Better Care for Your Heart Failure Patients

Patients and families want clarity and honesty

Ongoing communication with the heart failure patient and their family should be a critical component of their care. No patient or family member wants to be caught off guard or taken by surprise by a terminal diagnosis when they may only have weeks left to live. The patient and family may be very aware of the appropriate care for symptomatic heart failure, but they may not have an understanding of when a prognosis tips from chronic into terminal.

In addition to years of close cardiology follow up, guideline directed medical management, device implantation, and perhaps even heart transplant, the patient and family may harbor a belief that there is “one more thing to try”. This can often be fueled by not knowing the full disease trajectory or understanding all of their care options.

How do we know when it’s time to talk comfort instead of cure?

Although prognostication is challenging in heart failure patients given the unpredictable nature of the disease, there are a few milestones in the care of the chronic heart failure patients that may be signs that it’s time to open up the discussion of long-term prognosis and advance directives.

Milestones that indicate declining heart function:

• ICD implantation or battery change
• VAD discussion and implantation
• VAD re-hospitalization
• High risk PTCA / CABG / Valve surgery
• Transplant discussion and surgery
• Transplant re-hospitalization   
• TAVR / Mitral Clip
• Home inotropic therapy

Patients are considered to be in the terminal end stage of heart disease when they have a life expectancy of six months or less and doctors make the clinical determination that they have a primary diagnosis of congestive heart failure. Consideration of hospice eligibility using prognostic indicators may allow patients to reap the benefits of such care earlier than many currently do, thereby increasing needed support both for the management of physical symptoms to the often unmet practical, emotional, and spiritual concerns of patients and families.

Hospice Eligibility Criteria for Heart Failure Patients

Reference: Palmetto GBA CMS Local Coverage Determination

A knowledgeable hospice partner can create better outcomes for the cardiac patients you might see in your hospital, clinic, or facility. Hospice physicians and nurses can focus on providing the latest guideline-based therapies for end-of-life management of advanced cardiac disease, and education to provide support for patients and families in their home environment. In turn, this can help prevent unnecessary emergency department and hospital readmissions by focusing on symptom control, functional status, and quality of life.

The following American College of Cardiology / Heart Failure Society of America guidelines are considered best practice in taking care of your cardiac patients:

Clinical Care for Class IV Stage D End-Stage Heart Failure

• Guideline medication management and titration as appropriate IV/PO diuretic therapy management
• ICD / LVAD deactivation compatible with patient expectations of care
• IV inotropic therapy
• Emergency symptom management
• Oxygen for comfort and symptom management
• Cardiac Comfort Kit, including IV Furosemide

Starting the hospice conversation before hospice eligibility.

Optimal timing of advance care planning and hospice referral remains elusive for patients with heart failure. Ongoing effective communication between the cardiology team, the patient, and their family is important to ensuring that the care they receive is in alignment with their goals and values.

It takes a willingness to understand the trajectory of the disease, recognize the milestones of decline, and have ongoing meaningful communication with the patient and family about functional ability and quality of life as the disease progresses. These conversations can happen in a variety of care settings from the inpatient hospital, heart failure out-patient clinic and, via telemedicine.

It's important to note that while healthcare professionals might experience discomfort in bringing up hospice care before the patient needs it, it is crucial to familiarize the patient and their family with the concept of hospice well before they are at the 6-month prognosis mark. Fully explaining the options available to a heart failure patient will allow them to:

• More fully consider their goals of care
• Dispel myths around what hospice is and what it provides
• Avoid crisis situations such as re-hospitalizations or emergency room visits for routine care
• Allow them to define what living with their disease should look like, instead of reacting to circumstances in the moment

During Heart Failure Awareness Month, it’s critical to begin thinking about how caring for these patients and their families is a journey of care across a continuum, and how your conversations can facilitate smooth and appropriate transitions.

References:

1. Yancy CW, Jessup M, Bozkurt B. et al. 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 2013;128:e240-e327.
2. Fahlberg B, Panke J. Donaho, E Donaho (Chapter 10) Advanced Heart Failure. Compendium of Nursing Care for Common Serious Illnesses 3rd ed. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2019:16–24.