Perspectives| Volume 10, ISSUE 3, P200-209, June 2004

Download started.


Consensus statement: palliative and supportive care in advanced heart failure



      A consensus conference was convened to define the current state and important gaps in knowledge and needed research on “Palliative and Supportive Care in Advanced Heart Failure.”


      Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews.


      The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiac Failure
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gorkin L
        • Norvell N.K
        • Rosen R.C
        • Charles E
        • Shumaker S.A
        • McIntyre K.M
        • et al.
        Assessment of quality of life as observed from the baseline data of the Studies of Left Ventricular Dysfunction (SOLVD) trial.
        Am J Cardiol. 1993; 71: 1069-1073
        • Dracup K
        • Walden J.A
        • Stevenson L.W
        • Brecht M
        Quality of life with advanced heart failure.
        J Heart Lung Transplant. 1992; 11: 273-279
        • Murray S.A
        • Boyd K
        • Kendall M
        • Worth A
        • Benton T.F
        • Calusen H
        Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their careers in the community.
        BMJ. 2002; 325: 929-934
        • Linne A.B
        • Liedholm H
        • Jendteg S
        • Israelsson B
        Health care costs of heart failure: results from a randomized study of patient education.
        Eur J Heart Fail. 2002; 2: 291-297
      1. American Heart Association. Heart disease and stroke statistics—2003 update. Available from:

        • Ho K.K.L
        • Pinsky J.L
        • Kannel W.B
        • Levy D
        The epidemiology of heart failure: the Framingham Study.
        J Am Coll Cardiol. 1993; 22: 6A-13A
        • Hunt S.A
        • Baker D.W
        • Chin M.H
        • Cinquegrani M.P
        • Feldman A.M
        • Francis G.S
        • et al.
        American College of Cardiology/American Heart Association guidelines for the evaluation and management of chronic heart failure in the adult: executive summary.
        J Amer Col Cardiol. 2001; 38: 2101-2113
        • Grady K.L
        • Meyer P
        • Mattea A
        • White-Williams C
        • Ormaza S
        • Kaan A
        • et al.
        Improvement in quality of life outcomes 2 weeks after left ventricular assist device implantation.
        J Heart Lung Transplantation. 2001; 20: 657-669
        • Grady K.L
        • Jalowiec A
        • White-Williams C
        • Pifarre R
        • Kirklin J.K
        • Bourge R.C
        • et al.
        Predictors of quality of life in patients with advanced heart failure awaiting transplantation.
        J Heart Lung Transplant. 1995; 14: 2-10
        • Walden J.A
        • Stevenson L.W
        • Dracup K
        • Hook J.F
        • Moser D.K
        • Hamilton M
        • et al.
        Extended comparison of quality of life between stable heart failure patients and heart transplant recipients.
        J Heart Lung Transplant. 1994; 13: 1109-1118
        • Stanek E.J
        • Oates M.B
        • McGhan W.F
        • Denofrio D
        • Loh E
        Preferences for treatment outcomes in patients with heart failure: symptoms versus survival.
        J Card Fail. 2000; 6: 225-232
        • Kutner J.S
        • Kassner C.T
        • Nowels D.E
        Symptom burden at the end of life: hospice providers' perceptions.
        J Pain Symptom Manage. 2001; 21: 473-480
        • Rich M.W
        Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults.
        J Am Geriatr Soc. 1997; 45: 968-974
        • Masoudi F.A
        • Havranek E.P
        • Krumholz H.M
        The burden of chronic congestive heart failure in older persons: magnitude and implications for policy and research.
        Heart Failure Rev. 2002; 7: 9-16
        • The National Center for Health Statistics
        Second Supplement on Aging.
        Author, Hyattsville (MD)1994
        • National Center for Health Statistics
        Health, United States, 1999, with health and aging chartbook.
        National Center for Health Statistics, Hyattsville (MD)1999
      2. National Mortality Follow back Survey. National Center for Health Statistics, Centers for Disease Control and Prevention. Available from: Accessed January 2, 2004.

        • Lynn J
        An 88-year-old woman facing the end of life.
        JAMA. 1997; 277: 1633-1640
        • Heiat A
        • Gross C.P
        • Krumholz H.M
        Representation of the elderly, women, and minorities in heart failure clinical trials.
        Arch Intern Med. 2002; 162: 1682-1688
        • Rose E.A
        • Gellins A.C
        • Moskowitz A.J
        • Heitjan D.F
        • Stevenson L.W
        • Dembitsky W
        • for the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group
        • et al.
        Long-term use of a left ventricular assist device for end-stage heart failure.
        N Engl J Med. 2001; 345: 1435-1443
        • Mancini D
        • Nonan N
        • Ascheim D
        • Renlund D
        • et al.
        Predictors of survival in patients with end stage heart failure.
        Circulation. 2002; S-II: 601
        • Hershberger R.E
        • Nauman D
        • Walker T.L
        • Dutton D
        • Burgess D
        Care processes and clinical outcomes of Continuous Outpatient Support with Inotropes (COSI) in patients with refractory endstage heart failure.
        J Card Fail. 2003; 9: 180-187
        • Koglin J
        • Pehlivanli S
        • Schwaiblmair M
        • Vogeser M
        • Cremer P
        • van Scheidt W
        • et al.
        Role of brain natriuretic peptide in risk stratification of patients with congestive heart failure.
        J Am Coll Cardiol. 2001; 38: 1934-1941
        • Gottlieb S.S
        • Abraham W
        • Butler J
        • Forman D.E
        • Loh E
        • Massie B.M
        • et al.
        The prognostic importance of different definitions of worsening renal function in congestive heart failure.
        J Card Fail. 2002; 8: 136-141
        • Chatterjee K
        Heart failure therapy in evolution.
        Circulation. 1996; 94: 2689-2693
        • Murberg T.A
        • Bru E
        • Svebak S
        • Tveteras R
        • Aarsland T
        Depressed mood and subjective health symptoms as predictors of mortality in patients with congestive heart failure: a two-years follow-up study.
        Int J Psych Med. 1999; 29: 311-326
        • Sullivan M
        • Simon G
        • Spertus J
        • Russo J
        Depression-related costs in heart failure care.
        Arch Intern Med. 2002; 162: 1860-1866
        • Faris R
        • Purcell H
        • Henein M.Y
        • Coats A.J
        Clinical depression is common and significantly associated with reduced survival in patients with non-ischaemic heart failure.
        Eur J Heart Fail. 2002; 4: 541-551
        • Goldman L
        • De Marco T
        Predicting outcomes in severe heart failure.
        Circulation. 1997; 95: 2597-2599
        • Stuart B
        • Alexander C
        • Arenella C
        • Connor S
        • Herbst L
        • Jones D
        • for Standards and Accreditation Committee, Medical Guidelines Task Force
        Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases.
        National Hospice Organization, Arlington (VA)1996
        • Anderson F
        • Downing G.M
        • Hill J
        • Casorso L
        • Lerch N
        Palliative performance scale (PPS): a new tool.
        J Pall Care. 1996; 12: 5-11
        • Heart Failure Society of America (HFSA) practice guidelines
        HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction—pharmacological approaches.
        J Card Fail. 1999; 5: 357-382
        • The SOLVD Investigators
        Effect of enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure.
        N Engl J Med. 1991; 325: 293-302
        • Farrell M.H
        • Foody J.M
        • Krumholz H.M
        β-blockers in heart failure, clinical applications.
        JAMA. 2002; 287: 890-897
        • Krum H
        • Roecker E.B
        • Mohacsi P
        • Rouleau J.L
        • Tendera M
        • Coats A.J
        • et al.
        Effects of initiating carvedilol in patients with severe chronic heart failure; results from the COPERNICUS Study.
        JAMA. 2003; 289: 712-789
        • Köhnlein T
        • Welte T
        • Tan L.B
        • Elliott M.W
        Central sleep apnoea syndrome in patients with chronic heart disease: a critical review of the current literature.
        Thorax. 2002; 57: 547-554
        • Lenique F
        • Habis M
        • Lafaso F
        • Dubois-Randle J.L
        • Harf A
        • Brochard L
        • et al.
        Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure.
        Am J Respir Crit Care Med. 1997; 155: 500-505
        • Naughton M.T
        • Benard D.C
        • Liu P.P
        • Rutherford R
        • Rankin F
        • Bradley T.D
        Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea.
        Am J Respir Crit Care Med. 1995; 152: 473-479
        • Russell S.D
        • Koshkarian G.M
        • Medinger A.E
        • Carson P.E
        • Higginbotham M.B
        Lack of effect of increased inspired oxygen concentrations on maximal exercise capacity or ventilation in stable heart.
        Am J Cardiol. 1999; 84: 1412-1416
        • Zeppetella G
        The palliation of dyspnea in terminal disease.
        Am J Hospice Palliat Care. 1998; 15: 322-330
        • Jennings A.L
        • Davies A.N
        • Higgins J.P.T
        • Gibbs J.S.R
        • Broadley K.E
        A systematic review of the use of opioids in the management of dyspnoea.
        Thorax. 2002; 57: 939-944
        • Uretsky B.F
        • Jessup M
        • Konstam M.A
        • Dec G.W
        • Leier C.V
        • Benotti J
        • et al.
        Multicenter trial or oral enoximone in patients with moderate to moderately sever congestive heart failure: lack of benefit compared to placebo.
        Circulation. 1990; 82: 774-780
        • Kubo S.H
        Effects of pimobendan on exercise tolerance and quality of life in patients with heart failure.
        Cardiology. 1997; 88: 21-27
        • Lowes B.D
        • Higginbotham M
        • Petrovich L
        • De Wood M.A
        • Greenberg M.A
        • Rahko P.S
        • et al.
        Low-dose enoximone improves exercise capacity in chronic heart failure. Enoximone Study Group.
        J Amer Coll Cardiol. 2000; 36: 501-508
        • Grady K.L
        • Dracup K
        • Kennedy G
        • Moser D.K
        • Piano M
        • Stevenson L.W
        • et al.
        Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association.
        Circulation. 2000; 102: 2443-2456
        • Hunt S.A
        Current status of cardiac transplantation.
        JAMA. 1998; 280: 1692-1698
        • Moss A.J
        • Zareba W
        • Hall W.J
        • Klein H
        • Wilber D.J
        • Cannom D.S
        • et al.
        Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.
        N Engl J Med. 2002; 346: 877-883
        • Stevenson L.W
        Rites and responsibilities for resuscitation in heart failure, tread gently on the thin places.
        Circulation. 1998; 98: 619-622
        • Abraham W.T
        • Fisher W.G
        • Smith A.L
        • Delurgio D.B
        • Leon A.R
        • Loh E
        • et al.
        MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation.
        N Engl J Med. 2002; 346: 1845-1853
        • Young J.B
        • Abraham W.T
        • Smith A.L
        • Leon A.R
        • Lieberman R
        • Wilkoff B
        • et al.
        Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: The MIRACLE ICD Trial.
        JAMA. 2003; 289: 2685-2694
        • Martensson J
        • Dracup K
        • Fridlund B
        Decisive situations influencing spouses' support of patients with heart failure: a critical incident technique analysis.
        Heart Lung J Acute Crit Care. 2001; 30: 341-350
        • Evangelista L.S
        • Dracup K
        • Doering L
        • Westlake C
        • Fonarow G.C
        • Hamilton M
        Emotional well-being of heart failure patients and their caregivers.
        J Card Fail. 2002; 8: 300-305
        • Walden J.A
        • Dracup K
        • Westlake C
        • Erickson V
        • Hamilton M.A
        • Fonarow G.C
        Educational needs of patients with advanced heart failure and their caregivers.
        J Heart Lung Transplant. 2001; 20: 766-769
        • The SUPPORT Principal Investigators
        A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).
        JAMA. 1995; 274: 1591-1598
        • Teno J.M
        • Fisher E.S
        • Hamel M.B
        • Coppola K
        • Dawson N.V
        Medical care inconsistent with patients' treatment goals: association with 1-year medicare resource use and survival.
        J Am Geriatr Soc. 2002; 50: 496-500
        • Rector T.S
        • Tschumperlin L.K
        • Kubo S.H
        • Bank A.J
        • Francis G.S
        • McDonald K.M
        • et al.
        Use of the Living With Heart Failure questionnaire to ascertain patients' perspectives on improvement in quality of life versus risk of drug-induced death.
        J Card Fail. 1995; 1: 201-206
        • Teno J.M
        • Lynn J
        Putting advance-care planning into action.
        J Clin Ethics. 1996; 7: 205-213
        • Foley K.M
        The World Health Organization program in cancer pain relief and palliative care.
        in: Gebhart G.I Hammond D.L Jensen T.S Proceedings of the 7th World Congress on Pain: Progress in Pain Research and Management. Vol. 2. IASP Press, Seattle (WA)1994: 59-74
        • Committee on Quality Health Care in America
        Crossing the quality chasm: a new health system for the 21st century.
        National Academy Press, Washington, D.C2001
        • Lewis E.F
        • Johnson P.A
        • Johnson W
        • Collins C
        • Griffin L
        • Stevenson L.W
        Preferences for quality of life or survival expressed by patients with heart failure.
        J Heart Lung Transplant. 2001; 20: 1016-1024
        • Krumholz H.M
        • Phillips R.S
        • Hamel M.B
        • Teno J.M
        • Bellamy P
        • Broste S.K
        • for the SUPPORT Investigators
        • et al.
        Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT Project.
        Circulation. 1998; 98: 648-655
        • Back A
        • Arnold R.M
        • Quill T
        Hoping for the best, preparing for the worst.
        Ann Int Med. 2003; 138: 439-444
        • Butow P.N
        • Hagerty R
        • Tattersall M.H.N
        Communicating prognosis to patients with metastatic disease: what do they really want to know?.
        Supportive Care Cancer. 2002; 10: 161-168
        • Finucane T.E
        Care of patients nearing death: another view.
        J Am Geriatr Soc. 2002; 50: 551-553