End-of-life matters in chronic heart failure patients

Until recently, concepts of care for people with heart failure had rarely included preparation for unavoidable imminent death or caring for the dying.The purpose of this review is to provide an update on current end-of-life issues specific to heart failure patients.

Mortality in the heart failure population remains high, especially shortly after the first acute heart failure hospitalization. Patients with systolic heart failure die more frequently from progressive heart failure or sudden cardiac death; patients with diastolic heart failure for noncardiovascular reasons and sudden cardiac death. The mode of haemodynamic decline leading to heart failure death can be characterised by low cardiac output (with or without secondary end-organ dysfunction), congestion, or a combination of both. A new model of end-of-life trajectories has been proposed which takes into account influence of comorbidities on the prognosis of heart failure. Advance care planning for patients with implanted cardiac devices has been shown to be unsatisfactory. A recent strategy for managing implantable cardioverter defibrillators in patients approaching death is presented.

There is an emerging need to define specific challenges for end-of-life care for approaching death in heart failure patients. More research and education are needed to improve care for dying heart failure patients, including those with implanted cardiac devices.