Palliative care and non- oncological diseases Heart failure

Palliative care and non-oncological Palliative care and non-oncological diseasesdiseases

Heart failureHeart failure

Christine Waerenburgh, RNChristine Waerenburgh, RNMBE Noord-West-VlaanderenMBE Noord-West-Vlaanderen

Bart Van den Eynden, MD PhD Bart Van den Eynden, MD PhD Medical Director Centre for Palliative Care Sint-CamillusMedical Director Centre for Palliative Care Sint-Camillus

Chair of Palliative MedecineChair of Palliative MedecineUniversity of University of AntwerpAntwerp

Table of contentsTable of contents CaseCase Which patients would benefit from palliative care?Which patients would benefit from palliative care? EpidemiologyEpidemiology SymptomsSymptoms

– Dying from heart failureDying from heart failure How do patient and family experience heart failure and how How do patient and family experience heart failure and how

do patients with advanced heart failure consider dying?do patients with advanced heart failure consider dying? Care planCare plan

– Breaking the bad newsBreaking the bad news– Care in the case of a patient with heart failureCare in the case of a patient with heart failure– ACPACP– What in the case of a pacemaker - defibrillatorWhat in the case of a pacemaker - defibrillator– Different palliative care settingsDifferent palliative care settings

ConclusionConclusion






Case JoannesCase Joannes

Environment (2006)Environment (2006)– man, age of 70 man, age of 70 – lives with his son and his daughter of 12lives with his son and his daughter of 12– regularly visited byregularly visited by

– his neighbourhis neighbour

– some friendssome friends

– he likes travelling: last journey september 2003he likes travelling: last journey september 2003– But during this last year:But during this last year:

– able only to do minimal movements in his living roomable only to do minimal movements in his living room

– physical activity: nihilphysical activity: nihil

Case Joannes (2)Case Joannes (2)

Medical historyMedical history– Myocard infarct: 1984Myocard infarct: 1984– Depression: 1986Depression: 1986– Acute inferior infarct with cardiac arrest: 1991Acute inferior infarct with cardiac arrest: 1991– Hepatitis - icterus: 1991Hepatitis - icterus: 1991– Cholecystitis and cholangitis: 1991Cholecystitis and cholangitis: 1991– Bypass surgery: 1994Bypass surgery: 1994– Acute abdomen → appendectomie: 2003Acute abdomen → appendectomie: 2003


Problems December 2005Problems December 2005 Breathing difficultiesBreathing difficulties Chronic renal insufficiencyChronic renal insufficiency Abnormal liver enzymesAbnormal liver enzymes

Hospitalization March 2006Hospitalization March 2006 Severe dyspneaSevere dyspnea Swelled abdomenSwelled abdomen Feeling miserableFeeling miserable Not able to do anythingNot able to do anything


DiagnosisDiagnosis severe ischemic cardiomyopathy due to global heart severe ischemic cardiomyopathy due to global heart

failurefailure ascitesascites chronic renal insufficiencychronic renal insufficiency


Joannes left the hospital for his home (…for Joannes left the hospital for his home (…for the last time…)the last time…)

He feels more comfortable but not optimalHe feels more comfortable but not optimal He wants to go home to sort out his affairsHe wants to go home to sort out his affairs Professional and informal care are providedProfessional and informal care are provided Once again his medication has been adaptedOnce again his medication has been adapted

CaseJoannes (6)CaseJoannes (6)

– MedicationMedication– Dispril 75 mg – 1 compDispril 75 mg – 1 comp– Flixotide Rotadisk 250µgr/dos – 2 x dgFlixotide Rotadisk 250µgr/dos – 2 x dg– Lanoxin 0,250mg – 5 x/weekLanoxin 0,250mg – 5 x/week– Burinex Leo 5 mg – ½ Burinex Leo 5 mg – ½ – Lorametazepam 2mg (on request)Lorametazepam 2mg (on request)– Cedocard sublinguaal ( on request)Cedocard sublinguaal ( on request)– Spironolactone 100mg ¼ compSpironolactone 100mg ¼ comp– EmconcorEmconcor

– Till that day……..Till that day……..






Palliative care for cardiac patients?Palliative care for cardiac patients?

Heart failureHeart failure– Syndrome with symptoms, signs and objective evidence Syndrome with symptoms, signs and objective evidence

of left heart dysfunctionof left heart dysfunction– Caused by hypertension, coronary diseases, heart valve Caused by hypertension, coronary diseases, heart valve

stenosis or –insufficiency, primary cardiac diseasesstenosis or –insufficiency, primary cardiac diseases Pulmonary hypertensionPulmonary hypertension Angina pectoris resistant to further therapyAngina pectoris resistant to further therapy Congenital heart diseasesCongenital heart diseases






EpidemiologyEpidemiology Mainly elderly (but can start sometimes at young age)Mainly elderly (but can start sometimes at young age) Prevalence UK (Cowie et al, 1997): Prevalence UK (Cowie et al, 1997):

– Between 3.8 en 29.4/1000Between 3.8 en 29.4/1000– >65 : 80.5/1000>65 : 80.5/1000– >80 : 190/1000>80 : 190/1000

Prevalence USA: Prevalence USA: – Age 40-59j: 2%Age 40-59j: 2%– >70j: 10%>70j: 10%

Incidence: 2.3 – 3.3 (>75j: 43.5)/1000/yearIncidence: 2.3 – 3.3 (>75j: 43.5)/1000/year Number of patients:Number of patients:

– USA: nu 4.79 million pts USA: nu 4.79 million pts → 2037: 10 million pts→ 2037: 10 million pts– UK: 60000 deceases a yearUK: 60000 deceases a year– Europe: nu: 10 million pt - increase parallel with ageing of the populationEurope: nu: 10 million pt - increase parallel with ageing of the population– All over the world: 2030 →30 million ptAll over the world: 2030 →30 million pt

Prevalence, incidence and mortality increasePrevalence, incidence and mortality increase Heart failure will be an important, increasing problem and a hug Heart failure will be an important, increasing problem and a hug

challenge in/for the futurechallenge in/for the future


– Dying from heart failure Dying from heart failure How do patient and family experience heart failure and how How do patient and family experience heart failure and how




SymptomatologySymptomatology

2 mechanismes: 2 mechanismes: – Decrease of the heart beat volumeDecrease of the heart beat volume– Fluid retentionFluid retention

3 Phases:3 Phases:– Acute phase: needs most of the time an urgent Acute phase: needs most of the time an urgent

hospitalisationhospitalisation– Chronic phase: often progressive, with Chronic phase: often progressive, with

symptoms more and more noticeable and symptoms more and more noticeable and visiblevisible

– Terminal phase: when dying becomes Terminal phase: when dying becomes imminently (offering specific problems) imminently (offering specific problems)

Death

High

LowTime

Function

Death

High

LowTime

Function

Organ failure

6

Other2

Dementia, frailty and decline

7

3 possible disease trajects

Death

High

LowTime

Function

5

Cancer

GP has 20deaths per year

““Cancer” Trajectory, Diagnosis to DeathCancer” Trajectory, Diagnosis to Death

TimeOnset of incurable cancer-- Often a few years, but decline usually < 2 months

Fun

ctio

n

Death

High

Low

Cancer

Specialist palliative care available

Need: Excellent medical care meshed with supportive hospice care

Organ System Failure TrajectoryOrgan System Failure Trajectory

Fun

ctio

n

Death

High

Low

(mostly heart and lung failure)

Begin to use hospital often, self-care becomes difficult

~ 2-5 years, but death usually seems “sudden”

Time

Need: Disease management, advance care planning, rapid interventionNeed to avoid: prognostic paralysis

Dementia/Frailty TrajectoryDementia/Frailty Trajectory

Time Quite variable -up to 6-8 years

Death

High

Low

Onset could be deficits in ADL, speech, ambulation

Function

Needs: Supportive care over many years, carer support

Frequency of symptoms of patients with heart failure Frequency of symptoms of patients with heart failure in NYHAIII en IV (Norgren en Sörensen, 2003)in NYHAIII en IV (Norgren en Sörensen, 2003)


Typical symptoms are: Typical symptoms are: – Dyspnoe, breathlessnessDyspnoe, breathlessness

– Unpleasant feeling of asthenia and tirednessUnpleasant feeling of asthenia and tiredness

– Associated with: limitation of physical activity and mobility, Associated with: limitation of physical activity and mobility, loss of quality of life, anguish and depressive moodloss of quality of life, anguish and depressive mood

Dyspnoe and tiredness not directly caused by the Dyspnoe and tiredness not directly caused by the decrease of heart function (probably peripheral decrease of heart function (probably peripheral mechanisms are playing an important etiological mechanisms are playing an important etiological role) role)


Quality of Life (QoL) mostly bad (even more Quality of Life (QoL) mostly bad (even more bad than in the case of other chronic bad than in the case of other chronic diseases)diseases)– Psychological factors are playing a much more Psychological factors are playing a much more

important role than the physical handicapimportant role than the physical handicap– Major depression (DSM-IV): 36.5% ( only 17% Major depression (DSM-IV): 36.5% ( only 17%

in the case of heart diseases without heart in the case of heart diseases without heart failure) – often not treated, not even a failure) – often not treated, not even a psychiatric consult psychiatric consult

SymptomatologySymptomatology Very sensible for episodes of acute decompensation of Very sensible for episodes of acute decompensation of

heart failure with exacerbation of dyspnea, fluid retention heart failure with exacerbation of dyspnea, fluid retention and symptomatic deteriorationand symptomatic deterioration– Most of the time unexspectedMost of the time unexspected– In-hospital mortality of 8%In-hospital mortality of 8%– Re-hospitalisation: 29-47% within 3 months, 36-44% within 6 mm = Re-hospitalisation: 29-47% within 3 months, 36-44% within 6 mm =

the highest figure of re-hospitalisation of all hospitalized groups of the highest figure of re-hospitalisation of all hospitalized groups of patientspatients

– Causes of these frequent deterioration: Causes of these frequent deterioration: Deficient compliance (medication)Deficient compliance (medication) Faults and deficiency concerning diet (salt)Faults and deficiency concerning diet (salt) Failure of the social supportFailure of the social support Infections, myocardial ischemia, pulmonary embolismInfections, myocardial ischemia, pulmonary embolism Frequent co-morbidity (using medication like corticosteroids, Frequent co-morbidity (using medication like corticosteroids,

increasing the fluid retention)increasing the fluid retention)

SymptomatologySymptomatology Further progressive deteriorationFurther progressive deterioration

– leads to fluid retention:leads to fluid retention: with peripheral oedemawith peripheral oedema with pleural effusionswith pleural effusions with asciteswith ascites

– Worsening of the symptoms: breathlessness in rest, only easy Worsening of the symptoms: breathlessness in rest, only easy breathing when sitting upright, sleeping disturbances, anorexia, breathing when sitting upright, sleeping disturbances, anorexia, cachexia, muscle weakness, sexual dysfunction, nausea and cachexia, muscle weakness, sexual dysfunction, nausea and vomitingvomiting

– Pain:Pain: Important symptom in the case of terminal heart failureImportant symptom in the case of terminal heart failure Characteristics, pathophysiology and cause not totally understoodCharacteristics, pathophysiology and cause not totally understood SUPPORT-study (Lynn, 1997; USA): insufficient pain control in 9% of SUPPORT-study (Lynn, 1997; USA): insufficient pain control in 9% of

patients with heart failure (Desbiens, 1997)patients with heart failure (Desbiens, 1997)

Dying by heart failureDying by heart failure

Bad prognosis: in the case of a worsening Bad prognosis: in the case of a worsening left ventricle function continually more left ventricle function continually more serious symptoms and metabolic markers serious symptoms and metabolic markers

Simplest approach: New York Heart Simplest approach: New York Heart Association Classification of Heart FailureAssociation Classification of Heart Failure

No marker available to predict sudden deathNo marker available to predict sudden death


New York Heart Association Classification of Heart New York Heart Association Classification of Heart FailureFailure– NYHA class 1: NYHA class 1: No limitations – normal physical activity No limitations – normal physical activity

→ no excessive tiredness, dyspnoe, palpitations→ no excessive tiredness, dyspnoe, palpitations– NYHA class 2: Minor limitations of physical activities – NYHA class 2: Minor limitations of physical activities –

comfortable when in rest – normal physical activity leads comfortable when in rest – normal physical activity leads to tiredness, dyspnoe, palpitations, angorto tiredness, dyspnoe, palpitations, angor

– NYHA class 3: Clear limitations of physical activity – NYHA class 3: Clear limitations of physical activity – comfortable in rest – less than normal physical activity comfortable in rest – less than normal physical activity leads to tiredness, dyspnoe, angorleads to tiredness, dyspnoe, angor

– NYHA class 4: No physical activity without discomfort – NYHA class 4: No physical activity without discomfort – patient experiences symptoms while restingpatient experiences symptoms while resting

Dying caused by heart failureDying caused by heart failure

Dying of heart failure often more worse concerning Dying of heart failure often more worse concerning symptoms and distress than dying of cancersymptoms and distress than dying of cancer

Mortality: 31-48% after 1year – 76% after 3yearsMortality: 31-48% after 1year – 76% after 3years Most important difference with cancer: much more Most important difference with cancer: much more

uncertainty while approaching deathuncertainty while approaching death– mainly because of sudden death of otherwise stable mainly because of sudden death of otherwise stable

patientspatients– NYHA II: mild symptoms – yearly mortality: 5-15% - NYHA II: mild symptoms – yearly mortality: 5-15% -

sudden death: 50-80 %sudden death: 50-80 %– NYHA IV: very severe symptoms – yearly mortality: 30-NYHA IV: very severe symptoms – yearly mortality: 30-

70% - sudden death: 5-30%70% - sudden death: 5-30%

Dying because of heart failureDying because of heart failure

Most important cause of sudden death = Most important cause of sudden death = arrythmiasarrythmias

What about reanimation in the case of such What about reanimation in the case of such patients?patients?– SUPPORT: doctors often didn’t knew the wishes of SUPPORT: doctors often didn’t knew the wishes of

their patient and projected their own preferences on their patient and projected their own preferences on these patientsthese patients

– 69% preferred reanimation but was not enough 69% preferred reanimation but was not enough informed about their (real) quality of life after informed about their (real) quality of life after reanimation (in that situation they would not have reanimation (in that situation they would not have preferred reanimation)preferred reanimation)

Dying caused by heart failureDying caused by heart failure

Sudden death makes the classification of Sudden death makes the classification of ‘ terminal heart failure’ very uncertain and ‘ terminal heart failure’ very uncertain and ‘mysterious’ while ‘terminal’ refers to a ‘mysterious’ while ‘terminal’ refers to a clinical situation with criteria analogous to clinical situation with criteria analogous to the one of cancerthe one of cancer

Doctors are very bad in accurately Doctors are very bad in accurately recognizing the approaching death and recognizing the approaching death and hesitate to define and label heart failure hesitate to define and label heart failure patient as terminalpatient as terminal

Organ System Failure TrajectoryOrgan System Failure Trajectory

Fun

ctio

n

Death

High

Low

(mostly heart and lung failure)

Begin to use hospital often, self-care becomes difficult

~ 2-5 years, but death usually seems “sudden”

Time

Need: Disease management, advance care planning, rapid interventionNeed to avoid: prognostic paralysis






Living with heart failure = Living with heart failure =

Starting each day quietly…Starting each day quietly… Taking a rest when the body is asking for it…Taking a rest when the body is asking for it… Even better caring for a healthy lifestyle…Even better caring for a healthy lifestyle… Moderating the use of salt (sodium)Moderating the use of salt (sodium) Limiting fluid intake to a maximum of 2 litres a dayLimiting fluid intake to a maximum of 2 litres a day Loosing weight when obese…Loosing weight when obese… Being temperate with alcohol…Being temperate with alcohol… No smoking…No smoking…

Living with heart failure meansLiving with heart failure means

A radical eventA radical event

A adaptation processA adaptation process

PatientPatient– Changing realityChanging reality– Persistent consequencesPersistent consequences– Changes in :Changes in :

Personal reference framework;Personal reference framework;– selfimage, faith and conviction, meaning selfimage, faith and conviction, meaning

The own behaviourThe own behaviour– weight control, diet, medication, life style, weight control, diet, medication, life style, raising of negative feelings: fear, lonelinessraising of negative feelings: fear, loneliness

Patient and beloved one(s):Patient and beloved one(s):– Confrontation withConfrontation with

Physical and limitation(s)Physical and limitation(s) Cognitive limitation(s)Cognitive limitation(s)

– Changes in daily functioningChanges in daily functioning– Disappearing the self-evidence, self-trustDisappearing the self-evidence, self-trust– Consequences atConsequences at

a social levela social level a society levela society level

– Role patterns within the relationRole patterns within the relation– Changes in sexual functioning and relationshipChanges in sexual functioning and relationship

A duty for engaged professionals:A duty for engaged professionals:– Help and support in order to well complete the Help and support in order to well complete the

adaptation processadaptation process patientpatient partnerpartner

How does a patient with heart failure How does a patient with heart failure think about dying?think about dying?

Preparation to dying: yes/noPreparation to dying: yes/no– They think rarely on deathThey think rarely on death– They don’t believe their death will be caused by their They don’t believe their death will be caused by their

diseasedisease– Fear for death is mostly absentFear for death is mostly absent– Once they have been near to death, patients are more Once they have been near to death, patients are more

likely to think on itlikely to think on it– Thinking on the death impliesThinking on the death implies

Diminished quality of lifeDiminished quality of life Feeling of uselessnessFeeling of uselessness

How does a patient with heart failure How does a patient with heart failure think about dying? (2)think about dying? (2)

Decisions concerning end of lifeDecisions concerning end of life– Poor worry about end of lifePoor worry about end of life– Dimension of time plays an important roleDimension of time plays an important role– Avoiding to prolong the dying processAvoiding to prolong the dying process– No perspective of ameliorationNo perspective of amelioration– Patients desiring a quick death are concerned Patients desiring a quick death are concerned

about those left behindabout those left behind– Feeling useful and helpful = not being a burden Feeling useful and helpful = not being a burden

for the otherfor the other











To go about in truthTo go about in truth« In waarheid omgaan… »« In waarheid omgaan… »

patientpatient

the caregiverthe caregiver

In waarheid omgaan (2)In waarheid omgaan (2)

to associate with confrontationto associate with confrontation– ‘‘I have a disease’I have a disease’– ‘‘I am ill’I am ill’


‘‘I have a disease’I have a disease’– Heart failure can never be totally repairedHeart failure can never be totally repaired

periods of stabilityperiods of stability periods that heart failure increasesperiods that heart failure increases

– Comfort by means ofComfort by means of medicationmedication dietdiet rest and peace…rest and peace…


‘‘I am ill’I am ill’– Patient know that his/her comfort increases by Patient know that his/her comfort increases by

means of….means of….

– Adaptation to the new situationAdaptation to the new situation Experience of timeExperience of time ActivitiesActivities RelationshipRelationship


To go about with confessionTo go about with confession– ‘ ‘ to confess is difficultto confess is difficult

To confess that you are illTo confess that you are ill Can create anxiety and anguishCan create anxiety and anguish

– Feeling of guilt about the pastFeeling of guilt about the past– Fear for the coming futureFear for the coming future

To be able to go about with therapyTo be able to go about with therapy To give and to admit confidence and faithTo give and to admit confidence and faith


‘‘what means to go about in truth for me?’what means to go about in truth for me?’

– The relation with the patientThe relation with the patient Does de patient live in truth with his heart failure?Does de patient live in truth with his heart failure? Am I able to go about in truth with the patient?Am I able to go about in truth with the patient?


How can I discover that the patient goes How can I discover that the patient goes about in truth?about in truth?

How can I help the patient with his How can I help the patient with his adaptation process?adaptation process?






Care for patients with heart failureCare for patients with heart failure

General:General:– To continue the existing therapies?To continue the existing therapies?– Care in order to offer comfort and to relieve Care in order to offer comfort and to relieve

discomfortdiscomfort

Drug optionsDrug options No-medication possibilitiesNo-medication possibilities

Care for patients with heart failureCare for patients with heart failure

General:General:– To continue the actual treatments?To continue the actual treatments?

What does the patient like? What are his or her preferences? This What does the patient like? What are his or her preferences? This means communication, discussion and consultationmeans communication, discussion and consultation

ACE-inhibitors, diuretics, beta-blocking agents….ACE-inhibitors, diuretics, beta-blocking agents…. To continue or to stop?To continue or to stop? Co-morbidities like diabetes, COLD e.a. are in most of the cases Co-morbidities like diabetes, COLD e.a. are in most of the cases

not treated anymore in the palliative phasenot treated anymore in the palliative phase

– Care for comfortCare for comfort Patient-centred carePatient-centred care Quality of life and the relief of symptoms are the priority!!!Quality of life and the relief of symptoms are the priority!!!

Care for patient with terminale heart Care for patient with terminale heart failurefailure

MedicationMedication– OxygenOxygen– Pain treatmentPain treatment– Morphine: dyspnea (+ anxiety and agitation)Morphine: dyspnea (+ anxiety and agitation)– Anti-depressive medication (and psychological Anti-depressive medication (and psychological

support)support)

Care for patients with (terminal) Care for patients with (terminal) heart failureheart failure

Possibilities other than medicationPossibilities other than medication– Communication, (active) listeningCommunication, (active) listening– Interventions toInterventions to

Diminish anxietyDiminish anxiety In case of agitationIn case of agitation In case of dyspneaIn case of dyspnea In case of oedema of the legsIn case of oedema of the legs …………






Advance Care Directives Advance Care Directives (Advance Care Planning)(Advance Care Planning)

Tools allowing to develop a conversation and Tools allowing to develop a conversation and decision making about end of life on a decision making about end of life on a structured waystructured way

All aspects should get a chance as much as All aspects should get a chance as much as possiblepossible

Everything carefully written downEverything carefully written down Engagement of the caregivers to deliver to the Engagement of the caregivers to deliver to the

heart failure patient the optimal care, choosen heart failure patient the optimal care, choosen and permitted by the patient him/herselfand permitted by the patient him/herself

Advance care directivesAdvance care directivesACPACP

AimAim– To increase the possibilities to discuss the nearing end To increase the possibilities to discuss the nearing end

of lifeof life– The patient is allowed to formulate his wishes and The patient is allowed to formulate his wishes and

preferences and to negotiate about concrete care preferences and to negotiate about concrete care initiatives with the caregiversinitiatives with the caregivers

– ACP meets the duty to inform the patient about his right ACP meets the duty to inform the patient about his right to and the possibilities of palliative careto and the possibilities of palliative care

– Caregivers are learning (to explore) the wishes and Caregivers are learning (to explore) the wishes and exspectations of the patient; they can anticipate on exspectations of the patient; they can anticipate on these, while finally increasing the quality of the delivered these, while finally increasing the quality of the delivered carecare






Implanted Cardioverter Defibrillator(ICD)Implanted Cardioverter Defibrillator(ICD)en Pacemaker: Quid?en Pacemaker: Quid?

ICD in the case of chronic heart failureICD in the case of chronic heart failure– Life-saving tool for many heart failure patientsLife-saving tool for many heart failure patients– Protects against sudden death by ventricular fibrillation Protects against sudden death by ventricular fibrillation

and tachycardiaand tachycardia– But:But:

Firing off the electrical impulses in the terminal phase is often Firing off the electrical impulses in the terminal phase is often experienced as very disturbingexperienced as very disturbing

Does a ICD drag out the life of a heart failure patient needless?Does a ICD drag out the life of a heart failure patient needless?

Ethical considerationsEthical considerations Positioning and strategy within a palliative care Positioning and strategy within a palliative care

program/pathwayprogram/pathway






Palliative care settingsPalliative care settings

Palliative homecarePalliative homecare– Palliative daycentrePalliative daycentre– Palliative care consultationPalliative care consultation

Hospital-based palliative support team Hospital-based palliative support team (PST)(PST)

(Specialised) residential palliative care unit (Specialised) residential palliative care unit (PCU)(PCU)

Conclusion(1)Conclusion(1)

Patients with terminal heart failure have often bad symptom Patients with terminal heart failure have often bad symptom control and a lot of unmet needs.control and a lot of unmet needs.

An uncertain prognosis means that even during the An uncertain prognosis means that even during the treatment of heart failure with the intention to ameliorate treatment of heart failure with the intention to ameliorate symptoms and prognosis, always the possibility of symptoms and prognosis, always the possibility of (sudden) dying should be considered. Patient and family (sudden) dying should be considered. Patient and family should also be informed and supported about that should also be informed and supported about that eventuality. eventuality.

For the majority of patients with heart failure a clearly For the majority of patients with heart failure a clearly outlined terminal phase does not exist. outlined terminal phase does not exist.

Advance care planning implicate anticipating on and Advance care planning implicate anticipating on and reducing of a futile treatmentreducing of a futile treatment


Differences between the natural disease Differences between the natural disease course of heart failure and cancer implicates course of heart failure and cancer implicates that palliative care for heart failure patients that palliative care for heart failure patients necessarily will differ from the actually well necessarily will differ from the actually well structured palliative care for cancer!structured palliative care for cancer!


Therefore: need for research towardsTherefore: need for research towards– What are the needs, QoL, effectivity of symptom control…?What are the needs, QoL, effectivity of symptom control…?– Which interventions and programmes heart failure patients need?Which interventions and programmes heart failure patients need?– What are the models for ambulantory care of heart failure patient?What are the models for ambulantory care of heart failure patient?– Where do heart failure patients get the best treatment, depending Where do heart failure patients get the best treatment, depending

the phase of there disease (at home, hospital, palliative care unit)?the phase of there disease (at home, hospital, palliative care unit)?– How do the different care models and settings influence the How do the different care models and settings influence the

outcome?outcome? Only at the moment we will have the answers at these Only at the moment we will have the answers at these

questions a well outlined and supported treatment and care questions a well outlined and supported treatment and care for the heart failure patient will be possible; this will also for the heart failure patient will be possible; this will also have important implications for the organisation and the have important implications for the organisation and the available means for health care facilities.available means for health care facilities.

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Palliative care and non- oncological diseases Heart failure