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Palliative care for patients with advanced heart failure: Decision support, symptom management, and psychosocial assistance

Author
Larry Allen, MD, MHS
Section Editors
Sharon A Hunt, MD
R Sean Morrison, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Despite advances in cardiac therapy, heart failure remains a progressive, highly symptomatic, and deadly disease that places great demands on patients, caregivers, clinicians, and health care systems. Palliative care is an interdisciplinary approach to care that focuses on improving quality of life for patients and families facing serious illness. Palliative care has a role across the stages of heart failure, starting early in the course of illness, intensifying in end-stage disease, and extending into caregiver bereavement.

Advance care planning, symptom management, and psychosocial support as components of palliative care for patients with advanced heart failure will be reviewed here. Indications, estimation of prognosis, and strategies for palliative care in patients with advanced heart failure and general management of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction are discussed separately. (See "Palliative care for patients with advanced heart failure: Indications and strategies" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)

DECISION SUPPORT

Advance care directives and preparedness planning

Definitions and timing — Advance care planning for preference-sensitive decisions often arising at the end of life is an ongoing process in which patients, their families, and their health care providers discuss current and future health care choices in the context of what is medically reasonable [1]. The results of such discussions are typically recorded as an advance care directive. (See "Advance care planning and advance directives" and "Discussing goals of care".)

Given the somewhat unpredictable nature of heart failure, advance care planning should ideally begin early in the disease process. For patients with heart failure, advance care directives provide an avenue to express their wishes about a range of life-sustaining treatments, usually to withhold or withdraw, in the event of a terminal condition [2]. For providers of heart failure care, advance care directives can help ensure value-treatment concordant medical decision making, with improved quality of life and death. Patients tend to underestimate disease severity and may defer difficult discussions to the detriment of timely decision making [3]. In a longitudinal study of 608 United States heart failure patients, over half of the patients did not have an advance directive at the time of death [4]. A single-center study showed that involving a social worker who is charged with implementing the Serious Illness Care Program in the inpatient heart failure team increased the number of advance care directives and medical orders for life-sustaining preferences documented in the medical record and improved patient-provider prognostic concordance [5,6].

Preparedness planning encourages earlier completion of advance care directives. Advance care directives have traditionally focused on end-of-life care, while preparedness planning focuses on preparing for any adverse event. The focus of preparedness planning is specific to the individual patient’s situation, and it focuses on respecting patients’ beliefs and preferences [7]. Preparedness planning has been shown to improve attitudes and increase completion of advance care directives in patients with heart failure [8]. The concept of preparedness planning is often combined with a palliative care visit as the first step to the ultimate completion of advance care directives.

                           

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Literature review current through: Jul 2017. | This topic last updated: Mar 07, 2017.
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