Heart failure (HF) is a common and frequently life-limiting illness with increasing prevalence, particularly among the growing population of elderly persons. Nearly 300,000 persons in the United States die with HF annually, and HF was the primary cause of death for over 60,000 persons in 2006 in the United States. Hospitalization rates for decompensated HF are high and one-third or more of HF patients die within a year of a hospitalization for HF . The average life expectancy following diagnosis of HF is under six years. However, the course of HF is variable, and some persons live 10 years or more years with good medication response and dietary and lifestyle management. (See "Prognosis of heart failure" and "Predictors of survival in heart failure due to systolic dysfunction".)
Variability in the course of HF makes identifying the end of life in patients with HF challenging and limited data are available to guide end of life care. Nonetheless, clinicians and researchers have called for palliative care for advanced HF , and major cardiology society guidelines recognize the need for palliative care for HF patients [3-5].
IDENTIFICATION OF END-STAGE HF
Individuals with advanced or end-stage heart failure (HF) have marked symptoms of dyspnea, fatigue or symptoms relating to end-organ hypoperfusion at rest or with minimal exertion despite maximal medical therapy . This description conforms to stage D and the advanced phase of Stage C HF as defined in the American College of Cardiology/American Heart Association (ACC/AHA) HF guidelines . Persons with advanced HF typically have frequent admissions to the hospital or emergency department with decompensation and volume overload. Patients with advanced HF who comply with self-care management have rates of hospitalization and other events comparable to less ill HF patients . (See "Evaluation of the patient with heart failure or cardiomyopathy", section on 'Definition and classification'.)
The challenge for a clinician evaluating a patient who appears to have advanced HF is whether there are remediable interventions, adjustments to medications, or other therapies that might improve the patient's function, or whether the patient truly has end-stage disease . Heart failure patients may have dramatic worsening of functional status and then impressive recovery to a plateau of reasonable function with medical therapy and/or device or surgical interventions.
Clinicians should evaluate the HF patient with apparently refractory HF for high sodium intake, noncompliance with HF treatments, sleep disordered breathing (SDB), occult ischemia, deleterious medications, and other insults that may have contributed to the poor status. In addition, HF treatment should be reevaluated to maximize evidence-based therapies. (See "Evaluation of acute decompensated heart failure", section on 'Identification of precipitating factors' and "Sleep disordered breathing in heart failure" and "Overview of the therapy of heart failure due to systolic dysfunction", section on 'Drugs to avoid'.)