86 Advance care planning and the provision of palliative care for patients with heart failure within the last six months of life

Introduction Chronic heart failure (CHF) is characterised by breathlessness, fatigue and fluid retention – with a burden of symptoms comparable with many forms of cancer.1 Few patients with CHF are referred to palliative care services,2 and where this is done, it is often within the last days of life.3 We aimed to describe the provision of end of life care for patients hospitalised with worsening heart failure. Methods Consecutively admitted patients with worsening heart failure between 1st August and 30th October 2022 who were reviewed by a heart failure nurse specialist and who died within the subsequent 6 months were included. We recorded the proportion of patients with documented cardiopulmonary resuscitation decision, advance care planning using the recommended summary plan for emergency care and treatment (ReSPECT) process, and referral to palliative care and the timing in relation to admission and death. Results Patient demographics are summarised in table 1. Heart failure was the most common cause of death and the majority died in hospital (table 2). Of these, half died on a subsequent admission to hospital. 25 (50%) of patients had a pre-existing ceiling of care decision, and of the remaining patients only 3 (6%) had further decisions documented during this admission (figure 1). While discussions regarding cardiopulmonary resuscitation status took place during admission, most decisions were made after discharge in the community or during subsequent admissions (figure 1) such that although 56% of patients had not-for-resuscitation decision documented at the point of discharge following this admission for 90% a decision to not provide resuscitation was in place at the time of death. Similarly, referral to palliative care most frequently took place following this presentation, and commonly in the last days of life (figure 2): a third of patients died within 48 hours of a referral being made and 54% within a week of referral. One patient died following referral, but before the palliative care team were able to assess their needs. Overall, 46% of patients had palliative care input at the time of death. Three patients had implantable cardioverter-defibrillators and all had discussions around deactivation during this admission. Reviews by the specialist heart failure nurses documented symptom management advice taking end of life care into account where appropriate. Conclusions Recognition that patients may be in the final months of life was evident from the documentation of wishes for end-of-life care using the ReSPECT process, and from ICD deactivation discussions. However, the use of the ReSPECT process was poor during this admission, suggesting a missed opportunity for patients and their families to discuss and come to terms with these decisions. In addition, death in hospital may represent a poor outcome for patients. Referral to palliative care services typically occurred within the last days and weeks of life. Patients and their families may therefore be unable to access the additional support provided by specialist palliative care services. References O'Leary, et al. EJHF 2009. Murray and Boyd. Palliative Medicine 2011. Cheung, et al. Journal of Pain Symptom Management 2023. Conflict of Interest none