Clinical Review

Advance Care Planning Among Patients with Heart Failure: A Review of Challenges and Approaches to Better Communication

Journal of Clinical Outcomes Management. 2015 February;22(2)

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Finally, information gaps with regards to heart failure contribute to delayed or absent conversations about planning for future care. Many heart failure patients have a limited understanding of their disease [32,40,44,55], particularly an inaccurate perception that heart failure is not a terminal and life-limiting illness [42,49,64]. Compounding this is the fact that even some health care providers are reluctant to acknowledge the terminal nature of heart failure [50,56]. Without frank acknowledgement of the terminal nature of heart failure, the initiation of discussions regarding end-of-life care will remain difficult if not impossible.

Approaches to ACP in Heart Failure

A steadily emerging body of literature provides insight into approaches to ACP for patients with heart failure. Several models have been developed and found to be effective in increasing documentation of patient care wishes, care concordance with documented wishes, satisfaction with care communication, and reducing aggressive medical service use [29,30,36,37,65–67]. These models vary from multidisciplinary team approaches to trained, nonmedical facilitators. Table 1 contains a brief review of these structured approaches to ACP that demonstrate an improvement in patient-centered outcomes at the end of life. In addition to these structured models, an array of recommendations around the ACP process, including timing and structuring of discussions and physician training programs, exist and are discussed here.

When Is the Right Time?

Given the complexity and unpredictable trajectory of heart failure, indicators of disease progression, including changes in health status and health service use, may serve as useful signals to help clinicians identify the appropriate time to initiate care planning discussions. Repeated hospital admissions for heart failure are strongly associated with increased mortality. In a sample of community heart failure patients [8], median survival after the first, second, and third hospitalization was 2.4, 1.4, and 1.0 years, respectively. In light of this, a patient with 1 or more hospitalizations in a 12-month period may be an appropriate candidate for an ACP conversation. Similarly, comorbidity in patients with heart failure may signal the relevance and need for discussions about future care. In a sample of Medicare beneficiaries with advanced heart failure, an increasing burden of comorbidity was associated with significantly higher mortality, as were certain conditions (COPD, CKD, dementia, depression) and combinations of conditions (eg, CKD and dementia) [26]. Davidson and colleagues [68] suggest a list of clinical indicators signaling the need for an ACP conversation, including any of the following:

> 1 episodes of exacerbation of heart failure leading to hospital admission
New York Heart Association Class IV heart failure
Decline in function and mobility
Unexplained weight loss
Resting pulse rate greater than 100 beats/minute
Raised serum creatinine (> 150 µmol/L)
Low serum sodium (< 135 mmol/L)
Low serum albumen (< 33 g/L)
High dose of loop diuretic (eg, furosemide ≥ 160 mg daily)

Given the considerable complexity and multisystem nature of heart failure, none of these indicators alone can signal certainty about disease progression and consequent outcomes; however, they can serve as a useful heuristic for helping clinicians identify appropriate times to raise the topic of ACP with their patients.