Download End-of-Life Options for Patients with Advanced Heart Failure

Curr Heart Fail Rep (2010) 7:140–147
DOI 10.1007/s11897-010-0017-5
End-of-Life Options for Patients with Advanced
Heart Failure
Judith Z. Goldfinger & Eric D. Adler
Published online: 30 June 2010
# Springer Science+Business Media, LLC 2010
Abstract Heart failure is a progressive disease with
significant morbidity and mortality, but prognostication
often is difficult. Many of the evidence-based therapies for
heart failure provide symptomatic benefit, but may have
intolerable side effects for patients with advanced disease.
At the end of life, there is evidence of varying strengths for
pharmacologic and nonpharmacologic relief of common
symptoms like dyspnea, fatigue, pain, and depression.
Patients also may benefit from inotropic therapy, ventricular
assist devices, and hospice care. It is important for
physicians to encourage patients to formulate advance
directives, including decisions about do not resuscitate
orders and deactivation of implantable cardioverterdefibrillators and ventricular assist devices.
Keywords Heart failure . Palliative care . Hospice .
Inotropic therapy . Brain natriuretic peptide .
Ventricular assist device .
Implantable cardioverter-defibrillator .
ICD deactivation . Cardiac resynchronization therapy .
Advance directives . Do not resuscitate order
Introduction
Heart failure (HF) currently affects more than 5 million
Americans, and, unlike other forms of cardiovascular
disease, prevalence is rising. After diagnosis, 1-year
mortality is 1 in 5, with a six- to ninefold increased risk
of sudden cardiac death [1]. Roughly 5% of patients with
HF worldwide have end-stage disease that is refractory to
conventional medical management. Only a minority of
these end-stage patients are young enough, healthy enough,
and have the requisite social support to be eligible for a
heart transplant; of those who are eligible, only a fraction
will receive a heart. The patients who continue to live with
HF have worse quality of life and higher rates of
depression, pain, dyspnea, and fatigue [2, 3]. The focus of
this article will be options for patients and their caregivers
to improve the quality of life, as well as the “quality of
death.” Advanced therapies, such as heart transplantation,
may be appropriate for a small selection of patients but are
beyond the scope of this article.
Prognostication: Identification of the End-Stage Patient
J. Z. Goldfinger
Department of Medicine, Mount Sinai Medical Center,
One Gustave L. Levy Place, Box 1118,
New York, NY 10029, USA
E. D. Adler (*)
Cardiovascular Medicine, Oregon Health Sciences University,
3181 Southwest Sam Jackson Park Road,
Portland, OR 97239, USA
e-mail: [email protected]
HF is a progressive chronic disease that is generally
characterized by acute exacerbations superimposed on a
more gradual decline [4]. However, for many patients, the
trajectory of disease takes a more variable pattern.
Because of the variability in disease trajectory, it is
notoriously difficult to prognosticate in HF. Determining
prognosis is critical in establishing when patients may be
appropriate for advanced therapies, such as cardiac transplantation and mechanical circulatory support. Furthermore,
if a physician certifies that a patient has fewer than 6 months
to live and the patient agrees to forego curative or life-
Curr Heart Fail Rep (2010) 7:140–147
prolonging medical treatments, the patient is eligible for the
Medicare hospice benefit, which will cover the costs of care
designed to maximize comfort and symptom control.
Barriers to accurate prognosis can prevent or delay timely
referrals to hospice and also can lead to aggressive, though
futile, care at the end of life.
There are multiple predictive models to assist with
estimating prognosis in HF [5–7]. The Seattle Heart Failure
Model, available with online calculator, can help predict
mortality at 1, 2, and 5 years. Assuming maximal medical
management, other factors that can help physicians predict
an increased likelihood of death include New York Heart
Association (NYHA) class IV HF, frequent emergency
department visits or hospitalizations, functional decline
(Karnofsky score less than 50% or dependency in activities
of daily living), unintended weight loss greater than 10% of
total body weight, albumin less than 2.5 g/dL, severe left
ventricular dysfunction with an ejection fraction less than
20%, symptomatic arrhythmia, prior cardiopulmonary
resuscitation, prior syncope, embolic stroke, and concomitant HIV disease [8, 9]. Persistent elevation of brain
natriuretic peptide also has been associated with a worse
prognosis in advanced disease [10].
Even if patients do not qualify for the Medicare hospice
benefit, they still may benefit from a palliative care consultation in either the inpatient or outpatient setting. Palliative
care is a discipline that aims to relieve suffering, improve
quality of life, and provide support to patients and the family
members or friends who care for them. This requires a holistic
approach that addresses the physical, emotional, spiritual, and
logistical needs of patients and their caregivers. Palliative care
improves outcomes, including increased patient and family
satisfaction with care and improved symptom management, as
well as patient well-being and dignity, communication with
health care providers, emotional and spiritual support for
patients and caregivers, and access to community support
services [11–13].
Symptom Management for End-Stage Heart Failure
At all stages of disease, there are HF therapies both to
decrease mortality and to ameliorate symptoms. Three
classes of drugs, β-blockers [14], angiotensin-converting
enzyme (ACE) inhibitors [15], and aldosterone antagonists
[16], all have been shown to improve symptoms, decrease
hospitalizations, and improve mortality. Digoxin decreases
hospitalizations and may improve symptoms, but thus far
has not been demonstrated to improve mortality [17].
Cardiac resynchronization therapy (CRT), also called
biventricular pacing, is indicated for symptomatic patients
with interventricular conduction delay and an ejection
fraction less than 35%. CRT improves mortality, decreases
141
HF symptoms and hospitalizations, and improves quality of
life [18].
As disease progresses to end stage, patients commonly
develop hypotension and renal disease. Hypotension may
limit the use of β-blockers, ACE inhibitors, and aldosterone
antagonists. Renal failure may limit the use of ACE
inhibitors, aldosterone antagonists, and digoxin. When
patients are admitted to the hospital with an acute
decompensation, these medications are frequently held, or
doses are reduced, because of hypotension or a worsening
creatinine clearance. Often these medications are never
restarted, either appropriately or inappropriately, despite
improvements in blood pressure and renal function during
the hospital stay or after discharge. With advanced HF, it is
important to weigh the symptomatic or palliative benefits of
medications against their adverse effects. For example,
renal failure will limit diuretic use, leading to fluid overload
and consequent dyspnea and fatigue.
There also is a role for nonpharmacologic treatments in
symptom improvement [19]. However, these treatments
rarely have been studied in HF specifically. More often,
data were culled from studies of symptom management in
patients with cancer or, less commonly, patients with
chronic obstructive pulmonary disease (COPD). Here, we
will explore the most common symptoms of HF: dyspnea
(includes fluid retention), fatigue, pain, and depression. We
then will describe the treatments that are supported by
moderate to strong evidence and mention some treatments
that are not evidence based or are contraindicated.
Dyspnea
This is the symptom of HF that is reported most often
and has been studied most extensively. Pathogenesis is
generally multifactorial, and may include volume overload and pulmonary congestion due to poor systolic
function, as well as increased afterload. There is strong
evidence for loop diuretics with or without thiazides in
the management of breathlessness that is due to fluid
retention [20]. Patients who develop increasing levels of
diuretic resistance may benefit from aquapheresis [21].
There also is strong evidence for the use of low-dose
opioids for dyspnea [22]. The doses required typically are a
fraction of the doses required for analgesia, and tolerance to
central nervous system side effects occurs in less than a
week. Strong evidence supports the use of inotropes to
improve perfusion [23]. There also is strong evidence for
afterload reduction with long-acting nitroglycerin formulations such as isosorbide dinitrate, with or without the
vasodilator hydralazine, but use of these medications may
be limited by hypotension [24].
There is moderate strength of evidence for hawthorn
extract [25], breathing training, chest wall vibration, neuro-
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electrical muscle stimulation (extrapolated from studies of
patients with COPD), and walking aids or rollators
(extrapolated from studies of patients with COPD) [26].
There is inadequate or weak evidence for oxygen use in
patients who are not hypoxic [27] and for the use of
benzodiazepines, although they may help with symptoms of
panic associated with dyspnea [26].
Fatigue
Strong evidence supports treating underlying causes of
fatigue, like anemia or infection [28]. There also is strong
evidence for exercise training [29] and pharmacologic
stimulants like methylphenidate [30]. There is moderate
strength of evidence to support oral use of hawthorn extract
[25].
Pain
Strong evidence supports using opioids as first-line agents for
moderate to severe pain of all types [31•]. Bone pain can be
treated with bisphosphonates [31•]. Anginal pain can be
treated with nitrates, ranolazine, or even intracoronary
stenting in patients whose anginal pain does not improve
with pharmacotherapy [32]. Non-steroidal anti-inflammatory
drugs (NSAIDs) should be avoided due to the risk of
gastrointestinal bleeding, renal failure, and fluid retention
[21].
Depression
Depression is common in patients with HF [2]. There is
strong evidence for different categories of antidepressants,
including selective serotonin reuptake inhibitors, serotonin
norepinephrine reuptake inhibitors, and tricyclic antidepressants [3]. There is moderate strength of evidence for
exercise to treat depression [33]. There is only weak
evidence for psychological interventions like cognitive
behavioral therapy, counseling, or supportive therapy [34].
Inotropic Therapy
Inotropic agents, including dopamine, dobutamine, and
milrinone, are effective for treating refractory symptoms
of HF and can decrease hospitalizations. However, these
agents do not improve survival, and actually may increase
mortality [35, 36]. Because of concerns about the increase
in mortality, the American College of Cardiology/American
Heart Association (ACC/AHA) guidelines classify intravenous inotropes as a class IIb indication for patients with
end-stage HF with systolic dysfunction, hypotension, and
low cardiac output or hypoperfusion [1]. Chronic infusions
Curr Heart Fail Rep (2010) 7:140–147
of intravenous inotropes never have been studied in large
randomized controlled trials.
When deciding whether to initiate inotropes, patients and
their family members should be involved in the decisionmaking process and should be informed that benefits are
uncertain, that not all patients will have relief from
congestion or fewer hospitalizations. Risks include sudden
death, complications from the intravenous line, and the
possibility of dependence on inotropic therapy [37].
Though not well studied, patients with defibrillators who
are on inotropes likely will be at an increased risk for
shocks, both appropriate and inappropriate. When patients
are inotrope dependent and cannot be weaned, 1-year
mortality is extremely high [38].
Some hospices, either inpatient or home based, provide
intravenous inotrope therapy; however, cost considerations
prevent many agencies from providing them [39]. In a
recent study, both dobutamine and milrinone were associated with decrease in hospitalizations; dobutamine was
overall cost saving at 1 year, while milrinone was
significantly more costly than standard therapy [36].
Hospice
Hospice provides relief from pain and other symptoms, as
well as spiritual and emotional support to patients and
caregivers, either at home or in a homelike setting in a
hospice program. Late referrals to hospice correlate with
decreased family satisfaction, less satisfaction with hospice
services, more unmet needs, lack of awareness about what
to expect at time of death, and more concerns with
coordination of care [40]. Hospice also leads to cost
savings. Specifically, for patients with HF, enrollment in
hospice resulted in a reduction in mean Medicare cost per
patient from $53,528 to $46,792.37 [41]. This cost saving
occurs despite the relatively short time most patients are in
hospice. The mean length of stay is only about 2 months,
and median length of stay was 20 days [42].
HF is the second most common hospice diagnosis
(cancer is first). Cancer accounts for less than a quarter of
the deaths each year in the United States, but cancer
patients make up close to half of hospice patients. Patients
with HF account for 11% to 12% of hospice patients [43,
44•]. Both patient factors and hospital factors are associated
with likelihood of referral to hospice. Patients who were
referred to hospice were older, had been admitted for
decompensated HF in the previous 6 months, were more
likely to receive intravenous inotropic therapy, were less
likely to receive ACE inhibitors, and had low systolic blood
pressure and renal failure. Hospitals that had higher
adherence rates to quality indicators for HF were more
likely to refer patients to hospice [43]. There also are racial
Curr Heart Fail Rep (2010) 7:140–147
and ethnic disparities in hospice utilization; based on
Medicare claims data, black and Latino patients are about
half as likely to use hospice as white patients [44•].
143
use of nonpharmacologic interventions, which raised the
question of misinterpretation of the strict application of a
DNR order to cardiac arrest [48•].
Deactivating Implanted Cardioverter-Defibrillators
Advance Directives
The physician should initiate end-of-life planning early in
the relationship with the patient, when the patient is
cognitively intact and able to state his or her wishes. It is
helpful if the patient’s family members participate in these
conversations, so they understand both that HF is a
progressive and ultimately terminal disease and how their
loved one wants to manage the disease when it becomes
advanced. We have included a checklist for providers to use
at each visit to help assess patients and to remind providers
to begin and/or continue the ongoing discussion about
advance directives (Fig. 1).
Do Not Resuscitate Orders
A patient with HF is 10 times less likely than a patient
with AIDS or cancer to have a do not resuscitate (DNR)
order, even when prognoses are similar [45]. Studies
consistently show that most patients with HF prefer
resuscitation. At the start of the Study to Understand
Prognoses and Preferences for Outcomes and Risks of
Treatments trial, only 23% of patients with HF did not
want to be resuscitated, and 2 months later, 40% of those
changed their minds (at the 2-month follow-up, only 14% of
those who initially wanted resuscitation changed their minds).
In that trial, patients who did not want to be resuscitated were
more likely to be older, had a perception of a worse prognosis
and a life expectancy less than 2 months, had worse functional
status, and had higher income. Despite having advanced
disease, less than one fourth of these patients had discussed
resuscitation with their physician [46]. The inpatient setting,
where patients with HF often are acutely decompensated,
may be an anxiety-provoking and ultimately inappropriate
place to have a discussion about a DNR order [47]. The best
environment would be an outpatient visit with a provider
who knows the patient well.
It is unclear why patients with HF and their doctors are
resistant to DNR orders. The waxing and waning trajectory
of disease may play a role. Doctors may be concerned that a
DNR order may limit their patient’s care; if this order
precludes admission to an intensive care unit in a hospital
where inotropes are only given in those units, the order
stands in the way of appropriate care [47]. In one large
multicenter trial, patients with HF with DNR orders were
less likely to meet quality indicators for HF, including
assessment of left ventricular function, use of ACE
inhibitors or aldosterone antagonists, anticoagulation, or
Implanted cardioverter-defibrillators (ICDs) reduce mortality in patients with HF by decreasing sudden cardiac death
due to arrhythmias [49]. As systolic function worsens,
patients have more arrhythmias and are likely to receive
more frequent shocks, which cause significant pain and
anxiety [50] and are associated with worse quality of life
[51•] and increased mortality [52•]. The ACC/AHA guidelines include a class I recommendation, based on C-level
evidence, for physicians to discuss with their patients the
option for ICD deactivation at the end of life [1]. Still,
many clinicians do not address deactivation with their
patients, and most devices remain active until death;
patients receive shocks up until death [53]. Qualitative
studies have shown that patients may not fully understand
how ICDs work, which may contribute to reluctance to
deactivate their devices [54•]. Qualitative studies with
physicians showed that they regarded ICD deactivation as
separate and distinct from other end-of-life planning, and so
were more likely to address DNR orders than ICD
deactivation [54•].
Most hospice programs do not have formal rules about
ICDs. In a recent survey of 900 hospice programs, almost
all admitted patients with ICDs, but only 10% had a policy
that addressed deactivation. Nearly 6 out of 10 programs
reported that a patient had been shocked in the past year.
On average, 42% of patients with ICDs had the shocking
function deactivated, and patients in hospices with a
deactivation policy were almost twice as likely to have
their device turned off when compared to patients in
hospices with no formal policy [55•].
Before ICD implantation, doctors should discuss with
patients the possibility of deactivation in the future. It is
best if this dialogue occurs early while the patient is still
capable of participating in the discussion. Patients should
be reassured that deactivating an ICD will not result in
immediate death and that the process of deactivation is not
painful [55•]. The patient’s wishes should be documented
clearly in the medical record.
Is There a Role for Deactivation of Cardiac
Resynchronization Therapy?
CRT improves mortality and quality of life [18]. Because of
this symptomatic benefit, the AHA recommends CRT for
NYHA class III and IV HF, but not as salvage therapy in
very advanced patients in whom the risks and discomfort of
device placement may exceed the benefit they will derive
144
Curr Heart Fail Rep (2010) 7:140–147
Fig. 1 Checklist for providers.
ACE angiotensin-converting
enzyme; DNR do not resuscitate;
EF ejection fraction; ICD
implantable cardioverterdefibrillator; NYHA New York
Health Association; VAD
ventricular assist device
from ventricular synchrony. ICDs without CRT are contraindicated for patients with NYHA class IV HF [56]. It may
be appropriate to continue CRT for patients even when the
decision has been made to turn off ICDs.
Ventricular Assist Devices
A ventricular assist device (VAD) is a battery-operated
mechanical device that can be surgically implanted into either
ventricle and consists of a blood pump that decreases the
workload of the diseased ventricle. Mechanical circulatory
support with a VAD can be used either as a bridge to cardiac
transplantation or as destination therapy in patients who are
not eligible for transplant. Since 2003, based on the survival
and quality-of-life improvements reported in the Randomized
Evaluation of Mechanical Assistance for the Treatment of
Congestive Heart Failure trial [38], the Center for Medicare
and Medicaid Services approved the use of VAD as
destination therapy in patients who were not candidates for
transplant. In January 2010, the HeartMate II (Thoratec
Corporation, Pleasanton, CA) VAD became the first
continuous-flow device approved for destination therapy.
Given improvements in technology and increases in the
prevalence of HF, the use of VAD for treatment of HF is likely
to increase significantly. The ACC/AHA guidelines cite level
B evidence for a class IIa recommendation for a left
ventricular assist device as destination therapy in patients
with refractory end-stage HF and an estimated 1-year
mortality of over 50% despite medical therapy [1]. When
the physician begins to discuss implanting a VAD as
Curr Heart Fail Rep (2010) 7:140–147
destination therapy, patients should be made aware of the
common complications. They also should know that at the
end of life, VAD mechanical dysfunction can lead to a
sudden decrease in cardiac output and rapid decompensation.
In other patients, the devices continue to function, possibly
even after the patient is clinically brain dead, and may
prolong the dying process. Before implantation, the patient,
together with his or her family and doctor, should establish
advance directives that outline conditions where he or she
would want to turn off the VAD. Specifically, if the patient
were permanently unable to interact with loved ones, would
he or she want care focused on comfort or maximal
prolongation of life? If he or she chooses comfort, the
VAD would need to be turned off in that scenario. A patient
who is receiving a VAD for destination therapy may benefit
from increased palliation and hospice.
Conclusions
Despite progress, the prevalence of patients with HF
continues to increase. Early identification of patients with
end-stage disease facilitates their care, whether the patients
are appropriate for heart transplant or mechanical circulatory support or are more appropriate for palliative therapies.
Early identification also allows for timely discussions
between patients and health care providers about advance
care planning. These discussions should address patients’
preferences about resuscitation and, in appropriate patients,
defibrillator deactivation. As patients decline, a gradual
transition between life-saving therapies and comfort care
measures is appropriate. The expanding use of VAD
therapies may pose a unique challenge for health care
providers at the end of life.
Disclosures No potential conflicts of interest relevant to this article
have been reported.
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
1. Hunt SA, Abraham WT, Chin MH, et al.: 2009 Focused update
incorporated into the ACC/AHA 2005 Guidelines for the
Diagnosis and Management of Heart Failure in Adults A Report
of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines Developed
in Collaboration With the International Society for Heart and
Lung Transplantation. J Am Coll Cardiol 2009, 53:e1–e90.
(Published erratum appears in J Am Coll Cardiol 2009, 54:2464.)
145
2. Bekelman DB, Havranek EP, Becker DM, et al.: Symptoms,
depression, and quality of life in patients with heart failure. J Card
Fail 2007, 13:643–648.
3. Rutledge T, Reis VA, Linke SE, et al.: Depression in heart failure
a meta-analytic review of prevalence, intervention effects, and
associations with clinical outcomes. J Am Coll Cardiol 2006,
48:1527–1537.
4. Teno JM, Weitzen S, Fennell ML, Mor V: Dying trajectory in the
last year of life: does cancer trajectory fit other diseases? J Palliat
Med 2001, 4:457–464.
5. Aaronson KD, Schwartz JS, Chen TM, et al.: Development and
prospective validation of a clinical index to predict survival in
ambulatory patients referred for cardiac transplant evaluation.
Circulation 1997, 95:2660–2667.
6. Levy WC, Mozaffarian D, Linker DT, et al.: The Seattle Heart
Failure Model: prediction of survival in heart failure. Circulation
2006, 113:1424–1433.
7. Zugck C, Kruger C, Kell R, et al.: Risk stratification in middle-aged
patients with congestive heart failure: prospective comparison of the
Heart Failure Survival Score (HFSS) and a simplified two-variable
model. Eur J Heart Fail 2001, 3:577–585.
8. Fried LP, Kronmal RA, Newman AB, et al.: Risk factors for 5-year
mortality in older adults: the Cardiovascular Health Study. JAMA
1998, 279:585–592.
9. Walter LC, Brand RJ, Counsell SR, et al.: Development and
validation of a prognostic index for 1-year mortality in older
adults after hospitalization. JAMA 2001, 285:2987–2994.
10. Koglin J, Pehlivanli S, Schwaiblmair M, et al.: Role of brain
natriuretic peptide in risk stratification of patients with congestive
heart failure. J Am Coll Cardiol 2001, 38:1934–1941.
11. Casarett D, Pickard A, Bailey FA, et al.: Do palliative consultations
improve patient outcomes? J Am Geriatr Soc 2008, 56:593–599.
12. Finlay IG, Higginson IJ, Goodwin DM, et al.: Palliative care in
hospital, hospice, at home: results from a systematic review. Ann
Oncol 2002, 13(Suppl 4):257–264.
13. Higginson IJ, Finlay I, Goodwin DM, et al.: Do hospital-based
palliative teams improve care for patients or families at the end of
life? J Pain Symptom Manage 2002, 23:96–106.
14. Hjalmarson A, Goldstein S, Fagerberg B, et al.: Effects of controlledrelease metoprolol on total mortality, hospitalizations, and well-being
in patients with heart failure: the Metoprolol CR/XL Randomized
Intervention Trial in congestive heart failure (MERIT-HF). MERITHF Study Group. JAMA 2000, 283:1295–1302.
15. Effect of enalapril on survival in patients with reduced left
ventricular ejection fractions and congestive heart failure. The
SOLVD Investigators. N Engl J Med 1991, 325:293–302.
16. Pitt B, Zannad F, Remme WJ, et al.: The effect of spironolactone
on morbidity and mortality in patients with severe heart failure.
Randomized Aldactone Evaluation Study Investigators. N Engl J
Med 1999, 341:709–717.
17. The effect of digoxin on mortality and morbidity in patients with
heart failure. The Digitalis Investigation Group. N Engl J Med
1997, 336:525–533.
18. Cleland JG, Daubert JC, Erdmann E, et al.: The effect of cardiac
resynchronization on morbidity and mortality in heart failure. N
Engl J Med 2005, 352:1539–1549.
19. Adler ED, Goldfinger JZ, Kalman J, et al.: Palliative care in the
treatment of advanced heart failure. Circulation 2009, 120:2597–2606.
20. Faris R, Flather MD, Purcell H, et al.: Diuretics for heart failure.
Cochrane Database Syst Rev 2006, (1):CD003838.
21. Costanzo MR, Guglin ME, Saltzberg MT, et al.: Ultrafiltration versus
intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007, 49:675–683. (Published
erratum appears in J Am Coll Cardiol 2007, 49:1136.)
22. Currow DC, Abernethy AP: Pharmacological management of
dyspnoea. Curr Opin Support Palliat Care 2007, 1:96–101.
146
23. Sindone AP, Keogh AM, Macdonald PS, et al.: Continuous home
ambulatory intravenous inotropic drug therapy in severe heart
failure: safety and cost efficacy. Am Heart J 1997, 134:889–900.
24. Cotter G, Metzkor E, Kaluski E, et al.: Randomised trial of high-dose
isosorbide dinitrate plus low-dose furosemide versus high-dose
furosemide plus low-dose isosorbide dinitrate in severe pulmonary
oedema. Lancet 1998, 351:389–393.
25. Pittler MH, Guo R, Ernst E: Hawthorn extract for treating chronic
heart failure. Cochrane Database Syst Rev 2008, (1):CD005312.
26. Bausewein C, Booth S, Gysels M, Higginson I: Nonpharmacological interventions for breathlessness in advanced
stages of malignant and non-malignant diseases. Cochrane
Database Syst Rev 2008, (2):CD005623.
27. Booth S, Wade R, Johnson M, et al.: The use of oxygen in the
palliation of breathlessness. A report of the expert working group
of the Scientific Committee of the Association of Palliative
Medicine. Respir Med 2004, 98:66–77. (Published erratum
appears in Respir Med 2004, 98:476.)
28. Radbruch L, Strasser F, Elsner F, et al.: Fatigue in palliative care
patients: an EAPC approach. Palliat Med 2008, 22:13–32.
29. Keteyian SJ, Fleg JL, Brawner CA, Piña IL: Role and benefits of
exercise in the management of patients with heart failure. Heart
Fail Rev 2010 Jan 26 (Epub ahead of print).
30. Harris JD: Fatigue in chronically ill patients. Curr Opin Support
Palliat Care 2008, 2:180–186.
31. • Qaseem A, Snow V, Shekelle P, et al.: Evidence-based interventions
to improve the palliative care of pain, dyspnea, and depression at the
end of life: a clinical practice guideline from the American College of
Physicians. Ann Intern Med 2008, 148:141–146. This article
recommends regular assessments for symptoms that are common
at the end of life, including pain, dyspnea, and depression, and
provides graded evidence for management.
32. Fraker TD Jr, Fihn SD, 2002 Chronic Stable Angina Writing
Committee, et al.: 2007 chronic angina focused update of the
ACC/AHA 2002 guidelines for the management of patients with
chronic stable angina: a report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines Writing Group to develop the focused update of the
2002 guidelines for the management of patients with chronic
stable angina. J Am Coll Cardiol 2007, 50:2264–2274. (Published
erratum appears in J Am Coll Cardiol 2007, 50:e1.)
33. Strohle A: Physical activity, exercise, depression and anxiety
disorders. J Neural Transm 2009, 116:777–784.
34. Lane DA, Chong AY, Lip GY: Psychological interventions for
depression in heart failure. Cochrane Database Syst Rev 2005, (1):
CD003329.
35. Ewy GA: Inotropic infusions for chronic congestive heart failure:
medical miracles or misguided medicinals? J Am Coll Cardiol
1999, 33:572–575.
36. Hauptman PJ, Mikolajczak P, George A, et al.: Chronic inotropic
therapy in end-stage heart failure. Am Heart J 2006, 152:1096.e1–
1096.e8.
37. Stevenson LW: Clinical use of inotropic therapy for heart failure:
looking backward or forward? Part II: chronic inotropic therapy.
Circulation 2003, 108:492–497.
38. Rose EA, Gelijns AC, Moskowitz AJ, et al.: Long-term
mechanical left ventricular assistance for end-stage heart failure.
N Engl J Med 2001, 345:1435–1443.
39. Rich MW, Shore BL: Dobutamine for patients with end-stage
heart failure in a hospice program? J Palliat Med 2003, 6:93–97.
40. Schockett ER, Teno JM, Miller SC, Stuart B: Late referral to
hospice and bereaved family member perception of quality of endof-life care. J Pain Symptom Manage 2005, 30:400–407.
41. Pyenson B, Connor S, Fitch K, Kinzbrunner B: Medicare cost in
matched hospice and non-hospice cohorts. J Pain Symptom
Manage 2004, 28:200–210.
Curr Heart Fail Rep (2010) 7:140–147
42. Fox E, Landrum-McNiff K, Zhong Z, et al.: Evaluation of
prognostic criteria for determining hospice eligibility in patients
with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for
Outcomes and Risks of Treatments. JAMA 1999, 282:1638–1645.
43. Hauptman PJ, Goodlin SJ, Lopatin M, et al.: Characteristics of
patients hospitalized with acute decompensated heart failure who are
referred for hospice care. Arch Intern Med 2007, 167:1990–1997.
44. • Givens JL, Tjia J, Zhou C, et al.: Racial and ethnic differences in
hospice use among patients with heart failure. Arch Intern Med 2010,
170:427–432. This article uses Medicare data for more than 98,000
patients and highlights racial disparities in hospice utilization for
patients with heart failure, specifically, that black and Latino
patients are less likely to enter hospice than white patients.
45. Wachter RM, Luce JM, Hearst N, Lo B: Decisions about
resuscitation: inequities among patients with different diseases
but similar prognoses. Ann Intern Med 1989, 111:525–532.
46. Krumholz HM, Phillips RS, Hamel MB, et al.: Resuscitation
preferences among patients with severe congestive heart failure:
results from the SUPPORT project. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.
Circulation 1998, 98:648–655.
47. Stevenson LW: Rites and responsibility for resuscitation in heart
failure: tread gently on the thin places. Circulation 1998, 98:619–622.
48. • Chen JL, Sosnov J, Lessard D, Goldberg RJ: Impact of do-notresuscitation orders on quality of care performance measures in
patients hospitalized with acute heart failure. Am Heart J 2008,
156:78–84. This article raises the question of whether do not
resuscitate orders prevent patients from receiving appropriate
guideline-based heart failure care, including ACE inhibitors.
49. Moss AJ, Hall WJ, Cannom DS, et al.: Improved survival with an
implanted defibrillator in patients with coronary disease at high
risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996,
335:1933–1940.
50. Sears SF Jr, Conti JB: Quality of life and psychological
functioning of icd patients. Heart 2002, 87:488–493.
51. • Mark DB, Anstrom KJ, Sun JL, et al.: Quality of life with
defibrillator therapy or amiodarone in heart failure. N Engl J Med
2008, 359:999–1008. In this study, patients in the ICD group had
improved quality of life at 3 and 12 months, but equivalent quality
of life at 30 months, as compared to patients in the amiodarone
group. However, patients who received a shock from their ICD in
the previous month had worse quality of life.
52. • Poole JE, Johnson GW, Hellkamp AS, et al.: Prognostic
importance of defibrillator shocks in patients with heart failure.
N Engl J Med 2008, 359:1009–1017. In a trial with 829 patients
with heart failure who were followed for 45.5 months, receiving a
shock was associated with increased mortality, regardless of
whether the shock was appropriate. The most common cause of
death in the patients who were shocked was progressive heart
failure, not sudden cardiac death.
53. Goldstein NE, Lampert R, Bradley E, et al.: Management of
implantable cardioverter defibrillators in end-of-life care. Ann
Intern Med 2004, 141:835–838.
54. • Goldstein NE, Mehta D, Siddiqui S, et al.: “That’s like an act of
suicide” patients’ attitudes toward deactivation of implantable
defibrillators. J Gen Intern Med 2008, 23(Suppl 1):7–12. This
article reported that focus groups of patients with ICDs
highlighted patients’ anxieties and misconceptions about the
devices, as well as the lack of awareness about device
deactivation.
55. • Goldstein N, Carlson M, Livote E, Kutner JS: Brief communication: Management of implantable cardioverter-defibrillators in
hospice: A nationwide survey. Ann Intern Med 2010, 152:296–
299. The authors surveyed hospices and found that while few had
Curr Heart Fail Rep (2010) 7:140–147
a formal policy in place to address ICD and deactivation, the
existence of a formal policy was associated with an increase in
device deactivation.
56. Epstein AE, DiMarco JP, Ellenbogen KA, et al.: ACC/AHA/HRS
2008 Guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities: a report of the American College of Cardiology/
147
American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the ACC/AHA/NASPE 2002
Guideline Update for Implantation of Cardiac Pacemakers and
Antiarrhythmia Devices) developed in collaboration with the
American Association for Thoracic Surgery and Society of
Thoracic Surgeons J Am Coll Cardiol 2008, 51:e1–e62.