Prognostication |
Formulate an individualized estimate for patients to help them understand their disease status and prognosis while acknowledging the unpredictable nature of the disease; begin such conversations by asking if the patient wants this information to ensure the level of information delivered is in line with their desire for the knowledge. |
Communication |
Engage with patients and their families in shared decision-making by using open-ended question to explore patient understanding, desired outcomes, and how they define optimal outcomes. |
Advanced care planning |
Discuss goals of care and appropriate treatments based on those goals early in the disease process and re-evaluate these goals over time as the patient’s disease progresses. |
Palliative care |
Consider referral to specialty-level palliative care when patients have refractory symptoms or when barriers to communication and advance care planning are encountered. |
Palliation not withdrawal |
Effectively communicate with patients and their families that palliative care provides holistic person-centered care aimed at improving quality of life. It is not withdrawal of treatment and is not the same as hospice. |
Symptom management |
Recognize and treat common heart failure symptoms and sources of distress including dyspnea, pain, fatigue, anxiety, insomnia, and depression. |
Grief and bereavement |
Involve family members and caregivers in all plans of care to help them cope with the patient’s illness and reduce their risk of complicated bereavement. |
Spiritual aspect |
Integrate spiritual care for patients to improve their quality of life and provide holistic care of the patient and family. |
Device deactivation |
Discuss the option of device deactivation with patients with advanced illness as appropriate based on their goals and wishes for their health care. |
Legal and ethical perspective |
Understand and explain to patients and families that device deactivation is neither assisted suicide nor euthanasia. It is legally and ethically permissible. |