End-of-life discussions in advanced heart failure

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/).

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