title: The nature of heart failure as a challenge to the integration of palliative care services.
abstract: OBJECTIVE
  Despite its increasing prevalence and high mortality risk, heart failure is widely regarded as 'treatable'. Aggressive measures are employed even in its end stages. This review explores the clinical characteristics of heart failure, patterns of clinician response, and new data that may help to surmount current barriers to palliative approaches.
  
  
  RESULTS
  The 'treatment imperative' that has helped to reduce overall cardiovascular mortality marginalizes palliative approaches in heart failure. The possibility of dying remains unacknowledged, and communication about palliative options tends not to occur. Both the apparently benign nature of heart failure and its inherent unpredictability discourage end-of-life considerations. Recent studies, however, provide evidence that these barriers may be surmountable, and also furnish tools to help with prognosis. A true heart failure continuum including palliative care would be desirable, although structural barriers exist.
  
  
  CONCLUSIONS
  Therapeutic successes have encouraged clinicians to pursue heart failure treatment through the end stages of disease. These very successes, however, have made the course of advanced heart failure easier to predict. What is needed now is courage among clinicians to open early dialog about disease process, prognosis and palliative options with the growing number of patients with advanced disease.
authors.affiliation: Sutter Visiting Nurse Association and Hospice, Emeryville, California 94608, USA. stuartb@sutterhealth.org
authors.forename: Brad
authors.initials: B
authors.lastname: Stuart
mesh_terms: D001291:Attitude of Health Personnel; D006333:Heart Failure / Q000628:therapy*; D017051:Hospice Care; D006801:Humans; D010166:Palliative Care / Q000379:methods*; D010817:Physician-Patient Relations; D011368:Professional-Family Relations