End-of-life care for elderly patients with heart failure

The mortality rate of elderly persons with heart failure is high despite th e introduction of several effective therapeutic interventions during the pa st decade. The management of end of life, often associated with distressing symptoms and multiple hospitalizations, is a significant clinical problem. Skillful and effective management requires expert knowledge of the heart f ailure syndrome, but the critical dimension of care relates to detailed kno wledge about a patient's comorbidities, extent of debility, values, and des ires. Discussing end-of-life issues early in the course of illness is essen tial for determining the appropriate levels of intensity of care and for de fining the circumstances in which patients wish to be hospitalized and when hospital care offers little potential for increased comfort or longevity. Early and repeated discussions are needed to consider matters such as livin g wills, do-not-resuscitate orders, and power of attorney. In light of the complexity of the health care system, including involvement of multiple car egivers, end-of-life issues are among the most demanding of a physician's t ime, but when end-of-life care is managed effectively, health care provider s often are rewarded with the gratitude of patients and their families for minimizing suffering and providing optimal opportunities for patients to pa rticipate in the affairs of family and the community.