Perspective:

The following are 10 points to remember about this Scientific Statement from the American Heart Association:

1. There are complex trade-offs in the management of patients with several comorbidities that compel clinicians taking care of such patients to come up with a management plan that incorporates patients' goals, values, and preferences that are optimal for each individual patient.
   
   
2. It is important that the clinician recognizes the natural history of heart failure in the individual patient, especially the critical transition into advanced heart failure, because this is often accompanied by a transition in goals of care from the patient and family perspective, wherein palliative therapies may become the dominant treatment paradigm when transplantation and mechanical circulatory support are not an option.
   
   
3. Managing Expectations of the Future
   
   
   1. Frequent reappraisal of the clinical course helps manage expectations, improve communication, and inform rational decisions.
      
      
   2. A comprehensive discussion of prognosis includes the potential impact of worsening symptoms, limited functional capacity, loss of independence, reduced social functioning, decreased quality of life, and increased caregiver commitment in addition to the risk of death.
      
      
4. Framework of Options
   
   
   1. It is important for the physician to define the range of options that are medically appropriate.
      
      
   2. Presentation of major interventions should always include a specific description of alternative options, including continuation or withdrawal of ongoing treatments and focus on symptomatic care.
      
      
   3. Discussions should include a range of anticipated outcomes, including not only survival, but also major adverse events, independence, functional capacity, and quality of life for both patient and caregiver, even if to acknowledge lack of this information for some interventions.
      
      
   4. Therapies that may lead to dependence should be weighed carefully before initiation even when anticipated to be temporary (e.g., intravenous inotropes, renal replacement therapy, and intubation).
      
      
   5. It is important to review the benefits and risks of noncardiac procedures in the context of competing risks for death and functional limitation attributable to heart failure (e.g., hip replacement, repair of asymptomatic aortic aneurysm, or screening tests).
      
      
   6. Decisions for major cardiac and noncardiac interventions should include consideration of “what if” situations of unanticipated adversity.
      
      
5. Anticipation, Timing, and Review
   
   
   1. An annual heart failure review with patients should include discussion of current and potential therapies for both anticipated and unanticipated events.
      
      
   2. Responding to clinical milestones:
      
      
      i. On the day of hospital admission, it is far better to review rather than introduce advanced care decisions, which requires that patient preferences have been discussed previously and documented in the ambulatory setting.
      
      ii. Treatment changes such as percutaneous coronary interventions, CABG, implantable cardioverter-defibrillator (ICD) shocks, renal replacement therapy, or recurrent hospitalization should elicit interim review and discussion of therapeutic options and preferences.
      
      
6. End-of-Life Care Planning
   
   
   1. It is important for the clinician to initiate the development of a comprehensive plan for end-of-life care consistent with patient values, preferences, and goals.
      
      
   2. ICD deactivation is desirable to avoid unnecessary pain and distress for patients and families at the end of life.
      
      
   3. Active discontinuation of mechanical circulatory support is often appropriate and necessary at the end of life.
      
      
7. Family Dynamics: Although family units may have discussed end-of-life preferences, important barriers to such discussions include fear of death, trust in others to make decisions, family dynamics, uncertainty about preferences, and psychological burdens associated with surrogate decision making.
   
   
8. Decision-Making Process and Communication
   
   
   1. Collaborative shared decision-making process is based on trust.
      
      
   2. Early solicitation of values, goals, and preferences is necessary to guide the range of possible therapy options and decisions.
      
      
   3. Shared decision making is an iterative process that evolves over time as a patient's disease and quality of life change.
      
      
   4. Assessment and integration of the emotional readiness of the patient and family are vital to effective communication.
      
      
   5. 'Ask-Tell-Ask' provides a useful basis for communicating about prognosis and goals.
      
      
   6. Successful conflict resolution involves early recognition of conflict unfolding, with a shift in focus from winning an argument to trying to understand the reasons for conflict.
      
      
   7. Decision aids are tools that can enhance shared decision making by presenting numeric data in more understandable ways and assisting patients in clarifying their values.
      
      
9. The expert panel opined that future research is needed in a variety of areas related to shared decision making (including effective communication training, decision support interventions, group visits, health-related quality-of-life measures, and caregiver burden, needs, and outcomes).
   
   
10. Changes in organizational and reimbursement structure will be required to reward and integrate decision making into the delivery of patient-centered health care.