End of life care in advanced heart failure.

I individualize my approach to each patient based upon their understanding of their disease process, acuity of their progression to Stage D heart failure, clinical setting (hospitalized vs outpatient), and family needs. My first goal is to prove intolerance of traditional therapies for heart failure by challenging patients with various medication combinations, including staggered dosing regimens and alternatives to angiotensin-converting enzyme inhibitors/β-blockers, and by considering cardiac resynchronization therapy if they meet criteria. As patients develop progressive hypotension and side effects from medicines, I often will discontinue these medicines after careful communication. For patients with refractory heart failure, I consider cardiac transplantation for those who are candidates and left ventricular assist device as destination therapy for those who are not transplant candidates, both of which require multidisciplinary input from psychiatrists, social workers, nurses, and cardiac surgeons. If patients are not candidates for these advanced therapies, I try to delineate their goals for living and discuss strategies to maximize their survival (however limited) and increase my focus on their quality of life by minimizing unnecessary testing. For the select patient, I use continuous inotrope support only if this improves their quality of life and possibility of having a meaningful existence outside of the hospital. Palliative care consultants are often involved at this stage. For the patient who is clearly at the end of life, I refer to hospice and focus on comfort. Return ambulatory visits and extent of the care received are guided by the preferences of the patient and their family. When there are disparate views of family members, especially when the patient is not cognitively able to participate in the discussion, I tend to be more paternalistic in my approach to therapeutic options in an attempt to possibly dissipate family dynamic problems occurring after the patient dies.