End-of-Life Care for End-stage Heart Failure Patients

Abstract

Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.

Keywords: End of life; Heart failure; Palliative care.

Figure 1. Integrating palliative care and end-of-life care across heart failure disease trajectory. Integrating palliative care, including EOL care, into heart failure management across the whole disease trajectory is clearly challenging. Ideally, it should include symptom control for QOL, ACP, family and informal caregiver support (including bereavement), and trying to ensure a good death. This figure shows 1) transition timing for EOL care and 2) a method for patient-centered EOL care through a multidisciplinary team approach.

ACP = advanced care planning; CHF = congestive heart failure; EOL = end of life; GDMT = guideline-derived medical treatment; QOL = quality of life.

Figure 2. Main symptoms presented in heart-failure patients at the end of life and suggested mechanisms. Regardless of etiology, heart failure is characterized by neurohormonal derangement and a pro-inflammatory state, resulting in muscle remodeling/myopathy and a catabolic state. These neurohormonal and cytokine alterations result in respiratory and skeletal muscle atrophy and weakness, which contribute to symptoms of dyspnea, (anticipatory) anxiety, fatigue, and frailty. The activation of the ergoreflex in muscle affects the increased ventilator response to exercise. A catabolic state and related physical deconditioning result in dyspnea, fatigue, anorexia, and cachexia. Overt pulmonary congestion, volume overload, and increased left ventricular filling pressure are associated with dyspnea. Sleep-disordered breathing contributes to daytime fatigue. Comorbidities can also contribute to the symptom spectrum in heart failure.

COPD = chronic obstructive pulmonary disease; RAAS = renin-angiotensin-aldosterone system; TNF = tumor necrosis factor.