Promoting palliative care for people with heart failure: the P3HF study protocol

Background Heart failure is often a chronic, life-limiting illness associated with high symptom burden, frequent hospitalizations, and substantial suffering near the end of life. Although palliative care improves quality of life and is strongly recommended by clinical practice guidelines, fewer than 20% of people with heart failure receive it. We developed the Promoting Palliative Care for People with Heart Failure (P3HF) Clinical Decision Support (CDS) tool—an evidence-based, end-user informed tool integrating a validated prognostic-risk model, tiered functionality, and behavioral nudges in the electronic health record (EHR). This manuscript describes the development of the P3HF CDS and protocol for a clinical trial evaluating its effects. Methods We will conduct a pragmatic randomized clinical trial at two large urban hospitals, within a single health system, using an embedded, convergent mixed-methods design to evaluate the P3HF CDS. Eligible patients are adults (≥ 18 years) hospitalized with heart failure, N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥ 500 pg/mL, and receipt of intravenous diuretics within 24 h of admission. We will analyze data from the EHR and surveys and interviews with end-users (attending physicians, residents, fellows, advanced practice providers) of the CDS tool and palliative care clinicians to assess CDS usability, acceptability, appropriateness, feasibility (implementation outcomes), and efficacy in increasing inpatient palliative care (Primary clinical outcome) consultations. Secondary exploratory outcomes include increasing palliative care outpatient referrals, improved advance care planning documentation, higher hospice enrollment, and reductions in hospital length of stay and 30-day readmissions compared to usual care. Discussion The P3HF CDS is an evidence-based, theory and end-user informed tool designed to promote timely palliative care for people with heart failure. The P3HF trial will examine the acceptability and effects of the CDS in real-world clinical settings. Trial registration NCT06933875 (https://clinicaltrials.gov/study/NCT06933875, Registration date: 2025-04-18).