Palliative Care and Decision Making in Advanced Heart Failure

Abstract

The diagnosis of advanced heart failure (HF) is established in patients for whom symptoms are refractory to guideline-directed therapies. Palliative care (PC) is based on symptom management and support of the patient and family, making its integration into the care of those with advanced HF essential. Comorbidities including frailty, cognitive dysfunction, and depression are often under-recognized in patients with advanced HF and may correlate with outcomes. Decisions should be based on the patient's values, goals agreed upon by the clinician with the patient, and what is medically reasonable. Palliative Care should be integrated to help with both palliation of symptoms and support for families and patients.

Challenges in shared decision making in advanced cancer care: a qualitative longitudinal observational and interview study

“…The focus on treatment options and the lack of addressing the alternative of non‐treatment has been reported previously . More than 10 years ago, De Haes & Koedoot already described the preference of oncologists for chemotherapy without good evidence for life prolongation.…”

Incongruence between women's survey‐ and interview‐determined decision control preferences: A mixed methods study of decision‐making in metastatic breast cancer

“…Continuing to assess patients' preferred decision‐making role at different points in the illness trajectory may enable clinicians to be responsive to a patient's fluctuating role preference. Consulting palliative care specialists early and often to assist patients in understanding and matching their values and preferences for treatment can help with this goal …”

Advanced Heart Failure Treatment Options Among the Elderly

“…38 Despite these recommendations and the creation of a recognized palliative care subspecialty, the discussion tool and subsequent services have been underutilized. 39 One study revealed that only 6% of patients hospitalized for HF received palliative care consultation in spite of the fact that nearly 60% of patients studied were at elevated risk of mortality. 40 These findings are consistent with others who have examined palliative care consultation among HF and noncancer medical populations.…”

“…While age is often an important factor for palliative care referral, only after a thorough evaluation of all reasonable options in line with patient preference should end-of-life therapy be initiated. 39 Frailty and Advanced Heart Failure Therapy Options Frailty, particularly physical frailty, is a condition often recognized by the provider but difficult to quantify; however, it is often one of the most important factors influencing the answer to the question "Should we pursue AHF surgical options?" The traditional definition of frailty encompasses "a medical syndrome with multiple causes and contributors characterized by diminished strength, endurance, and physiologic function that increases an individual's vulnerability for developing increased dependency and/or death."…”