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End of life considerations for heart failure patients

INTRODUCTION

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 [1]. 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 [2], 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 [2]. 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 [4]. 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 [6]. (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 [2]. 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'.)

                 

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Literature review current through: Nov 2014. | This topic last updated: Nov 13, 2014.
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References
Top
  1. Setoguchi S, Stevenson LW. Hospitalizations in patients with heart failure: who and why. J Am Coll Cardiol 2009; 54:1703.
  2. Goodlin SJ, Hauptman PJ, Arnold R, et al. Consensus statement: Palliative and supportive care in advanced heart failure. J Card Fail 2004; 10:200.
  3. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
  4. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.
  5. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008; 29:2388.
  6. Lee CS, Moser DK, Lennie TA, Riegel B. Event-free survival in adults with heart failure who engage in self-care management. Heart Lung 2011; 40:12.
  7. Goldberg LR, Jessup M. A time to be born and a time to die. Circulation 2007; 116:360.
  8. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001; 345:1435.
  9. Setoguchi S, Stevenson LW, Schneeweiss S. Repeated hospitalizations predict mortality in the community population with heart failure. Am Heart J 2007; 154:260.
  10. Lee DS, Austin PC, Rouleau JL, et al. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA 2003; 290:2581.
  11. Levy WC, Mozaffarian D, Linker DT, et al. The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation 2006; 113:1424.
  12. Ko DT, Alter DA, Austin PC, et al. Life expectancy after an index hospitalization for patients with heart failure: a population-based study. Am Heart J 2008; 155:324.
  13. Mozaffarian D, Anker SD, Anand I, et al. Prediction of mode of death in heart failure: the Seattle Heart Failure Model. Circulation 2007; 116:392.
  14. Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting. J Am Coll Cardiol 2003; 41:62.
  15. Jong P, Gong Y, Liu PP, et al. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 2003; 108:184.
  16. Kfoury AG, French TK, Horne BD, et al. Incremental survival benefit with adherence to standardized heart failure core measures: a performance evaluation study of 2958 patients. J Card Fail 2008; 14:95.
  17. Teuteberg JJ, Lewis EF, Nohria A, et al. Characteristics of patients who die with heart failure and a low ejection fraction in the new millennium. J Card Fail 2006; 12:47.
  18. Derfler MC, Jacob M, Wolf RE, et al. Mode of death from congestive heart failure: implications for clinical management. Am J Geriatr Cardiol 2004; 13:299.
  19. Carson P, Anand I, O'Connor C, 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; 46:2329.
  20. Luu M, Stevenson WG, Stevenson LW, et al. Diverse mechanisms of unexpected cardiac arrest in advanced heart failure. Circulation 1989; 80:1675.
  21. Teno JM, Weitzen S, Fennell ML, Mor V. Dying trajectory in the last year of life: does cancer trajectory fit other diseases? J Palliat Med 2001; 4:457.
  22. Hopp FP, Thornton N, Martin L. The lived experience of heart failure at the end of life: a systematic literature review. Health Soc Work 2010; 35:109.
  23. Strachan PH, Ross H, Rocker GM, et al. Mind the gap: Opportunities for improving end-of-life care for patients with advanced heart failure. Can J Cardiol 2009; 25:635.
  24. Allen LA, Stevenson LW, Grady KL, et al. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 2012; 125:1928.
  25. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
  26. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240.
  27. Goodlin SJ, Quill TE, Arnold RM. Communication and decision-making about prognosis in heart failure care. J Card Fail 2008; 14:106.
  28. Allen LA, Yager JE, Funk MJ, et al. Discordance between patient-predicted and model-predicted life expectancy among ambulatory patients with heart failure. JAMA 2008; 299:2533.
  29. Back AL, Arnold RM, Quill TE. Hope for the best, and prepare for the worst. Ann Intern Med 2003; 138:439.
  30. Lampert R, Hayes DL, Annas GJ, et al. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 2010; 7:1008.
  31. Almeida OP, Garrido GJ, Beer C, et al. Cognitive and brain changes associated with ischaemic heart disease and heart failure. Eur Heart J 2012; 33:1769.
  32. Pressler SJ. Cognitive functioning and chronic heart failure: a review of the literature (2002-July 2007). J Cardiovasc Nurs 2008; 23:239.
  33. Kindermann I, Fischer D, Karbach J, et al. Cognitive function in patients with decompensated heart failure: the Cognitive Impairment in Heart Failure (CogImpair-HF) study. Eur J Heart Fail 2012; 14:404.
  34. Zuccalà G, Onder G, Marzetti E, et al. Use of angiotensin-converting enzyme inhibitors and variations in cognitive performance among patients with heart failure. Eur Heart J 2005; 26:226.
  35. Goodlin SJ, Kutner JS, Connor SR, et al. Hospice care for heart failure patients. J Pain Symptom Manage 2005; 29:525.
  36. Hauptman PJ, Swindle J, Hussain Z, et al. Physician attitudes toward end-stage heart failure: a national survey. Am J Med 2008; 121:127.
  37. Goodlin SJ, Trupp R, Bernhardt P, et al. Development and evaluation of the "Advanced Heart Failure Clinical Competence Survey": a tool to assess knowledge of heart failure care and self-assessed competence. Patient Educ Couns 2007; 67:3.
  38. Kim DH, Hunt SA. Heart failure management: caregiver versus care plan. Circulation 2003; 108:129.
  39. Komajda M, Hanon O, Hochadel M, et al. Management of octogenarians hospitalized for heart failure in Euro Heart Failure Survey I. Eur Heart J 2007; 28:1310.
  40. Dracup K, Walden JA, Stevenson LW, Brecht ML. Quality of life in patients with advanced heart failure. J Heart Lung Transplant 1992; 11:273.
  41. Krum H, Gilbert RE. Demographics and concomitant disorders in heart failure. Lancet 2003; 362:147.
  42. Goodlin SJ, Wingate S, Pressler SJ, et al. Investigating pain in heart failure patients: rationale and design of the Pain Assessment, Incidence & Nature in Heart Failure (PAIN-HF) study. J Card Fail 2008; 14:276.
  43. Walke LM, Gallo WT, Tinetti ME, Fried TR. The burden of symptoms among community-dwelling older persons with advanced chronic disease. Arch Intern Med 2004; 164:2321.
  44. Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs 2005; 4:198.
  45. Bekelman DB, Rumsfeld JS, Havranek EP, et al. Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients. J Gen Intern Med 2009; 24:592.
  46. Brater DC. Diuretic therapy. N Engl J Med 1998; 339:387.
  47. Vargo DL, Kramer WG, Black PK, et al. Bioavailability, pharmacokinetics, and pharmacodynamics of torsemide and furosemide in patients with congestive heart failure. Clin Pharmacol Ther 1995; 57:601.
  48. Murray MD, Deer MM, Ferguson JA, et al. Open-label randomized trial of torsemide compared with furosemide therapy for patients with heart failure. Am J Med 2001; 111:513.
  49. Müller K, Gamba G, Jaquet F, Hess B. Torasemide vs. furosemide in primary care patients with chronic heart failure NYHA II to IV--efficacy and quality of life. Eur J Heart Fail 2003; 5:793.
  50. Wargo KA, Banta WM. A comprehensive review of the loop diuretics: should furosemide be first line? Ann Pharmacother 2009; 43:1836.
  51. Beattie JM, Johnson MJ. Subcutaneous furosemide in advanced heart failure: has clinical practice run ahead of the evidence base? BMJ Support Palliat Care 2012; 2:5.
  52. Verma AK, da Silva JH, Kuhl DR. Diuretic effects of subcutaneous furosemide in human volunteers: a randomized pilot study. Ann Pharmacother 2004; 38:544.
  53. Zacharias H, Raw J, Nunn A, et al. Is there a role for subcutaneous furosemide in the community and hospice management of end-stage heart failure? Palliat Med 2011; 25:658.
  54. Zatarain-Nicolás E, López-Díaz J, de la Fuente-Galán L, et al. Subcutaneous Infusion of Furosemide Administered by Elastomeric Pumps for Decompensated Heart Failure Treatment: Initial Experience. Rev Esp Cardiol 2013; 66:1002.
  55. Hershberger RE, Nauman D, Walker TL, et al. Care processes and clinical outcomes of continuous outpatient support with inotropes (COSI) in patients with refractory endstage heart failure. J Card Fail 2003; 9:180.
  56. Evangelista LS, Moser DK, Westlake C, et al. Correlates of fatigue in patients with heart failure. Prog Cardiovasc Nurs 2008; 23:12.
  57. Colín Ramírez E, Castillo Martínez L, Orea Tejeda A, et al. Effects of a nutritional intervention on body composition, clinical status, and quality of life in patients with heart failure. Nutrition 2004; 20:890.
  58. Mancini DM, Katz SD, Lang CC, et al. Effect of erythropoietin on exercise capacity in patients with moderate to severe chronic heart failure. Circulation 2003; 107:294.
  59. Williams SG, Wright DJ, Marshall P, et al. Safety and potential benefits of low dose diamorphine during exercise in patients with chronic heart failure. Heart 2003; 89:1085.
  60. Notarius CF, Morris B, Floras JS. Caffeine prolongs exercise duration in heart failure. J Card Fail 2006; 12:220.
  61. Bitar F, Akhter MW, Khan S, et al. Survey of the use of organic nitrates for the treatment of chronic congestive heart failure in the United States. Am J Cardiol 2004; 94:1465.
  62. Bradley TD, Logan AG, Kimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005; 353:2025.
  63. Arzt M, Bradley TD. Treatment of sleep apnea in heart failure. Am J Respir Crit Care Med 2006; 173:1300.
  64. Beniaminovitz A, Lang CC, LaManca J, Mancini DM. Selective low-level leg muscle training alleviates dyspnea in patients with heart failure. J Am Coll Cardiol 2002; 40:1602.
  65. Johnson MJ, McDonagh TA, Harkness A, et al. Morphine for the relief of breathlessness in patients with chronic heart failure--a pilot study. Eur J Heart Fail 2002; 4:753.
  66. Chua TP, Harrington D, Ponikowski P, et al. Effects of dihydrocodeine on chemosensitivity and exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol 1997; 29:147.
  67. Levenson JW, McCarthy EP, Lynn J, et al. The last six months of life for patients with congestive heart failure. J Am Geriatr Soc 2000; 48:S101.
  68. Weiss SC, Emanuel LL, Fairclough DL, Emanuel EJ. Understanding the experience of pain in terminally ill patients. Lancet 2001; 357:1311.
  69. Goldberg SH, Von Feldt JM, Lonner JH. Pharmacologic therapy for osteoarthritis. Am J Orthop (Belle Mead NJ) 2002; 31:673.
  70. Anker SD, Negassa A, Coats AJ, et al. Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study. Lancet 2003; 361:1077.
  71. Nordgren L, Sörensen S. Symptoms experienced in the last six months of life in patients with end-stage heart failure. Eur J Cardiovasc Nurs 2003; 2:213.
  72. Opasich C, Gualco A, De Feo S, et al. Physical and emotional symptom burden of patients with end-stage heart failure: what to measure, how and why. J Cardiovasc Med (Hagerstown) 2008; 9:1104.
  73. De Smedt RH, Denig P, Haaijer-Ruskamp FM, Jaarsma T. Perceived medication adverse effects and coping strategies reported by chronic heart failure patients. Int J Clin Pract 2009; 63:233.
  74. Hafermann MJ, Namdar R, Seibold GE, Page RL 2nd. Effect of intravenous ondansetron on QT interval prolongation in patients with cardiovascular disease and additional risk factors for torsades: a prospective, observational study. Drug Healthc Patient Saf 2011; 3:53.
  75. Siddique SM, Shariff N, Vesuwala N, Hafiz T. Metoclopramide as a possible cause of prolonged QT syndrome and torsade de pointes in a patient with heart failure and renal insufficiency. Ann Intern Med 2009; 150:502.
  76. Claassen S, Zünkler BJ. Comparison of the effects of metoclopramide and domperidone on HERG channels. Pharmacology 2005; 74:31.
  77. Alvelos M, Ferreira A, Bettencourt P, et al. Effect of saline load and metoclopramide on the renal dopaminergic system in patients with heart failure and healthy controls. J Cardiovasc Pharmacol 2005; 45:197.
  78. Gillilan, R, Puchalski, C. Spiritual issues in heart failure. In: Supportive Care in Heart Failure, Beattie, J, Goodlin, S (Eds), Oxford University Press, Oxford 2008. p.299.
  79. Murray SA, Kendall M, Boyd K, et al. Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliat Med 2004; 18:39.
  80. Horne G, Payne S. Removing the boundaries: palliative care for patients with heart failure. Palliat Med 2004; 18:291.
  81. Doering LV, Dracup K, Caldwell MA, et al. Is coping style linked to emotional states in heart failure patients? J Card Fail 2004; 10:344.
  82. Cowan DS, Hatfield K. Support in Heart Failure Care. In: Supportive Care in Heart Failure, Beattie J, Goodlin SJ (Eds), Oxford University Press, 2008.
  83. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 2000; 3:129.
  84. Sullivan M, Levy WC, Russo JE, Spertus JA. Depression and health status in patients with advanced heart failure: a prospective study in tertiary care. J Card Fail 2004; 10:390.
  85. Goodlin SJ. Sadness in heart failure: what is a clinician to do? J Am Coll Cardiol 2010; 56:700.
  86. Gottlieb SS, Kop WJ, Thomas SA, et al. A double-blind placebo-controlled pilot study of controlled-release paroxetine on depression and quality of life in chronic heart failure. Am Heart J 2007; 153:868.
  87. O'Connor CM, Jiang W, Kuchibhatla M, 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; 56:692.
  88. Bekelman DB, Sullivan M. Depression and Anxiety in Patients with Chronic Heart Failure. In: Supportive Care in Heart Failure, Beattie J, Goodlin SJ (Eds), Oxford University Press, 2008.
  89. Kirby D, Ames D. Hyponatraemia and selective serotonin re-uptake inhibitors in elderly patients. Int J Geriatr Psychiatry 2001; 16:484.
  90. Goldstein N, Carlson M, Livote E, Kutner JS. Brief communication: Management of implantable cardioverter-defibrillators in hospice: A nationwide survey. Ann Intern Med 2010; 152:296.
  91. Stuart, B, Alexander, C, Arenella, C, et al for Standards and Accreditation Committee, Medical Guidelines Task Force. Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. Arlington, VA: National Hospice Organization, 1996.
  92. Setoguchi S, Glynn RJ, Stedman M, et al. Hospice, opiates, and acute care service use among the elderly before death from heart failure or cancer. Am Heart J 2010; 160:139.
  93. Unroe KT, Greiner MA, Hernandez AF, et al. Resource use in the last 6 months of life among medicare beneficiaries with heart failure, 2000-2007. Arch Intern Med 2011; 171:196.
  94. Hauptman PJ, Goodlin SJ, Lopatin M, et al. Characteristics of patients hospitalized with acute decompensated heart failure who are referred for hospice care. Arch Intern Med 2007; 167:1990.
  95. Wingate S, Bain KT, Goodlin SJ. Availability of data when heart failure patients are admitted to hospice. Congest Heart Fail 2011; 17:303.