A decision algorithm for palliative care initiation in heart failure patients

Introduction Patients suffering from heart failure (HF) are recognized as having palliative care (PC) needs. They experience a significant symptom burden, more intense, persistent, and disabling over time, especially if refractory to optimized medical therapy. The highly variable and unpredictable clinical trajectory of HF, with several acute exacerbations and the possibility of sudden cardiac death, along with the difficulty to estimate prognosis, cast doubt on which is the right moment to initiate PC and/or refer patients for specialised teams. Aim To clarify when and to which HF patients PC should be offered, and develop a tool that can help clinicians determine, on a case-by-case basis and at each moment, the appropriateness of initiating PC. Methods A review of the literature published up to 2019 on MEDLINE (n=300) was conducted, from which 42 references were selected, mostly observational studies or guidelines and consensus statements from scientific societies. Based on the situations that reached the greatest consensus, a decision-making algorithm was developed for initiating PC and referring patients to specialised teams. Results It was found that the introduction of PC is appropriate at any point in the HF trajectory and should be based on an assessment of quality of life, symptom burden, and the patient's palliative needs rather than on prognostic models or pathophysiological markers. The type of PC to be initiated, ranging from a palliative approach to specialised PC (e.g., in cases of complex needs), should also be determined accordingly. Among the referral triggers identified, the criteria that generated the greatest consensus were: frequent hospitalizations due to HF decompensation, complex clinical conditions and/or needs, uncertainty regarding treatment goals, advanced HF, pre- or post-transplant periods, or long-term mechanical circulatory support implantation, and ineligibility for or failure of these therapeutic measures. Based on these findings gathered from the literature, a comprehensive algorithm was developed, to help determine the best timing for referral of HF patients to PC. Conclusions All HF patients are candidates for PC; therefore, our tool suggests to start by recognizing referral triggers to determine the treatment goal and assess palliative needs, then decide between a palliative approach and/or referral to a specialised PC team. This approach aims to provide earlier intervention in preventing and alleviating the suffering of these patients. Further studies are needed to evaluate the performance and useful of this tool. The findings of this review were found to be in line with the 2020's position paper of the Heart Failure Association and the expert position statement of the European Association for Palliative Care.