Table 2.

Summary of Key Heart Failure Guidelines Advocating for the Integration of Palliative Care

Guideline title	Sponsoring society/organization	Key palliative care domains covered in document	Notable specific mentions of palliative care
2011 CCS HF Management Guidelines Update36	The CCS	The provision of palliative care to patients with HF should be based on a thorough assessment of needs and symptoms, rather than on individual estimate of remaining life expectancy	CCS adapted WHO definition of palliative care: “Palliative care is a patient-centered and family-centered approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. It is applicable early, as well as later, in the course of illness, in conjunction with other therapies that are intended to prolong life, including but not limited to in the setting of heart failure, oral pharmacotherapy, surgery, implantable device therapy, hemofiltration or dialysis, the use of intravenous inotropic agents, and ventricular assist devices.”
		Clinicians looking after HF patients should initiate and facilitate regular discussions with patients and family regarding advance care planning
		In the presence of persistent advanced HF symptoms (NYHA III–IV) despite optimal therapy be confirmed, offer palliative care ideally by an interdisciplinary team with expertise in HF management, to ensure appropriate HF management strategies have been considered and optimized, in the context of patient goals and comorbidities.
2012 AHA Scientific Statement “Decision Making in Advanced HF”33	American Heart Association	Recommend referral to palliative care for assistance with difficult decision making, symptom management in advanced disease, and caregiver support even as patients continue to receive disease-modifying therapies	“…[I]t is important to integrate palliative care into the care of patients with HF before they enter stage D. Even as patients are being considered for transplantation, mechanical circulatory support, or trials of novel therapeutics and pharmacological agents, palliative care can be increasingly integrated to ensure that patients' symptoms are appropriately controlled and that patients understand the nature of these interventions, as well as the full complement of alternative therapies.”
		The use of palliative care services should not be considered equivalent to the withdrawal of disease-modifying therapies
		Highly skilled communication is essential to shared decision making
2013 Guidelines for the Management of HF10	American College of Cardiology Foundation and the American Heart Association Task Force on Practice Guidelines	Comprehensive palliative care for HF delivered by clinicians should include expert symptom assessment and management	“Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed…consideration for palliative care or hospice care in selected patients.”
2013 ISHLT Guidelines for Mechanical Circulatory Support34	International Society for Heart and Lung Transplantation	Palliative care consultation should be a component of the treatment of end-stage HF during the evaluation phase for mechanical circulatory support	“Palliative care consultation should be a component of the treatment of end-stage heart failure during the evaluation phase for MCS. In addition to symptom management, goals and preferences for end of life should be discussed with patients receiving MCS as DT.”
		Goals and preferences for end-of-life care should be discussed with patients receiving mechanical circulatory support as destination therapy	“A multidisciplinary team led cooperatively by cardiac surgeons and cardiologists and composed of subspecialists (i.e., palliative care, psychiatry, and others as needed) …is indicated for the in-hospital management of MCS patients.”
The 2015 Statement from the HFSA Guidelines Committee on Advanced (Stage D) HF35	Heart Failure Society of America	Incorporation of palliative care and hospice care into the care plans for patients with advanced HF	“The optimal approach [to advance care planning] involves shared decision making, where options for medical care are discussed with acknowledgment and legitimization of the complex trade-offs behind each choice…Involving palliative care specialists can facilitate the [advance care planning] conversation and, for patients who prioritize comfort over longevity, help to ensure access to necessary resources for enactment of a less aggressive path. Ideally, such conversations should be initiated before the transition to terminal stages of HF…”
		Specifying that decision making should involve incorporating the patient's wishes for survival versus quality of life.
2015 HF Management in Skilled Nursing Facilities87	American Heart Association and Heart Failure Society of America	Advance care planning	“Decisions to balance palliative and disease-directed treatments may include withholding treatments of marginal potential efficacy, withdrawal decisions after treatments have been started, hospice referral for palliation, and determining whether end-of-life care will occur in the SNF or elsewhere. End-of-life care plan quality measures may be very important considerations for HF patients and potentially of value for improving patterns of care… These measures should be strongly considered for application in HF patients in SNFs.”
		Symptom management
		End-of-life care
		Hospice
		Transitions
		Care management
		Device management
		Caregiver support
JCAHO Advanced Certification Program for VAD for Destination Therapy37	Joint Commission for the Accreditation of Hospital Organizations	Revised requirements for the DSC advanced certification program for VAD for Destination Therapy	“The Joint Commission announced revisions to requirements for the DSC advanced certification program for VAD for Destination Therapy… to add a palliative care representative to the core interdisciplinary team.”
		Specifically added a requirement to have a palliative care representative to the core interdisciplinary team.
CMS Memorandum for VADs for Bridge-to-Transplant and Destination Therapy38	Centers for Medicaid and Medicare Services	Mandated the inclusion of palliative care specialists in the multidisciplinary team of medical professionals caring for beneficiaries receiving VADs for DT.	“Beneficiaries receiving VADs for DT must be managed by an explicitly identified cohesive multidisciplinary team of medical professionals with the appropriate qualifications, training, and experience. The team embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. Collectively, the team must ensure that patients and caregivers have the knowledge and support necessary to participate in shared decision-making and to provide appropriate informed consent. The team members must be based at the facility and must include individuals with experience working with patients before and after placement of a VAD.”
			“The team must include a palliative care specialist.”

AHA, American Heart Association; CCS, Canadian Cardiovascular Society; CMS, Centers for Medicare & Medicaid Services; DSC, disease-specific care; DT, destination therapy; HFSA, Heart Failure Society of America; ISHLT, International Society for Heart and Lung Transplantation; MCS, mechanical circulatory support; VAD, ventricular assist device; WHO, World Health Organization.