Heart Disease and Hospice


For practitioners, preventing recurrent patient hospitalizations for exacerbations is a daily challenge. And, most of the staggering cost associated with the care of these patients is attributable to hospitalizations. So, when is it time to consider end-of-life care?

The Heart Failure Society of America has developed extensive guidelines and recommendations for end-of-life care patients experiencing one or more of the following:

    • Frequent hospitalization (3 or more
      per year)
    • Chronic poor quality of life with inability
      to accomplish activities of daily living
    • Need for intermittent or continuous
      intravenous support
    • Consideration of assist devices as
      destination therapy

In an important article published in the Journal of Palliative Medicine, Dr. Brad Stuart suggested criteria for hospice eligibility as follows:

    • Severity of illnesses (severe left
      ventricular dysfunction)
    • Recent clinical progression (eg, 2 or
      more hospital admissions, decline in
      performing activities of daily living, and
      other organ system dysfunction)
    • Evaluation for advanced therapeutic
       options (eg, implanted devices or
       heart transplant)
    • Preference for comfort care over
       life-sustaining treatment

Advance directives and end-of-life care.

Heart failure has a shorter life expectancy than many common cancers; and the mortality rate is high, making advance directives and end-of-life care important issues for patients with this condition.

Discussion of end-of-life care is easier if the patient and family are aware early in the course of care. Some data suggest that patients prefer to be informed about issues related to their disease and its prognosis when they are relatively well. The inclusion of family members/caregivers is important because these patients often suffer from cognitive impairment, functional disabilities, and other conditions that limit their ability to fully comprehend.

In considering these issues, it is important to understand the distinction between advance directives and end-of-life care. Advance directives are legal documents created to identify desired or undesired treatments if an individual becomes incapacitated and incapable of making decisions about care. All patients should be encouraged to have this documentation in place.