End-of-Life Options for Patients with Advanced Heart Failure Judith Z. Goldfinger & Eric D. Adler Published online: 30 June 2010 # Springer Science+Business Media, LLC 2010 Abstract Heart failure is a progressive disease with significant morbidity and mortality, but prognostication often is difficult. Many of the evidence-based therapies for heart failure provide symptomatic benefit, but may have intolerable side effects for patients with advanced disease. At the end of life, there is evidence of varying strengths for pharmacologic and nonpharmacologic relief of common symptoms like dyspnea, fatigue, pain, and depression. Patients also may benefit from inotropic therapy, ventricular assist devices, and hospice care. It is important for physicians to encourage patients to formulate advance directives, including decisions about do not resuscitate orders and deactivation of implantable cardioverter- defibrillators and ventricular assist devices. Keywords Heart failure . Palliative care . Hospice . Inotropic therapy . Brain natriuretic peptide . Ventricular assist device . Implantable cardioverter-defibrillator . ICD deactivation . Cardiac resynchronization therapy . Advance directives . Do not resuscitate order Introduction Heart failure (HF) currently affects more than 5 million Americans, and, unlike other forms of cardiovascular disease, prevalence is rising. After diagnosis, 1-year mortality is 1 in 5, with a six- to ninefold increased risk of sudden cardiac death [1]. Roughly 5% of patients with HF worldwide have end-stage disease that is refractory to conventional medical management. Only a minority of these end-stage patients are young enough, healthy enough, and have the requisite social support to be eligible for a heart transplant; of those who are eligible, only a fraction will receive a heart. The patients who continue to live with HF have worse quality of life and higher rates of depression, pain, dyspnea, and fatigue [2, 3]. The focus of this article will be options for patients and their caregivers to improve the quality of life, as well as the “quality of death.” Advanced therapies, such as heart transplantation, may be appropriate for a small selection of patients but are beyond the scope of this article. Prognostication: Identification of the End-Stage Patient HF is a progressive chronic disease that is generally characterized by acute exacerbations superimposed on a more gradual decline [4]. However, for many patients, the trajectory of disease takes a more variable pattern. Because of the variability in disease trajectory, it is notoriously difficult to prognosticate in HF. Determining prognosis is critical in establishing when patients may be appropriate for advanced therapies, such as cardiac trans- plantation and mechanical circulatory support. Furthermore, if a physician certifies that a patient has fewer than 6 months to live and the patient agrees to forego curative or life- J. Z. Goldfinger Department of Medicine, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1118, New York, NY 10029, USA E. D. Adler (*) Cardiovascular Medicine, Oregon Health Sciences University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA e-mail: adler@ohsu.edu Curr Heart Fail Rep (2010) 7:140–147 DOI 10.1007/s11897-010-0017-5