Skip to main content

Advertisement

SpringerLink
Log in

End of Life Care in Advanced Heart Failure

  • Valvular, Myocardial, Pericardial, and Cardiopulmonary Diseases
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion Statement

I individualize my approach to each patient based upon their understanding of their disease process, acuity of their progression to Stage D heart failure, clinical setting (hospitalized vs outpatient), and family needs. My first goal is to prove intolerance of traditional therapies for heart failure by challenging patients with various medication combinations, including staggered dosing regimens and alternatives to angiotensin-converting enzyme inhibitors/β-blockers, and by considering cardiac resynchronization therapy if they meet criteria. As patients develop progressive hypotension and side effects from medicines, I often will discontinue these medicines after careful communication. For patients with refractory heart failure, I consider cardiac transplantation for those who are candidates and left ventricular assist device as destination therapy for those who are not transplant candidates, both of which require multidisciplinary input from psychiatrists, social workers, nurses, and cardiac surgeons. If patients are not candidates for these advanced therapies, I try to delineate their goals for living and discuss strategies to maximize their survival (however limited) and increase my focus on their quality of life by minimizing unnecessary testing. For the select patient, I use continuous inotrope support only if this improves their quality of life and possibility of having a meaningful existence outside of the hospital. Palliative care consultants are often involved at this stage. For the patient who is clearly at the end of life, I refer to hospice and focus on comfort. Return ambulatory visits and extent of the care received are guided by the preferences of the patient and their family. When there are disparate views of family members, especially when the patient is not cognitively able to participate in the discussion, I tend to be more paternalistic in my approach to therapeutic options in an attempt to possibly dissipate family dynamic problems occurring after the patient dies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lloyd-Jones D, Adams RJ, Brown TM, et al.: Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation 2010, 121:e46–e215.

    Article  PubMed  Google Scholar 

  2. Lewis EF, Lamas GA, O’Meara E, et al.: Characterization of health-related quality of life in heart failure patients with preserved versus low ejection fraction in CHARM. Eur J Heart Fail 2007, 9:83–91.

    Article  PubMed  Google Scholar 

  3. Hunt SA, Abraham WT, Chin MH, et al.: ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). Developed in Collaboration With the American College of Chest Physicians and the International Society for Heart and Lung Transplantation. Endorsed by the Heart Rhythm Society. Circulation 2005, 112:e154–235.

    Article  PubMed  Google Scholar 

  4. Roger VL, Weston SA, Redfield MM, et al.: Trends in heart failure incidence and survival in a community-based population. JAMA 2004, 292:344–350.

    Article  CAS  PubMed  Google Scholar 

  5. Costanzo MR, Mills RM, Wynne J: Characteristics of “Stage D” heart failure: insights from the Acute Decompensated Heart Failure National Registry Longitudinal Module (ADHERE LM). Am Heart J 2008, 155:339–347.

    Article  PubMed  Google Scholar 

  6. Kittleson M, Hurwitz S, Shah MR, et al.: Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality. J Am Coll Cardiol 2003, 41:2029–2035.

    Article  CAS  PubMed  Google Scholar 

  7. Jessup M, Abraham WT, Casey DE, et al.: 2009 focused update: ACCF/AHA 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, 119:1977–2016.

    Article  PubMed  Google Scholar 

  8. Lindenfeld J, Albert NM, Boehmer JP, et al.: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010, 16:e1–194.

    Article  PubMed  Google Scholar 

  9. Balboni TA, Paulk ME, Balboni MJ, et al.: Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. J Clin Oncol 2010, 28:445–452.

    Article  PubMed  Google Scholar 

  10. Tindle HA, Chang YF, Kuller LH, et al.: Optimism, cynical hostility, and incident coronary heart disease and mortality in the Women’s Health Initiative. Circulation 2009, 120:656–662.

    Article  PubMed  Google Scholar 

  11. Giltay EJ, Geleijnse JM, Zitman FG, et al.: Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly Dutch men and women. Arch Gen Psychiatry 2004, 61:1126–1135.

    Article  PubMed  Google Scholar 

  12. Allison PJ, Guichard C, Fung K, Gilain L: Dispositional optimism predicts survival status 1 year after diagnosis in head and neck cancer patients. J Clin Oncol 2003, 21:543–548.

    Article  PubMed  Google Scholar 

  13. Aaronson KD, Schwartz JS, Chen TM, et al.: Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Circulation 1997, 95:2660–2667.

    CAS  PubMed  Google Scholar 

  14. Stempfle HU, Alt A, Stief J, Siebert U: The Munich score: a clinical index to predict survival in ambulatory patients with chronic heart failure in the era of new medical therapies. J Heart Lung Transplant 2008, 27:222–228.

    Article  PubMed  Google Scholar 

  15. Levy WC, Mozaffarian D, Linker DT, et al.: The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation 2006, 113:1424–1433.

    Article  PubMed  Google Scholar 

  16. Fonarow GC, Adams Jr KF, Abraham WT, et al.: Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 2005, 293:572–580.

    Article  CAS  PubMed  Google Scholar 

  17. 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, 290:2581–2587.

    Article  CAS  PubMed  Google Scholar 

  18. Christakis NA, Lamont EB: Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ 2000, 320:469–472.

    Article  CAS  PubMed  Google Scholar 

  19. Spertus JA: Evolving applications for patient-centered health status measures. Circulation 2008, 118:2103–2110.

    Article  PubMed  Google Scholar 

  20. Vaishnava P, Lewis EF: Assessment of quality of life in severe heart failure. Curr Heart Fail Rep 2007, 4:170–177.

    Article  PubMed  Google Scholar 

  21. Lewis EF, Johnson PA, Johnson W, et al.: Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant 2001, 20:1016–1024.

    Article  CAS  PubMed  Google Scholar 

  22. Stevenson LW, Hellkamp AS, Leier CV, et al.: Changing preferences for survival after hospitalization with advanced heart failure. J Am Coll Cardiol 2008, 52:1702–1708.

    Article  PubMed  Google Scholar 

  23. Hertz MI, Aurora P, Christie JD, et al.: Registry of the International Society for Heart and Lung Transplantation: a quarter century of thoracic transplantation. J Heart Lung Transplant 2008, 27:937–942.

    Article  PubMed  Google Scholar 

  24. Slaughter MS, Rogers JG, Milano CA, et al.: Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009, 361:2241–2251.

    Article  CAS  PubMed  Google Scholar 

  25. Kirklin JK, Naftel DC, Kormos RL, et al.: Second INTERMACS annual report: more than 1, 000 primary left ventricular assist device implants. J Heart Lung Transplant 2010, 29:1–10.

    Article  PubMed  Google Scholar 

  26. Wilson SR, Mudge Jr GH, Stewart GC, Givertz MM: Evaluation for a ventricular assist device: selecting the appropriate candidate. Circulation 2009, 119:2225–2232.

    Article  PubMed  Google Scholar 

  27. Hernandez AF, Shea AM, Milano CA, et al.: Long-term outcomes and costs of ventricular assist devices among Medicare beneficiaries. JAMA 2008, 300:2398–2406.

    Article  CAS  PubMed  Google Scholar 

  28. Metra M, Eichhorn E, Abraham WT, et al.: Effects of low-dose oral enoximone administration on mortality, morbidity, and exercise capacity in patients with advanced heart failure: the randomized, double-blind, placebo-controlled, parallel group ESSENTIAL trials. Eur Heart J 2009, 30:3015–3026.

    Article  CAS  PubMed  Google Scholar 

  29. Yancy CW, Krum H, Massie BM, et al.: Safety and efficacy of outpatient nesiritide in patients with advanced heart failure: results of the Second Follow-Up Serial Infusions of Nesiritide (FUSION II) trial. Circ Heart Fail 2008, 1:9–16.

    Article  CAS  PubMed  Google Scholar 

  30. Bourge RC, Abraham WT, Adamson PB, et al.: Randomized controlled trial of an implantable continuous hemodynamic monitor in patients with advanced heart failure: the COMPASS-HF study. J Am Coll Cardiol 2008, 51:1073–1079.

    Article  PubMed  Google Scholar 

  31. Adler ED, Goldfinger JZ, Kalman J, et al.: Palliative care in the treatment of advanced heart failure. Circulation 2009, 120:2597–2606.

    Article  PubMed  Google Scholar 

  32. 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, 160:139–144.

    Article  PubMed  Google Scholar 

  33. Goodlin SJ: Palliative care in congestive heart failure. J Am Coll Cardiol 2009, 54:386–396.

    Article  PubMed  Google Scholar 

  34. Dracup K: Beyond the patient: caring for families. Commun Nurs Res 2002, 35:53–61.

    PubMed  Google Scholar 

  35. Mark DB, Anstrom KJ, Sun JL, et al.: Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med 2008, 359:999–1008.

    Article  CAS  PubMed  Google Scholar 

  36. Padeletti L, Arnar DO, Boncinelli L, et al.: EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy. Europace 2010, 12(10):1480–1489.

    Google Scholar 

  37. Sherazi S, Daubert JP, Block RC, et al.: Physicians’ preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator. Mayo Clin Proc 2008, 83:1139–1141.

    Article  PubMed  Google Scholar 

  38. Walling AM, Asch SM, Lorenz KA, et al.: The quality of care provided to hospitalized patients at the end of life. Arch Intern Med 2010, 170:1057–1063.

    Article  PubMed  Google Scholar 

  39. Publication Committee for the VMAC Investigators: Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA 2002, 287:1531–1540.

    Google Scholar 

  40. 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, 29:147–152.

    Article  CAS  PubMed  Google Scholar 

  41. Hochgerner M, Fruhwald FM, Strohscheer I: Opioids for symptomatic therapy of dyspnoea in patients with advanced chronic heart failure—is there evidence? Wien Med Wochenschr 2009, 159:577–582.

    Article  PubMed  Google Scholar 

  42. Redline S, Lewis EF: Gravitational influences and shifting propensity for sleep apnea: another source of heterogeneity or a new intervention target? Circulation 2010, 121:1583–1585.

    Article  PubMed  Google Scholar 

  43. Yeh GY, Wood MJ, Lorell BH, et al.: Effects of tai chi mind-body movement therapy on functional status and exercise capacity in patients with chronic heart failure: a randomized controlled trial. Am J Med 2004, 117:541–548.

    Article  PubMed  Google Scholar 

  44. Sullivan MD, Newton K, Hecht J, et al.: Depression and health status in elderly patients with heart failure: a 6-month prospective study in primary care. Am J Geriatr Cardiol 2004, 13:252–260.

    Article  PubMed  Google Scholar 

  45. 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, 56:692–699.

    Article  PubMed  Google Scholar 

  46. Sullivan MJ, Wood L, Terry J, et al.: The Support, Education, and Research in Chronic Heart Failure Study (SEARCH): a mindfulness-based psychoeducational intervention improves depression and clinical symptoms in patients with chronic heart failure. Am Heart J 2009, 157:84–90.

    Article  PubMed  Google Scholar 

  47. Mamdani M, Juurlink DN, Lee DS, et al.: Cyclo-oxygenase-2 inhibitors versus non-selective non-steroidal anti-inflammatory drugs and congestive heart failure outcomes in elderly patients: a population-based cohort study. Lancet 2004, 363:1751–1756.

    Article  CAS  PubMed  Google Scholar 

  48. Konstam MA, Gheorghiade M, Burnett Jr JC, et al.: Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA 2007, 297:1319–1331.

    Article  CAS  PubMed  Google Scholar 

  49. Silveira MJ, Kim SY, Langa KM: Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010, 362:1211–1218.

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosure

Eldrin F. Lewis has received research funding from Amgen, Novartis, Sanofi Aventis, and a consulting fee from Amgen (minor conflict). He has a career development grant from the Robert Wood Johnson Foundation.

Author information

Authors and Affiliations

  1. Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, 02115, USA

    Eldrin F. Lewis MD, MPH

Authors
  1. Eldrin F. Lewis MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eldrin F. Lewis MD, MPH.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lewis, E.F. End of Life Care in Advanced Heart Failure. Curr Treat Options Cardio Med 13, 79–89 (2011). https://doi.org/10.1007/s11936-010-0100-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11936-010-0100-y

Keywords

Search

Navigation