Integrating palliative care into routine care of patients with heart failure: models for clinical collaboration


Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF.

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  1. 1.

    Whellan DJ, Goodlin SJ, Dickinson MG et al (2014) End-of-life care in patients with heart failure. J Cardiac Fail 20(2):121–134

    Article  Google Scholar 

  2. 2.

    Blinderman CD, Homel P, Billings JA et al (2008) Symptom distress and quality of life in patients with advanced congestive heart failure. J Pain Symptom Manag 35(6):594–603

    Article  Google Scholar 

  3. 3.

    Lynn J, Teno JM, Phillips RS et al (1997) Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med 126(2):97–106

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Bekelman DB, Havranek EP, Becker DM et al (2007) Symptoms, depression, and quality of life in patients with heart failure. J Cardiac Fail 13(8):643–668

    Article  Google Scholar 

  5. 5.

    Bekelman DB, Rumsfeld JS, Havranek EP et al (2009) Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients. J Gen Intern Med 24(5):592–598

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Gadoud A, Kane E, Macleoud U et al (2014) Palliative care among heart failure patients in primary care: a comparison to cancer patients using English family practice data. PLoS One 9(11):e113188

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Setoguchi S, Glynn RJ, Stedman M et al (2010) Hospice, opiates, and acute care utilization among the elderly prior to death from heart failure or cancer. Am Heart J 160(1):139–144

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Bakitas M, MacMartin M, Trzepkowski K et al (2013) Palliative care consultations for heart failure patients: how many, when, and why? J Cardiac Fail 19(3):193–201

    Article  Google Scholar 

  9. 9.

    Institute of Medicine Committee on Approaching Death (2015) Dying in America: improving quality and honoring individual preferences near the end of life. National Academies Press. doi:10.17226/18748

  10. 10.

    Tulsky JA (2015) Improving quality of care for serious illness: findings and recommendations of the Institute of Medicine report on dying in America. JAMA Intern Med 175(5):840–841

    Article  PubMed  Google Scholar 

  11. 11.

    McIlvennan CK, Allen LA (2016) Palliative care in patients with heart failure. BMJ 353:i1010

    Article  PubMed  Google Scholar 

  12. 12.

    Meyers DE, Goodlin SJ (2016) End-of-life decisions and palliative care in advanced heart failure. Can J Cardiol 32(9):1148–1156

    Article  PubMed  Google Scholar 

  13. 13.

    Teuteberg JJ, Teuteberg WG (2016) Palliative care for patients with heart failure. JACC.

  14. 14.

    Lindenfeld J, Alber NM, Boehmer JP et al (2010) HFSA 2010 comprehensive heart failure practice guideline. J Card Fail 16(6):e1–194

    Article  PubMed  Google Scholar 

  15. 15.

    McMurray JJ, Adamopoulous S, Anker SD et al (2012) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. E Heart J 33:1787–1847

    Article  Google Scholar 

  16. 16.

    Feldman D, Pamboukian SV, Teuteberg JJ et al (2013) The 2013 international society for heart and lung transplantation guidelines for mechanical circulatory support: executive summary. J Heart lung Transplant 32(2):157–187

    Article  PubMed  Google Scholar 

  17. 17.

    Yancy CW, Jessup M, Bozkurt B et al (2013) 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol 62(16):e147–e239

    Article  PubMed  Google Scholar 

  18. 18.

    Nishimura RA, Otto CM, Bonow RO et al (2014) 2014 AHA/ACC guidelines for the management of patients with valvular heart disease: a report of the American college of cardiology/american heart association task force on practice guidelines. Circ 129:e521–e643

    Article  Google Scholar 

  19. 19.

    Allen LA, Stevenson LW, Grady KL et al (2012) Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 125:1928–1952

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Fang JC, Ewald GA, Allen LA et al (2015) Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee. J Cardiac Fail 21:519–534

    Article  Google Scholar 

  21. 21.

    Centers for Medicare & Medicaid Services. Decision Memorandum for Ventricular Assist Devices. Administrative File: CAG-00432R. Available from: Accessed 20 May 2016

  22. 22.

    The Joint Commission. Ventricular Assist Device Destination Therapy Requirements. February 2014. Available from: Accessed 02 July 2016

  23. 23.

    Goldstein NE, May CW, Meier DE (2011) Comprehensive care for mechanical circulatory support: a new frontier for synergy with palliative care. Circ Heart Fail 4(4):519–527

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Swetz KM, Freeman MR, AbouEzzeddine OF et al (2011) Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist device as destination therapy. Mayo Clini Proc 86(6):493–500

    Article  Google Scholar 

  25. 25.

    Park SJ, Milano CA, Tatooles AJ et al (2012) Outcomes in advanced heart failure patients with left ventricular assist devices for destination therapy. Circ Heart Fail. 5:241–248

    Article  PubMed  Google Scholar 

  26. 26.

    Jorde UP, Kushwaha SS, Tatooles AJ et al (2014) Results of the destination therapy post-food and drug administration approval study with continuous flow left ventricular assist device. JACC 63(17):1751–1757

    Article  PubMed  Google Scholar 

  27. 27.

    Slaughter MS, Rogers JG, Milano CA et al (2013) Advanced heart failure treated with continuous-flow left ventricular assist device. NEJM 361(23):2241–2251

    Article  Google Scholar 

  28. 28.

    Stevenson LW (2015) Crisis awaiting heart transplantation: sinking the lifeboat. JAMA Intern Med 175(8):1406–1409

    Article  PubMed  Google Scholar 

  29. 29.

    Teuteberg W, Maurer M (2016) Palliative care throughout the journey of life with a left ventricular assist device. Circ Heart Fail 9:e003564

    Article  PubMed  Google Scholar 

  30. 30.

    Sidebottom AB, Jorgenson A, Richards H et al (2015) Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial. J Palliat Med 16(2):134–142

    Article  Google Scholar 

  31. 31.

    Bekelman DB, Nowels CT, Allen LA et al (2011) Outpatient palliative care for chronic heart failure: a case series. J Palliat Med 14(7):815–821

    Article  PubMed  Google Scholar 

  32. 32.

    Evangelista LS, Faan F, Lombardo D et al (2012) Examining the effects of an outpatient palliative care consultation on symptom burden, depression, and quality of life in patients with symptomatic heart failure. J Cardiac Fail 18(12):894–899

    Article  Google Scholar 

  33. 33.

    Bekelman DB, Hooker S, Nowels CT et al (2014) Feasibility and acceptability of a collaborative care intervention to improve symptoms and quality of life in chronic heart failure: mixed methods pilot trial. J Palliat Med 17(2):145–151

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Dionne-Odom JN, Kono A, Frost J et al (2014) Translating and testing the ENABLE: CHF-PC concurrent palliative care model for older adults with heart failure and their family caregivers. J Palliat Med 17(9):995–1004

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Wong FK, Ng AY, Lee PH et al (2016) Effects of a transitional palliative care model on patients with end-stage heart failure: a randomized controlled trial. Heart 102(14):1100–1108

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Brannstrom M, Boman K (2014) Effect of person-centred and integrated chronic heart failure and palliative home care. PREFER: a randomized controlled study. Eur J of Heart Fail 16:1142–1151

    Article  Google Scholar 

  37. 37.

    O’Connor NR, Moyer ME, Kirkpatrick JN (2016) Scripted nurse visits: a resource-efficient palliative care model for ventricular assist devices. J Palliat Med. doi:10.1089/jpm.2016.0065

    Google Scholar 

  38. 38.

    Jorgenson A, Sidebottom AC, Richards H, Kirven J (2015) A description of inpatient palliative care actions for patients with acute heart failure. Am J Hosp Palliat Care. doi:10.1177/1049909115593064

    PubMed  Google Scholar 

  39. 39.

    Thompson JS, Matlock DD, McIlvennan CK et al (2015) Development of a decision aid for patients with advanced heart failure considering a destination therapy left ventricular assist device. JACC Heart Fail 3(12):965–976

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    El-Jawahri A, Paasche-orlow MK, Matlock D et al (2016) Randomized controlled trial of an advance care planning video decision support tool for patients with advanced heart failure. Circulation 134(1):52–60

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Jackson VA, Jacobsen J, Greer JA et al (2013) The cultivation of prognostic awareness through the provision of early palliative care in the ambulatory setting: a communication guide. J Palliat Med 16(8):894–900

    Article  PubMed  Google Scholar 

  42. 42.

    Sagin A, Kirkpatrick JN, Pisani BA et al (2016) Emerging collaboration between palliative care specialists and mechanical circulatory support teams: a qualitative study. J Pain Symptom Manag. doi:10.1016/j.jpainsymman.2016.03.017

    Google Scholar 

  43. 43.

    Ben Gal T, Jaarsma T (2013) Self-care and communication issues at the end of life of recipients of a left ventricular assist device as destination therapy. Curr Opin Support Palliat Care 7(1):29–35

    Article  PubMed  Google Scholar 

  44. 44.

    Murray MA, Osaki S, Edwards NM et al (2009) Multidisciplinary approach decreases length of stay and reduces cost for ventricular assist device therapy. Interact Cardiovasc Thorac Surg 8(1):84–88

    Article  PubMed  Google Scholar 

  45. 45.

    Munoz-Mendoza J (2015) Competencies in palliative care for cardiology fellows. JACC 65(7):750–752

    Article  PubMed  Google Scholar 

  46. 46.

    Thoonsen B, Groot M, Verhagen S, van Weel C, Vissers K, Engels Y (2016) Timely identification of palliative patients and anticipatory care planning by GPs: practical application of tools and a training programme. BMC Pall Care 15:39

    Article  Google Scholar 

  47. 47.

    Mentz RJ, Tulsky JA, Granger BB et al (2014) The palliative care in heart failure trial: rationale and design. Am Heart J 168(5):645–651

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Rogers JG, Patel CB, Mentz RJ, et al. (2016) Palliative care in the management of heart failure: primary results of the PAL-HF trial. J Cardiac Fail. November 2016. In press

  49. 49.

    O’Donnell A, Schaefer KG, Stevenson LW, Mehra MR, Desai AS (2016) Oral Abstract: A Randomized Controlled Trial of a Social Worker-Aided Palliative Care Intervention in High Risk Patients with Heart Failure (SWAP-HF). Orlando: Heart Failure Society of America Annual Scientific Meeting

  50. 50.

    Kelemen AM, Ruiz G, Groninger H (2016) Choosing words wisely in communication with patients with heart failure and families. Am J Cardiol 117(11):1779–1782

    Article  PubMed  Google Scholar 

  51. 51.

    Berlacher K, Teuteberg W, Reitschuler-Cross E, Arnold RM (2015) Oral Abstract: CardioTalk: The Future of Communication Training in Cardiovascular Medicine. San Diego: American College of Cardiology 65th Annual Scientific Session

  52. 52.

    Stewart GC, Kittleson MM, Patel PC et al (2016) INTERMACS (interagency registry for mechanically assisted circulatory support) profiling identifies ambulatory patients at high risk on medical therapy after hospitalizations for heart failure. Circ Heart Fail 9:e003032

    Article  PubMed  Google Scholar 

  53. 53.

    Enguidanos S, Vesper E, Lorenz K (2012) 30-day readmissions among seriously ill older adults. J Palliat Medicine 15(12):1356–1361

    Article  Google Scholar 

  54. 54.

    Quill TE, Abernathy AP (2013) Generalist plus specialist palliative care—creating a more sustainable model. NEJM 368(13):1173–1175

    CAS  Article  PubMed  Google Scholar 

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Correspondence to Warren H. Lewin.

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Lewin, W.H., Schaefer, K.G. Integrating palliative care into routine care of patients with heart failure: models for clinical collaboration. Heart Fail Rev 22, 517–524 (2017).

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  • Palliative care
  • Supportive cardiology
  • Early palliative care
  • Models of care