Chapter 13 Heart FailureEnd-of-life considerations
Recommendations
Class I
1 Ongoing patient and family education regarding
prognosis for functional capacity and survival is rec-
ommended for patients with HF at the end of life.
(Level of Evidence: C)
2 Patient and family education about options for
formulating and implementing advance directives
and the role of palliative and hospice care services
with re-evaluation for changing clinical status is rec-
ommended for patients with HF at the end of life.
(Level of Evidence: C)
3 Discussion is recommended regarding the option
of inactivating ICDs for patients with HF at the end
of life. (Level of Evidence: C)
4 It is important to ensure continuity of medical
care between inpatient and outpatient settings
for patients with HF at the end of life. (Level of
Evidence: C)
5 Components of hospice care that are appropriate
to the relief of suffering, including opiates, are rec-
ommended and do not preclude the options for use
of inotropes and intravenous diuretics for symptom
palliation for patients with HF at the end of life.
(Level of Evidence: C)
6 All professionals working with HF patients should
examine current end-of-life processes and work
toward improvement in approaches to palliation
and end-of-life care. (Level of Evidence: C)
Class III
Aggressive procedures performed within the fi nal
days of life (including intubation and implantation
of a cardioverter-defi brillator in patients with NYHA
functional class IV symptoms who are not antici-
pated to experience clinical improvement from
available treatments) are not appropriate. (Level of
Evidence: C)
Performance measures and standards
Simultaneous to the publication of the ACC/AHA
Guidelines for the management of chronic heart
failure, the ACC/AHA published a comprehensive
set of performance measures for both the inpatient
and outpatient care of heart failure patients [2].
Tables 13.4 and 13.5 outline the key recommenda-
tions. Likewise, a resource for data standards has
also become available, so that common terminology
in databases and registries might be attained
[3].A comparison of the ACC/AHA Guidelines
with other recommendations
The recent proliferation of heart failure guidelines
has prompted an inevitable comparison between the
recommendations found in one set with that in
another [4]. Table 13.6 depicts a brief comparison
between recently published guidelines. Fortunately,
some fundamental commonalities exist among the
guidelines for low ejection fraction heart failure.
These commonalities include a mandated trial of
ACE inhibitors and beta-blockers for all patients;
however, even this consensus is lessened somewhat
by the details discussed in the individual guidelines
with respect to issues such as which beta-blockers
should be used or the symptomatic status of the
patient with systolic dysfunction.
What are the reasons for the lack of uniformity
between heart failure guidelines? Presumably, every-
one has access to the same clinical trial publications.
In a thoughtful editorial by McMurray and Swed-
berg, both of whom are prominent heart failure
clinicians and trialists, several potential diffi culties
that face guideline writing committees were dis-
cussed. One major source of interpretive discrepan-
cies is the increasing use of composite endpoints in
heart failure trials. A new therapy, “Drug X,” may
reach a statistically signifi cant outcome in a multi-
center trial but only on the basis of a decrease in
heart failure hospitalizations while no apparent
effect on mortality is noted. Each guideline commit-
tee must then decide how to incorporate Drug X
into its patient care recommendations.
Another source for the lack of uniformity between
guidelines is the increasing complexity of a heart
failure regimen upon which new therapies must be
added. For example, several important trials have
examined the morbidity and mortality effect
of an additional investigational treatment onto a
baseline regimen of diuretics, beta-blockers, and
ACE-inhibitors in symptomatic patients. These
trials have explored interventions with ARBs,
aldosterone antagonists, implantable defi brillators
(ICDs), cardiac resynchronization, and a specially