
Impact of self-directed e-learning on nurses' competency in arrhythmia interpretation in cardiology
(2025) Al Nsair, Nezam
Accurate electrocardiogram (ECG) interpretation is an essential competency for nurses, particularly in cardiology, where the timely identification of arrhythmias can be lifesaving and significantly impact patient outcomes. Nurses often serve as the first line of clinical observation, making their ability to interpret ECGs critical for early intervention and safe patient care. However, numerous studies have highlighted persistent gaps in ECG interpretation skills among nursing staff, emphasizing the urgent need for effective, accessible educational strategies. This study aimed to assess the effectiveness of a self-directed e-learning (SDL) package in improving nurses' knowledge and competency in arrhythmia interpretation within the cardiology department of Rashid Hospital, Dubai. A quasi-experimental, one-group pre-test/post-test design was utilized with a sample of 50 nurses working in Coronary Care Units. Data were collected using a validated, structured questionnaire that included demographic data and ECG interpretation tests. The SDL package covered foundational ECG knowledge, rhythm analysis, and arrhythmia management. Results showed a statistically significant 15.92% improvement in knowledge following the intervention (t = -6.668, p < .001). A notable correlation was observed with years of experience; nurses with 1-5 years of experience demonstrated the highest improvement (p = .020). No significant differences were found based on gender (p = .234) or area of practice (p = .139). This study highlights the critical need to strengthen nurses' arrhythmia interpretation skills and demonstrates that SDL is an effective, flexible, and scalable approach to bridging competency gaps in high-acuity clinical areas such as cardiology.
Neonatal research: A reflection on the impact of patient and public involvement (PPI) on the Neo-SILT study
(Elsevier BV, 2025-01) Boyle, Breidge
Integrating parental input into neonatal research development is crucial for producing ethically sound, practi cally applicable, studies with real-world context based on lived experiences. Parents, as primary caregivers, offer invaluable insights into the daily realities and emotional aspects of neonatal care that healthcare professionals may overlook. Their lived experiences can highlight subtle, yet significant, impacts of medical conditions and treatments on their children, thereby enriching the research with a deeper understanding of infant’s needs. Parental involvement ensures that research questions and outcomes are aligned with family priorities, enhancing the relevance and applicability of the studies. Moreover, the ethical design of studies benefits greatly from parental input, as it grounds the research in the lived experiences of those most affected, fostering greater empathy and sensitivity. This approach also helps build trust between researchers and the study participants, which is essential for improving recruitment and retention rates. The Neo-SILT study demonstrated this by significantly revising its Post Traumatic Stress Disorder (PTSD) measurement timelines, shaping the research question, adjusting the methodology and highlighting potential barriers and facilitators to participation based on parental feedback, ensuring a more accurate depiction of symptom onset and trajectory. Additionally, the co design of recruitment materials and parent information leaflets resulted in resources that were not only infor mative but also emotionally mindful and visually appealing, further facilitating parental engagement. Reflective practice has provided the nurse researcher with the framework to share the value and importance of integrating parental perspectives into neonatal research that can address potential oversights and biases, ensuring that studies are scientifically rigorous, ethically sound, and practically relevant.
Challenges faced when masking a single discoloured tooth - Part 1: aetiology and non-invasive management.
(2025-06) Aljanahi, May; Alhussin, Argwan; Elbishari, Haitham
Encountering a single discoloured tooth is a common occurrence in dentistry and it poses a significant concern affecting both aesthetic appearance of natural teeth and patient confidence. Management of tooth discolouration involves a wide variety of options and requires specific protocols for both the clinician and patient to achieve an aesthetic result. One of the toughest challenges in restorative dentistry is being able to mimic natural teeth. This review is the first of two articles that will broadly discuss the aetiology of discolouration and the challenges faced when masking a single discoloured tooth. It will also examine various approaches, encompassing the conservative options, such as scaling, microabrasion, air abrasion, vital and non-vital tooth whitening, and resin infiltration. By integrating current and clinical evidence, this review aims to identify the causes of single tooth discolouration, highlight the challenges/variables faced when masking discoloured teeth and appraise possible minimally invasive procedures.
Exploring symptom clusters across the menopausal stages - systematic review and meta-analysis.
(2025-08-12) Khalaf, Atika
This study aimed to identify and compare symptom clusters and their severity among perimenopausal and postmenopausal women using a systematic literature review on publications from 1996 to 2023 across PubMed, Medline, Cochrane Library, and APA PsycINFO. The meta-analysis followed the PRISMA guideline, initially screening 425 articles, with 14 articles meeting the criteria of relevance, scientific rigor, and a focus on symptom clustering in climacteric women. Data from the 14 selected studies (n = 14,760) were extracted, including study characteristics, participant demographics, methods for identifying symptom clusters, specific symptoms within each cluster, and associations with lifestyle factors, genetics, or psychosocial elements. The findings were synthesized to quantify relationships between different symptom clusters, identifying four distinct groups: somatic, vasomotor, psychological, and sexual symptoms. The overall standardized mean difference (SMD) of -0.89 [95 % CI = -1.70, -0.07] was found for somatic symptom clusters, indicating significant differences. However, no conclusive distinctions were observed in vasomotor, sexual, and psychological symptoms, highlighting variability in symptom presentation. Despite this heterogeneity, the overall effect for somatic symptoms remained statistically significant (Z = 2.14, P = 0.03). The findings emphasize the complexity of symptomatology in climacteric women and underscore the need for tailored person-centered interventions and longitudinal studies.
Association Between Perceived Control and Acute Coronary Syndrome Symptom Severity: A Prospective Cohort Study
(2025) AbuRuz, Mohannad Eid
Aim: To determine whether there are differences in patterns of symptom severity in three major ACS symptoms (i.e., chest pain, fatigue, and dyspnoea) over the days of CCU stay between patients with higher and lower levels of perceived control. Design: A prospective cohort study with 3 days of follow- up. Methods: Hundred and thirty- five patients were followed prospectively for 3 days, collecting data on (1) perceived control, using the Arabic version of the Controlled Attitude Scale (CAS- R); and (2) symptom severity, using a symptoms diary. A mixed repeated measure design ANOVA was used for data analysis. Results: Comparative analysis of the high- and low- perceived control groups revealed that there was a significant reduction in chest pain, fatigue, and dyspnoea symptom severity over the course of the 3 days for both groups. Compared to the low- perceived control group, the high- perceived control group had significantly lower chest pain on day 3, fatigue on days 2 and 3, and dyspnoea on all days. Conclusion: Patients with high levels of perceived control have lower levels of symptom severity than those with low perceived control. Interventions to improve perceived control among this population are highly recommended.
Professional Competence and Spiritual Care Provision Among Zambian Maternal Healthcare Providers: Through the Lens of Watson's Theory of Human Caring.
(2025-02-27) Khalaf, Atika
Purpose: Spiritual care is a multifaceted and integral part of holistic health within the medical standard of care, and it is a crucial component of healthcare providers' (HCPs) job descriptions. This study aimed to investigate Zambian HCPs' professional competence and practice of spiritual care in maternal healthcare settings, with a comparative focus on nurses. Methods: A cross-sectional design was applied among 311 maternal HCPs using an online survey with two validated instruments: Professional Competence in Spiritual Care (PCSC) and the Nurse Spiritual Care Therapeutics Scale (NSCTS). Results: Most participants were females (63.0%) and nurses or midwives (25.1% each). The mean PCSC score was 135.4 (SD = 26.5), indicating excellent competence in spiritual care. The mean NSCTS score was 24.5 (SD = 14.2), indicating that HCPs seldom provide spiritual care. No significant differences were found in PCSC scores across different HCPs ( = 0.065). However, midwives and medical practitioners scored significantly higher on NSCTS compared to nurses ( < 0.001). Conclusions: Zambian HCPs demonstrate excellent competence in spiritual care but seldom provide it. Nurses appear to provide inadequate spiritual care compared to other HCPs. These findings highlight the need for further investigation to identify barriers preventing nurses from delivering comprehensive spiritual care.
Association of contraception use and pregnancy intention with perinatal depression risk among Omani mothers-a longitudinal cohort study.
(2025) Khalaf, Atika
Unplanned pregnancy is significantly associated with an increased risk of perinatal depression (antenatal and postnatal depression), emphasizing its prevalence and its potentially detrimental effects on both maternal and child health. This study aimed to investigate the association of contraception use and pregnancy intention with the risk of perinatal depression among Omani mothers.
Ups and downs of expatriate health sciences students: towards an understanding of experiences, needs, and suggested recommendations in an Emirati university
(Frontiers Media SA, 2025-02-06) Mohannad Eid AbuRuz
Aim To describe the lived experiences of expatriate students enrolled in an academic institution in the UAE and explore suggested improvement strategies to address their challenges. Background Exploring the experiences of expatriate students is crucial for three main reasons. First, expatriate students play a key role in the UAE’s sustainable socio-economic development and diversification. Second, cultural differences among expatriate students raise personal, social, and academic challenges, including pedagogical issues concerning teaching and learning styles and effectiveness. Third, given the global importance of internationalization, expatriates’ experiences should be considered an issue of customer satisfaction. Method A descriptive, qualitative, narrative study using indirect Colaizzi content analysis of 23 expatriate students’ reflections on their experiences and suggested recommendations. Results The consistent themes cited by participants concerning their experiences centered on dormitory-study life balance, socialization and support networks, and navigating financial challenges. They identified areas for improvement in terms of professional, social, peer, and self-support. Conclusion Developing an effective support system is essential to ensure a smooth expatriate student experience. The study findings propose suggestions and recommendations that may help in future planning, including maximizing professional support, providing peer tutoring, boosting academic advising and consultation, encouraging student socialization, and guiding self-development as necessary.
What do patients want from a digital device that supports heart failure self-management?
(2024-08) Hill, Loreena
Abstract Objective: To assess patients' needs and the factors determining their acceptance of an e-Health intervention. Methods: Purposive sample of patients with heart failure, attending an outpatient consultation were invited to complete a questionnaire designed to assess their needs and acceptance of an e-Health intervention. Data analysis was performed using Chi-square tests with post-hoc corrections. Results: Response rate was 61 % (n = 101), with most patients (>70 %) indicating they could see themselves using an e-Health intervention to manage their heart failure. Participants with a healthy lifestyle (i.e., non-smoker and consumed alcohol < once/week) were more likely to have a positive attitude towards technology (p adj.=0.013). Those willing to use an e-Health intervention were convinced of its advantages by other patients with heart failure (p adj.=0.013). Advanced age, education level, employment or marital status did not influence patient attitudes toward health technology. Conclusions & practice implications: Results indicate patients have a positive attitude towards the use of e-Health interventions to enable their self-management of heart failure. These findings will inform further development and delivery strategies of e-Health interventions.
The lived experiences of fatigue among patients receiving haemodialysis in Oman: a qualitative exploration
(2024-07) Gormley, Kevin
Abstract Background: Fatigue among patients with end-stage kidney disease (ESKD) receiving haemodialysis imposes a substantial burden on patients' quality of life and expected treatment outcomes. This study explores the perspective on ESKD-related fatigue and contributing factors among Omani patients receiving haemodialysis. Methods: An exploratory qualitative design was used. Participants (N = 25) were recruited from two Omani haemodialysis centres, and data were collected through semi-structured interviews, which were transcribed and analysed using a thematic analysis approach. NVivo 11 is used to manage qualitative data and create memos, nodes, and codes. Results: Findings highlighted three themes: (i)"Inevitability of fatigue," (ii)"Contributors to physical fatigue," and (iii)"Contributors to mental fatigue." Theme one alluded to the inevitability of fatigue and the unique experience encountered by patients. Theme two addressed the physical fatigue associated with ESKD-related factors, such as chronically low haemoglobin levels, and the exhausting impact caused by the frequency and travelling distance for treatment sessions. Theme three, mental fatigue, was notably driven by heightened emotional disturbance, encompassing frustration, guilt, anxiety, and distress, that in turn impacted family interactions, frequently triggering anger and remorse. Moreover, mental fatigue is a result of disturbances in expressing physical sexuality in marriage, as physical fatigue was found to be a significant contributor to unsatisfactory sexual experiences and, thus, straining the relationships between couples. Conclusions: This study offers an explanation of fatigue among Omani patients with ESKD who are receiving haemodialysis. The study emphasises close links between physiological change, the haemodialysis process, and mental tiredness, together with their contribution to supporting the need for a holistic approach and care strategies in managing these patients and promoting patient and family well-being.
An Exploration of the Day to Day Professional Experiences of School Nurses Globally: A Narrative Review
(2024-07) Boyle, Breidge
Abstract To explore school nurses roles globally through their own perceptions of what they do and how they do it and to compare the realities for the role its representation in professional literature. A comprehensive narrative literature review, using ENTREQ guidelines, with "qualitizing" of the quantitative literature, and athematic analysis was carried out. Findings were reviewed in relation to established theory. CINAHL, Medline, Cochrane Library, and Embase were systematically searched from 2000-2021. Included studies focused on school nurses perceptions of their own practice. Five themes: direct care, health promotion, collaboration, support from school and health authorities and promoting the school nurses role were found. These themes were closely aligned to the National Association for School Nurses' framework for 21st century practice. However, the school nurses signposted areas where they need support in carrying out their job to the highest standard. School nurses are important to support the health needs of students while at school. They also, particularly in areas like the United Arab Emirates where resources are being invested in the role, have a unique role to play in health promotion, leading to improved health literacy, as positive health behaviors tend to be learned young. However, worldwide, the potential for the school nursing role needs to be recognized and supported by health and education providers, by families and within the schools for its full potential to be achieved.
Summer musings
(2024-06) Boyle, Breidge
Abstract Reflecting on the title, I suppose that I should acknowledge that while it is summer here in the northern hemisphere, our colleagues in the south are in the depths of winter. Whatever time of year it is I hope that these offerings bring you food for thought. Starting, as usual, with review articles, Adriana Pacheco, and her colleagues from Portugal, offer us our first course, with a scoping review of music as a non-pharmacological method of pain relief in the neonate. We tend to see scoping reviews where there is little published literature and I commend them on finding 20 articles worthy of inclusion. The fact that they find a positive result for neonates but not for infants indicates that more research in needed in this very interesting area. Yu-Ju Shao and colleagues from Taiwan have started the process, showing that there is a statistical difference in the heart rate and blood oxygen levels in those babies exposed to music therapy compare to those receiving normal care. I am sure that there is more to come on this subject. On the other hand, Sin Yan Victoria Linda Fong, writing in Hong Kong, found much less literature on trauma caused by the rotation of the interface devices used when neonates require non-invasive ventilation. Again a really interesting area where there is much more research available on how well individual devices protect neonates’ noses than on the practice of alternating devices. Alternation is common practice and it is good to see evidence to support it. More is required.
Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care
(2023) Hill, Loreena
Abstract: The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.

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