Table 3 Measures and Instrument for Specific Aim 1 (Data collection at baseline, 3, and 6 months)

1a. Patient’s Kansas City Cardiomyopathy Questionnaire (KCCQ) [37] 12-item Likert.^{a, c, d, e} [completed by patient]

Management of HF status, HF-related symptoms (i.e. breathlessness) and physical function status, α = 0.90.^a

1a. Tabulate proportion of patients selecting HF EOLPC options and signing advance directives, and.

Identify preferred HF conservative care options.

Signed directives and confirmed EOLPC options

1a.1b Patient Health Questionnaire (PHQ-4) Scale, [38] 4-item Likert.^{a, b,e} [completed by patient & caregiver]

Assess patient’s/family caregiver’s depression and anxiety, α = 0.82.^a Referral will be made [39].

1a.1b HF Home-Care Skills, [40] 9-item Likert.^{a, b, d, e} [completed by patient & caregiver]

HF home care skills (i.e., if the patient’s legs/ feet are swollen, I contact MD/nurse), α = 0.80.

1a.1b. Confidence in HF home care, [41] 4-item multiple choice.^{a, e, f} [completed by patient & caregiver]

Perceived confidence in providing home HF EOLPC, α = 0.87^a “How confident are you in managing your worsening HF at home?”

1a.1b. Preparedness for HF EOLPC Home Care, [42] 1-item Likert.^{c, e} [completed by patient & caregiver]

Perceived readiness/ability to manage home HF EOLPC.

1b. Caregivers’ quality of life (QoL) SF12v2, [43] 12-item Likert ^{a, c, d, e} [completed by caregiver]

Caregivers’ physical and mental health outcomes.

α = 0.90 to 0.93.

1b. Short-form Zarit Caregiver Burden Interviews, [44, 45] 12-item Likert.^{a, c, d, e} [completed by caregiver]

Record physical, social, financial, and emotional components of home caregiving burden, α = 0.89.^{a, b}