Elsevier

Heart Failure Clinics

Volume 13, Issue 3, July 2017, Pages 633-644
Heart Failure Clinics

End-of-Life Care in the Treatment of Heart Failure in Older Adults

https://doi.org/10.1016/j.hfc.2017.02.014Get rights and content

Section snippets

Key points

  • 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

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

First page preview

First page preview
Click to open first page preview

References (97)

  • P. Carson et al.

    Mode of death in advanced heart failure: the comparison of medical, pacing, and defibrillation therapies in heart failure (COMPANION) trial

    J Am Coll Cardiol

    (2005)
  • J.J. Bax et al.

    Cardiac resynchronization therapy. Part 2: issues during and after device implantation and unresolved questions

    J Am Coll Cardiol

    (2005)
  • P.S. Mueller et al.

    Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life

    Mayo Clin Proc

    (2003)
  • S.J. Goodlin et al.

    Consensus statement: palliative and supportive care in advanced heart failure

    J Card Fail

    (2004)
  • American Geriatrics Society Position Statement: the care of dying patients

    J Am Geriatr Soc

    (1995)
  • S.J. Goodlin

    End-of-life care in heart failure

    Curr Cardiol Rep

    (2009)
  • E.F. Lewis

    End of life care in advanced heart failure

    Curr Treat Options Cardiovasc Med

    (2011)
  • E.B. Lamont et al.

    Prognostic disclosure to patients with cancer near the end of life

    Ann Intern Med

    (2001)
  • E.B. Lamont et al.

    Complexities in prognostication in advanced cancer

    JAMA

    (2003)
  • P.J. Cowburn et al.

    Risk stratification in chronic heart failure

    Eur Heart J

    (1998)
  • W.H. Lee et al.

    Prognostic importance of serum sodium concentration and its modification by converting enzyme inhibition in patients with severe chronic heart failure

    Circulation

    (1986)
  • W.C. Levy et al.

    The Seattle Heart Failure Model: prediction of survival in heart failure

    Circulation

    (2006)
  • E.Z. Gorodeski et al.

    Application of the Seattle Heart Failure Model in ambulatory patients presented to an advanced heart failure therapeutics committee

    Circ Heart Fail

    (2010)
  • B.C. Huynh et al.

    Long-term survival in elderly patients hospitalized for heart failure: 14-year follow-up from a prospective randomized trial

    Arch Intern Med

    (2006)
  • B.C. Huynh et al.

    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

    (2008)
  • J.N. Cohn et al.

    A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure

    N Engl J Med

    (1991)
  • A. Maisel

    B-type natriuretic peptide levels: diagnostic and prognostic in congestive heart failure

    Circulation

    (2002)
  • R. Berger et al.

    B-type natriuretic peptide predicts sudden death in patients with chronic heart failure

    Circulation

    (2002)
  • J. Watanabe et al.

    Accumulation of risk markers predicts the incidence of sudden death in patients with chronic heart failure

    Eur J Heart Fail

    (2006)
  • G.H. Bardy et al.

    Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure

    N Engl J Med

    (2005)
  • J.C. Weeks et al.

    Relationship between cancer patients’ predictions of prognosis and their treatment preferences

    JAMA

    (1998)
  • S.A. Murray et al.

    Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community

    BMJ

    (2002)
  • K. Faber-Langendoen

    A multi-institutional study of care given to patients dying in hospitals: ethical and practice implications

    Arch Intern Med

    (1996)
  • L.A. Allen et al.

    Identifying patients hospitalized with heart failure at risk for unfavorable future quality of life

    Circ Cardiovasc Qual Outcomes

    (2011)
  • N.E. Goldstein et al.

    Trajectory of end-stage heart failure: the influence of technology and implications for policy change

    Perspect Biol Med

    (2006)
  • A.G. Rizzieri et al.

    Ethical challenges with the left ventricular assist device as a destination therapy

    Philos Ethics Humanit Med

    (2008)
  • M. McCarthy et al.

    Dying from heart disease

    J R Coll Physicians Lond

    (1996)
  • L.S. Zier et al.

    Surrogate decision makers’ interpretation of prognostic information: a mixed-methods study

    Ann Intern Med

    (2012)
  • K. Covinsky et al.

    The impact of serious illness on patients’ families

    JAMA

    (1994)
  • 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

    (1995)
  • J. Lynn et al.

    Perceptions of family members of the dying experience of older and seriously ill patients

    Ann Intern Med

    (1997)
  • E.J. Emanuel et al.

    Talking with terminally ill patients and their caregivers about death, dying, and bereavement: Is it stressful? Is it helpful?

    Arch Intern Med

    (2004)
  • E.D. Adler et al.

    Palliative care in the treatment of advanced heart failure

    Circulation

    (2009)
  • S. Stewart et al.

    Palliative care for heart failure: time to move beyond treating and curing to improving the end of life

    BMJ

    (2002)
  • S.A. Murray et al.

    Palliative care in chronic illness: we need to move from prognostic paralysis to active total care

    BMJ

    (2005)
  • P.J. Hauptman et al.

    Integrating palliative care into heart failure care

    Arch Intern Med

    (2005)
  • World Health Organization. Palliative Care [Fact Sheet number 402]. 2015. Available at:...
  • Cited by (9)

    • Palliative care in Brasil: Present and future

      2019, Revista da Associacao Medica Brasileira
    View all citing articles on Scopus

    This is an updated version of an article that appeared in Heart Failure Clinics, Volume 3, Issue 4.

    View full text