- •
Prognostic uncertainty makes end-stage heart failure a more challenging entity than cancer that requires a more nuanced approach to therapeutic planning.
- •
Improved communication requires a more robust effort to frankly discuss the disease entity, its therapeutic challenges, patient preferences, and palliative care as early as possible.
- •
Device therapy and cardiopulmonary resuscitation provide their own complexity when discussing end-of-life issues.
- •
Palliative sedation requires careful planning and
End-of-Life Care in the Treatment of Heart Failure in Older Adults
Section snippets
Key points
How do we know we have arrived?
The ability of physicians to accurately predict mortality has been demonstrated to be questionable in advanced heart failure and in cases of advanced malignancy.5, 6, 7 Attempts to ascertain variables predictive of mortality in patients with heart failure have proven to be significantly difficult. An exhaustive review of the literature conducted in 1998 found few consistently predictive variables. Factors accounting for this included small sample size, differing patient populations, selective
Improving communication
Interviews conducted in Great Britain with patients dying of heart failure and their caregivers identified several problems unique to the treatment of this patient population.22 Patients tended not to recall receiving any written information about their condition and often did not see an association between symptoms, such as dyspnea and edema, and their cardiac status. Similarly, patients and caregivers did not feel particularly involved in the decision-making process regarding the illness.
Palliative care in heart failure
The previously described uncertainty regarding the trajectory of terminal heart failure can induce what has been termed “prognostic paralysis” regarding the initiation of discussion about palliative care and its actual implementation.35 One commentator has suggested that patients with heart failure should be considered candidates for palliative care if a clinician answers “no” to the question, “Would I be surprised if my patient were to die in the next 12 months?”36 Another suggested algorithm
Device therapy
The increasingly common use of device therapy has significantly reduced the morbidity and mortality associated with heart failure. Notwithstanding, these devices pose significant problems for the end-stage patient who may wish to minimize or reduce the intensity of his or her care. The right of a patient with intact decision making capacity to refuse any and all medical interventions has a long and established history in bioethics and common law.63, 64 This right applies equally to the
Cardiopulmonary resuscitation
Cardiopulmonary arrest, as an isolated episode, is not uncommon in patients with heart failure and does not, in and of itself, portend end-stage disease.79 This may account for the observation that only 23% of patients with heart failure in the SUPPORT database initially preferred not to be resuscitated in the event of an arrest.80 It probably also underpins the high percentage of patients (14%) who changed their preference in favor of resuscitation during the course of their hospitalization.
Palliative sedation
Patients at the end stages of pump failure not uncommonly present with hallucinations, delirium, myoclonic jerks, and sometimes seizures that frequently exceed the capability of nonpharmacologic measures for control. Hallucinations and delirium are pharmacologically managed in many situations with small doses of haloperidol, olanzapine, or risperidone.84 For those patients in whom delirium is not controlled and for those who present with myoclonus and frank seizures, sedative therapy may be
Caveats of palliative care
One perhaps unexpected response to the gradual growth of palliative care initiatives has been the concept of what one author has called “palliative care triumphalism.”92 Although a somewhat pejorative label, it refers to the observation that the carefully managed palliative efforts of dedicated professionals, including the use of palliative sedation, run the risk of ignoring that death represents a chaotic disintegration of life that is fundamentally not controllable. To attempt to control it
Summary
The terminal stages of heart failure present challenges to the patient and the clinician that are at least the equal of terminal cancer, but with facets that are unique to cardiovascular disease. Among these unique characteristics are prognostic uncertainty, episodes of acute decompensation followed by rapid improvement, and the relative frequency of device therapy. It is clear from the published literature that communication between patients, their family members, and caregivers remains
References (97)
- et al.
End-of-life planning in heart failure: it should be the end of the beginning
Can J Cardiol
(2010) - et al.
Prediction of rehospitalization and death in severe heart failure by physicians and nurses of the ESCAPE trial
J Card Fail
(2007) - et al.
Utility of the Seattle Heart Failure Model in patients with advanced heart failure
J Am Coll Cardiol
(2009) - et al.
Predictive value of ventricular arrhythmia inducibility for subsequent ventricular tachycardia or ventricular fibrillation in multicenter automatic defibrillator implantation trial (MADIT) II patients
J Am Coll Cardiol
(2006) Palliative care in congestive heart failure
J Am Coll Cardiol
(2009)- et al.
Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality
J Am Coll Cardiol
(2003) - et al.
Appropriate evaluation and treatment of heart failure patients after implantable cardioverter-defibrillator discharge: time to go beyond the initial shock
J Am Coll Cardiol
(2009) - et al.
Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial
J Am Coll Cardiol
(2010) - et al.
Physician attitudes toward end-stage heart failure: a national survey
Am J Med
(2008) - et al.
Cardiac pacemakers and implantable defibrillators in terminal care
J Pain Symptom Manage
(1999)
Mode of death in advanced heart failure: the comparison of medical, pacing, and defibrillation therapies in heart failure (COMPANION) trial
J Am Coll Cardiol
Cardiac resynchronization therapy. Part 2: issues during and after device implantation and unresolved questions
J Am Coll Cardiol
Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life
Mayo Clin Proc
Consensus statement: palliative and supportive care in advanced heart failure
J Card Fail
American Geriatrics Society Position Statement: the care of dying patients
J Am Geriatr Soc
End-of-life care in heart failure
Curr Cardiol Rep
End of life care in advanced heart failure
Curr Treat Options Cardiovasc Med
Prognostic disclosure to patients with cancer near the end of life
Ann Intern Med
Complexities in prognostication in advanced cancer
JAMA
Risk stratification in chronic heart failure
Eur Heart J
Prognostic importance of serum sodium concentration and its modification by converting enzyme inhibition in patients with severe chronic heart failure
Circulation
The Seattle Heart Failure Model: prediction of survival in heart failure
Circulation
Application of the Seattle Heart Failure Model in ambulatory patients presented to an advanced heart failure therapeutics committee
Circ Heart Fail
Long-term survival in elderly patients hospitalized for heart failure: 14-year follow-up from a prospective randomized trial
Arch Intern Med
Identification of older patients with heart failure who may be candidates for hospice care: development of a simple four-item risk score
J Am Geriatr Soc
A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure
N Engl J Med
B-type natriuretic peptide levels: diagnostic and prognostic in congestive heart failure
Circulation
B-type natriuretic peptide predicts sudden death in patients with chronic heart failure
Circulation
Accumulation of risk markers predicts the incidence of sudden death in patients with chronic heart failure
Eur J Heart Fail
Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure
N Engl J Med
Relationship between cancer patients’ predictions of prognosis and their treatment preferences
JAMA
Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community
BMJ
A multi-institutional study of care given to patients dying in hospitals: ethical and practice implications
Arch Intern Med
Identifying patients hospitalized with heart failure at risk for unfavorable future quality of life
Circ Cardiovasc Qual Outcomes
Trajectory of end-stage heart failure: the influence of technology and implications for policy change
Perspect Biol Med
Ethical challenges with the left ventricular assist device as a destination therapy
Philos Ethics Humanit Med
Dying from heart disease
J R Coll Physicians Lond
Surrogate decision makers’ interpretation of prognostic information: a mixed-methods study
Ann Intern Med
The impact of serious illness on patients’ families
JAMA
A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT)
JAMA
Perceptions of family members of the dying experience of older and seriously ill patients
Ann Intern Med
Talking with terminally ill patients and their caregivers about death, dying, and bereavement: Is it stressful? Is it helpful?
Arch Intern Med
Palliative care in the treatment of advanced heart failure
Circulation
Palliative care for heart failure: time to move beyond treating and curing to improving the end of life
BMJ
Palliative care in chronic illness: we need to move from prognostic paralysis to active total care
BMJ
Integrating palliative care into heart failure care
Arch Intern Med
Cited by (9)
End-Stage/Advanced Heart Failure: Geriatric Palliative Care Considerations
2023, Clinics in Geriatric MedicineTrends and Changes in Intensive Care Use for Patients With Heart Failure in the Last Month of Life
2024, Inquiry (United States)Nurses' symptom management and views on death and caring for heart failure and chronic obstructive pulmonary disease
2022, International Journal of Palliative NursingReferral Criteria to Palliative Care for Patients With Heart Failure: A Systematic Review
2020, Circulation: Heart FailurePalliative care in Brasil: Present and future
2019, Revista da Associacao Medica Brasileira
This is an updated version of an article that appeared in Heart Failure Clinics, Volume 3, Issue 4.