End-of-life care for elderly patients with heart failure

The mortality rate of elderly persons with heart failure is high despite the introduction of several effective therapeutic interventions during the past decade. The management of end of life, often associated with distressing symptoms and multiple hospitalizations, is a significant clinical problem. Skillful and effective management requires expert knowledge of the heart failure syndrome, but the critical dimension of care relates to detailed knowledge about a patient's comorbidities, extent of debility, values, and desires. Discussing end-of-life issues early in the course of illness is essential for determining the appropriate levels of intensity of care and for defining the circumstances in which patients wish to be hospitalized and when hospital care offers little potential for increased comfort or longevity. Early and repeated discussions are needed to consider matters such as living wills, do-not-resuscitate orders, and power of attorney. In light of the complexity of the health care system, including involvement of multiple caregivers, end-of-life issues are among the most demanding of a physician's time, but when end-of-life care is managed effectively, health care providers often are rewarded with the gratitude of patients and their families for minimizing suffering and providing optimal opportunities for patients to participate in the affairs of family and the community.