Shared Decision Making and Effective Communication in Heart Failure-Moving from "Code Status" to Decisional Readiness

Despite advances in treatment options, heart failure (HF) remains a progressive, symptomatic, and terminal disease for a large number of patients. The need for enhanced discussions regarding prognosis and goals of care has been recognised by multiple professional societies and public health policy, yet these conversations rarely occur in a timely manner. Shared decision making (SDM) is the process through which clinicians and patients work toward treatment decisions that are aligned with the patients' values, goals, and preferences. SDM is especially appropriate when treatments carry an uncertain benefit and potential risk, and it emphasises the fact that neither medical evidence nor patient values alone can determine the best treatment for a patient. The foundation of these discussions should focus on a general understanding of disease trajectory and prognosis, with a clear acknowledgment of prognostic uncertainty. These discussions should include not only the risks of death but also the potential burden of worsening symptoms and decreased quality of life. The goal of these discussions should not be to rule in or rule out specific therapies in a future hypothetical scenario, but instead to prepare our patients and their loved ones to make "in-the-moment" treatment decisions when faced with an acute decompensation, taking into context the state of their illness at that time.