Table 1.

Primary Palliative Care versus Specialist Palliative Care for patients with HF and Their Families

Domains		Primary palliative care (PPC)	When to refer to Specialist Palliative Care (SPC)
Symptom Management	Shortness of breath	Maximize HF therapies to relieve congestion	Debilitating refractory dyspnea despite PPC interventions
	Pain	-Maximize antianginal medications and recommend activity modification for anginal pain -Acetaminophen or single agent opioid therapy for somatic pain -Referral to physical therapy for musculoskeletal pain if patient is possible	-Pain refractory to PPC interventions -Neuropathic pain
	Depressed mood	Treat low mood from an adjustment reaction by referral for psychotherapy or initiation of anti-depressant medication if appropriate	- Symptoms of major depressive disorder such as incapacitating hopelessness and anhedonia requiring medical management
	Anxiety	Treat mild anxiety with referral to psychologist for help with relaxation techniques and psychotherapy or initiation of anxiolytic medication if appropriate	Debilitating anxiety or panic symptoms that prevent the patient from participating in regular activities
	Nausea	-Adjust HF therapies -Consider adding single agent anti-emetic	Ongoing symptoms despite PPC interventions
	Fatigue	-Maximize HF therapies -Referral to cardiac rehabilitation -Evaluate and treat for insomnia -Evaluate for sleep disordered breathing if indicated	-Ongoing symptoms despite PPC -Patients unable to participate in cardiac rehabilitation -SPC can provide pharmacotherapy for fatigue.
	Insomnia	-Education on sleep hygiene -Treat mild associated anxiety with psychotherapy and relaxation techniques	-Refractory to PPC interventions -SPC can provide pharmacotherapy for insomnia and/or associated anxiety and advanced education on sleep hygiene
Communication	Discussing code status	Patients with clear wishes and an understand of prognosis after CPR	- Patients unable to verbalize understanding of their illness and prognosis after CPR
	Advance care planning	Patients with clear wishes, has already identified a surrogate and family/surrogates who support those wishes.	-Patients unable to verbalize understanding of their illness and prognosis -Patients and families who are in disagreement about the patient’s end-of-life choices -Disagreement about the chosen surrogate or the patient is ambivalent about choice
	Discussions to withdraw life sustaining therapies	Patients and/or surrogates who verbalize a clear understanding of the patients prognosis with and without therapy and can base decisions made on patient’s goals and values.	-Patients and/or surrogates unable to verbalize clear understanding of prognosis -Patients and/or surrogates who are in disagreement (conflict) about the treatment that best matches patient’s goals and values -Surrogates with lack of insight into patient’s goals and values
	Request for assisted suicide	Referral to specialist level palliative care	SPC to navigate complex request and explore other options
Psychosocial support	Patient support	-Supportive listening -Referral to HF team social worker	Refer to SPC when needs exceed the expertise of HF social worker, especially around issues of end of life care such as counseling parents on how to talk to their children
	Caregiver support	-Supportive listening -Referral to HF team social worker	Refer to SPC when needs exceed the expertise of the HF social worker, especially when caregiver has significant needs or the patient and caregiver are in conflict
Care coordination		-Communication with other providers caring for the patient -Straightforward referral for home hospice for patients with good support at home and without complex medical or social needs	Complex hospice or home care referral for patients who require placement in facilities with need for complex medical management (e.g. palliative home inotropes)