Clinical question
When and how should I start end-of-life (EOL) discussions with older patients with advanced heart failure (HF)?
Bottom line
Guidelines recommend discussing goals of care (GOC) and EOL issues with patients with advanced HF1; and, as specialists do not consistently do this, primary care providers are often left with this critical role.
Evidence
The defining features of HF in older persons are complexity and comorbidities. Patients with HF older than age 75 have on average more than 5 concurrent chronic conditions, including a 2-fold increased risk of dementia.2,3 Therefore, HF been referred to as a cardiogeriatric syndrome.4
A Canadian study of older patients discharged from hospital found mortality rates of 17% and 27% at 6 and 12 months, respectively.5 Using criteria for advanced HF, mortality can be as high as 75% at 1 year.6 There is a clear need for advance care planning and GOC and EOL discussions, as well as a palliative care approach.
Approach
First we need to recognize when patients have developed advanced or end-stage HF; its presentation can be non-specific and includes fatigue, anorexia, and delirium.7 It is characterized by severe and nonreversible HF symptoms despite optimal therapy. An excellent review of advanced (or stage D) HF is available,6 and Box 1 lists markers of the disease6 but presents only a partial picture focused on 1 system. To learn how to factor in other comorbidities, read “An approach to management of advanced heart failure in the older person.”8 Another useful resource for prognostication is ePrognosis (https://eprognosis.ucsf.edu/).
Indicators of advanced HF
Repeat (≥ 2) hospitalizations or ED visits for HF in past year
Progressive deterioration in renal function (eg, rise in blood urea nitrogen and creatinine levels)
Weight loss without other cause (eg, cardiac cachexia)
Intolerance of ACEI due to hypotension or worsening renal function
Intolerance of β-blockers because of worsening HF or hypotension
Frequent SBP of < 90 mm Hg
Persistent dyspnea with activities (eg, dressing, bathing) requiring rest
Inability to walk 1 block on level ground owing to dyspnea or fatigue
Need to escalate diuretics to maintain volume status—often reaching daily furosemide equivalent dose of > 160 mg or use of supplemental metolazone therapy
Progressive decline in serum sodium, usually < 133 mEq/L
Frequent implantable cardioverter defibrillator shocks
ACEI—angiotensin-converting enzyme inhibitor, ED—emergency department, HF—heart failure, SBP—systolic blood pressure. Data from Fang et al.6
Ideally, the cardiologist provides prognosis based on cardiac factors and device-based therapy, while the primary care provider, knowing the patient and family best, discusses prognosis in the broader context of the whole patient.
Implementation
Once advanced HF is recognized, the Serious Illness Communication Guide (www.ariadnelabs.org/areas-of-work/serious-illness-care) can assist with productive discussions. Four questions can help structure a discussion: Does the patient know his or her prognosis? What does the patient want to achieve in the time that is left? What is his or her biggest fear for what lies ahead? What is the patient willing to sacrifice for the possibility of more time? Another useful resource for GOC discussions is the Speak Up website (www.advancecareplanning.ca). To learn more about the nuances of advance care planning in different provinces and territories, read “Facilitating effective end-of-life communication—helping people decide.”9
Notes
Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.
Footnotes
Competing interests
None declared
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