Table 4.

Triggers for Formally Assessing Prognosis and Having Conversations About Goals of Care and Voluntary Advance Care Planning

Routine “Annual Heart Failure Review” with a scheduled clinic visit Event-driven “milestones” that should prompt reassessment Increased symptom burden and/or decreased quality of life Significant decrease in functional capacity Loss of ADLs Falls Transition in living situation (independent to assisted or LTC) Worsening heart failure prompting hospitalization, particularly if recurrent57 Serial increases of maintenance diuretic dose Symptomatic hypotension, azotemia, or refractory fluid retention necessitating neurohormonal medication underdosing or withdrawal58 Circulatory-renal limitations to ACEI/ARB Decrease or discontinuation of β-blockers because of hypotension First or recurrent ICD shock for VT/VF59 Initiation of intravenous inotropic support Consideration of renal replacement therapy Other important comorbidities: new cancer, etc Major “life events”: death of a spouse

ADL indicates activities of daily living; LTC, long-term care; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; ICD, implantable cardioverter-defibrillator; VT, ventricular tachycardia; and VF, ventricular fibrillation.