Patterns of Care During the Terminal Hospital Admission for Patients With Advanced Heart Failure: A Retrospective Cohort Study

Costs of end of life care for patients who have advanced heart failure (HF) are increasing. There is a perception that many of these patients receive aggressive treatments near the end of life. However, actual patterns of care are unclear. In this article we describe the use of life-sustaining treatments and the timing of goals of care discussions during patients' terminal admission for HF. We conducted a single-centre retrospective cohort study of patients aged 18 years or older with a most responsible discharge diagnosis of HF who died between April 2012 and December 2013. We identified 133 eligible decedents of whom 67 (50%) received some form of life-sustaining treatment, although only 14 (11%) received cardiopulmonary resuscitation (CPR). The first documented orders for scope of treatment were: CPR for 39 (29%), active medical treatment with no CPR for 81 (61%), and comfort care with no CPR for 11 (8%) patients. The last documented orders were for comfort care in 85 (64%) patients. There were 28 (21%) patients who received palliative care consultation. Median time between palliative care consultation and death was 6 days and between orders for comfort care and death was 24 hours. In contrast to the high mortality risk of our study cohort, palliative care consultation was often absent or in the final days of life, with orders for comfort-oriented care being written only 24 hours before death, suggesting there remain opportunities for earlier integration of palliative and goal-directed approaches to therapy for patients who have advanced HF.