Palliative Care in the Treatment of Advanced Heart Failure

Abstract

H eart failure is epidemic in developed countries and is expanding rapidly worldwide. Roughly 5% of patients with heart failure have end-stage disease that is refractory to medical therapy (stage D heart failure). 1 Palliative care consultation relieves symptoms, improves patient satisfaction, and decreases the costs of care for these patients. Despite this, only a small fraction of end-stage heart failure patients receive palliative care consultation. In recognition of this, palliative/hospice care referral was recommended for endstage heart failure (Level of Evidence 1A) in the most recent American College of Cardiology/American Heart Association heart failure guidelines. 2 To identify evidence-based studies of palliative care in heart failure, we searched the Medline database for literature with the medical subject headings "heart failure" and "palliative care," "supportive care," or "symptom management" and found 394 results. We identified 92 systematic reviews, 44 of which were English-language systematic reviews published within the past 5 years.

Palliative care in heart failure: facts and numbers

“…Turning again to data from the UK, the National Heart Failure Audit data from 2013 to 2014 report that only 4% of patients with heart failure were referred to specialist palliative care services, a proportion which has been relatively constant over several years 7. Whilst not significantly different from the earlier reported 5% threshold of need,3 this low referral rate to specialist palliative care services likely represents an under provision of support for these acute heart failure patients who may have particularly complex needs.…”

“…The mode of death for those surviving to develop advanced heart failure is through symptomatic congestion and multi‐organ failure. About 5% of all heart failure patients are considered to have advanced disease with refractory symptoms 7. These patients merit consideration for support from specialist palliative care.…”

Role of Peritoneal Ultrafiltration in Heart Failure Treatment

“…Intravenous inotrope therapy, cardiac resynchronization treatment, mechanical ventilation support, and cardiac transplantation are more aggressive approaches (28).…”

The Changing Landscape – Palliative Care in the Heart Failure Patient Population

“…Hospitalization is an independent risk factor for shortened survival in patients with chronic HF, and is associated with an average life expectancy of approximately two years (Howlett 2011), which is less than that of many cancers. Even as the national death rate decreased by 2% from 1994 to 2004, deaths due to heart failure increased by 28% (Adler et al 2009). …”

“…Although both physicians and patients tend to be wary of opioids, addiction is rare in the terminal patient population (Kanner 2001). For moderate to severe pain, opioids should be used as first-line agents (Adler et al 2009). …”