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EART FAILURE ACCOUNTS DIrectly for 55 000 deaths and indirectly for an additional 230 000 deaths in the United States each year. 1 Despite advances in care, the prognosis for patients with symptomatic heart failure remains poor, with median life expectancy of less than 5 years. 2 For those with the most advanced disease, 1-year mortality rates approach 90%. 3,4 About half of these deaths are due to progressive pump failure, while the remainder are sudden. 5 Prognosis is highly dependent on a multitude of patient characteristics, and a number of prognostic models have been developed to help predict survival in patients with heart failure. 6-9 Given the progressive nature of heart failure, its high mortality rate, and its predilection for affecting elderly persons, end-of-life issues should be at the forefront of heart failure management. In recognition of this, practice guidelines from major cardiovascular societies include sections on end-oflife considerations, which advocate ongoing patient and family education regarding prognosis for quality of life and survival. 10-12 Despite these guidelines, data on end-of-life issues in heart fail-For editorial comment see p 2566.

BACKGROUND Advanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life. OBJECTIVES . We investigated whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes. METHODS We randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC; n =75) or UC plus a palliative care intervention (UC+PAL; n =75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy - Palliative Care scale (FACIT-Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale [HADS]), spiritual well-being (measured via the FACIT - Spiritual Well-Being scale [FACIT-Sp]), hospitalizations, and mortality. RESULTS Patients randomized to UC+PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT-Pal scores from randomization to 6 months (KCCQ difference =9.49 points, 95% CI 0.94 to 18.05, p =0.030; FACIT-Pal difference =11.77 points, 95% CI 0.84 to 22.71, p =0.035). Depression improved in UC+PAL patients (HADS-depression difference =−1.94 points; p =0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference =−1.83 points; p =0.048). Spiritual well-being was improved in UC+PAL versus UC-alone patients (FACIT-Sp difference =3.98 points; p =0.027). Randomization to UC+PAL did not affect rehospitalization or mortality. CONCLUSIONS An interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. Trial Registration ClinicalTrials.gov Identifier: NCT01589601

Background The progressive nature of heart failure (HF) coupled with high mortality and poor quality of life mandates greater attention to palliative care as a routine component of advanced HF management. Limited evidence exists from randomized, controlled trials supporting the use of interdisciplinary palliative care in HF. Methods The Palliative Care in Heart Failure trial (PAL-HF) is a prospective, controlled, unblinded, single-center study of an interdisciplinary palliative care intervention in 200 patients with advanced HF estimated to have a high likelihood of mortality or re-hospitalization in the ensuing 6 months. The 6-month PAL-HF intervention focuses on physical and psychosocial symptom relief, attention to spiritual concerns and advanced care planning. The primary endpoint is health-related quality of life measured by the Kansas City Cardiomyopathy Questionnaire and the Functional Assessment of Chronic Illness Therapy with Palliative Care Subscale score at 6 months. Secondary endpoints include changes in anxiety/depression, spiritual well-being, caregiver satisfaction, cost and resource utilization, and a composite of death, HF hospitalization and quality of life. Conclusions PAL-HF is a randomized, controlled clinical trial that will help evaluate the efficacy and cost-effectiveness of palliative care in advanced HF using a patient-centered outcome as well as clinical and economic endpoints.

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