It’s Time to Talk: Challenges in Providing Integrated Palliative Care in Advanced Congestive Heart Failure. A Narrative Review

摘要

Background: Congestive heart failure is an increasingly prevalent terminal illness in aglobally aging population. Prognosis for this disease remains poor despite optimal therapy. Evidencesuggests that a palliative care approach may be beneficial – and is currently recommended –in advanced congestive heart failure but these services remain underutilized.Objectives: To identify the main challenges to the access and delivery of palliative care in patientswith advanced congestive heart failure, and to summarize recommendations for clinical practicebased on the available literature.Methods: MEDLINE and EMBASE were searched for articles published from 1995-2017pertaining to end of life care in individuals suffering from CHF. Only four randomized controlledtrials were found.Results: We identified ten key challenges to access and delivery of palliative care services in thispatient population: (1) Prognostic uncertainty, (2) Provider education/training, (3) Ambiguity surroundingcoordination of care, (4) Timing of palliative care referral, (5) Inadequate communitysupports, (6) Difficulty communicating uncertainty, (7) Fear of taking away hope, (8) Insufficientadvance care planning, (9) Inadequate understanding of illness, and (10) Discrepant patient/familycare goals. Provider and patient education, early discussion about prognosis, and a multidisciplinaryteam-based approach are recommended as we move towards a model where symptom palliation existsconcurrently with active disease-modifying therapies.Conclusion: Despite evidence that palliative care may improve symptom control and quality of lifein patients with advanced congestive heart failure, a multitude of current challenges hinder accessto these services. Education, early discussion of prognosis and advance care planning, andmultidisciplinary team-based care may be a helpful initial approach as further targeted work addressesthese challenges.