Prevalence and Definition
An estimated 1.2 million Australians over the age of 18 have one or more conditions associated with cardiovascular disease, and of those nearly 105 000 people have heart failure.  Nearly two thirds of those with heart failure are over the age of 65.  Heart failure is a collection of symptoms caused by a 'structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress'.  p.898 Many people with cardiovascular disease will develop heart failure and with interventions and pharmacological management, people with heart failure are living longer but despite the improvements in treatment, heart failure remains a progressive clinical condition which will lead to advanced chronic heart failure and finally end stage heart failure and death. 
Heart failure is commonly classified according to the severity of symptoms experienced by the person using the New York Heart Association (NYHA) functional classification system which classifies both patient symptoms and objective assessment. [2,4] The NYHA divides heart failure into four classes, ranging from class I, a person having no symptoms during normal physical activity to class IV, a person having severe dyspnoea at rest and severe impedance of their functional ability.  In 2018 the Heart Failure Association of the European Society for Cardiology updated the definition of advanced chronic heart failure to include not only clinical symptoms but also additional prognostic markers and presence of end stage organ damage. 
Advanced heart failure is defined as:
- Severe and persistent symptoms (NYHA III or IV),
- Severe cardiac dysfunction defined by a reduced Left Ventricular Ejection Fraction less than 30 per cent, isolated Right Ventricular failure or non-operable severe valve abnormalities or congenital abnormalities
- Episodes of pulmonary or systemic congestion requiring high-dose intravenous diuretics (or diuretic combinations) or episodes of low cardiac output requiring inotropes or vasoactive drugs causing more than one unplanned visit or hospitalization in the last 12 months.
- Severe impairment of exercise capacity with inability to exercise estimated to be of cardiac origin.
- Other organ dysfunction due to heart failure (e.g. liver or kidney dysfunction) or type 2 pulmonary hypertension may be present but are not required. 
Heart failure symptoms may be exacerbated by other life-limiting illnesses such as such as severe respiratory disease, liver or renal failure and these patients may have more severe care needs.  Advanced heart failure is considered unstable as more advanced treatments are required to manage symptoms and over time will lead to end-stage heart failure, where treatments focused on maintaining cardiac function are no longer useful. 
Prognosis and Need for Palliative Care
Prognosis in any chronic disease can be challenging and heart failure is similar. There is increasing recognition of the need to involve palliative care in earlier stages of heart failure. [3,6] There are many different trajectories in heart failure, ranging from sudden cardiac death at any point during the illness to either alternating periods of stability with periods of loss of control of symptoms, or prolonged periods of disability and distress with poor quality of life.  Sudden cardiac death is seen less commonly due to the increasing use of implantable cardiac devices (ICD) and beta blockers. 
A number of prognostic tools have been developed and tested in heart failure and those recommended for advanced heart failure, non-hospitalised patients are the Heart Failure Survival Score (HFSS), the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC).  Another prognostic tool, the Seattle Heart Failure Model may not be as sensitive in advanced heart failure. 
Recent heart failure guidelines recognise the need for palliative care options for patients in advanced and end stage heart failure, indicating that assessment of symptoms and care needs should be initiated early.  A recent position statement from the European Association of Palliative Care recommends the Needs Assessment Tool: Progressive Disease- Heart Failure as a useful tool to recognise when a person with heart failure may benefit from palliative care.  The natural course of the advancing heart failure means it is characterised by acute decompensation followed by periods of stability where a person may respond favourably to interventions. A systematic review found that fewer than six per cent of heart failure patients who could have been referred to palliative care services were actually referred.  Recognising the significance and irreversibility of multi-organ failure occurring in advanced heart failure may stop inappropriate investigation and invasive management, which can contribute significantly to patients’ and families’ distress in end stage heart failure. 
Advance care planning is an important component of palliative care and can allow a person to complete an Advance Care Directive and discuss their end of life preferences including treatment options and limitations.  A recent systematic review examined the impact of advanced care plans (ACP) for patients with heart failure.  ACP improved quality of life, patient satisfaction with end of life care and end of life communication.  The authors recommend that the introduction of ACP be done after a major event in the disease trajectory, such as a hospital admission, that follow-up be scheduled to continue the discussions around ACP and to include family and carers as well as the broader multidisciplinary team. 
As advanced heart failure progresses the burden of symptoms increases. The most common symptoms experienced by a person in advanced heart failure are pain, dyspnoea, fatigue, and depression. [3,7] Like any other life-limiting illness, heart failure patients may not exhibit these symptoms or may have others which affect them more acutely, which makes individual assessment and treatment of diagnosed symptoms important. CareSearch Clinical Evidence-Patient Management pages describe the evidence on supporting the common symptoms seen at the end of life. The following section outlines the evidence to managing these common symptoms in advanced heart failure.
Pain is a common symptom at the end of life, including for those with heart failure.  It can be associated with heart disease, peripheral neuropathy or from interventions such as surgery.  Managing pain will depend on the type of pain and response to treatment. Particular care should be taken with certain analgesics, such as NSAIDs which can cause renal dysfunction and medications which can disrupt the QT interval, such as methadone and amitriptyline. 
Opioids for palliation of dyspnoea have been well studied. They are a safe and effective approach for patients with both malignant and non-malignant causes of dyspnoea.  A recent systematic review examining the use of opioids for the treatment of dyspnoea in heart failure found low quality evidence to support its use. Clinical practice guidelines suggest using opioids to manage dyspnoea with caution.  Other suggested management approaches include increasing diuretic medications to reduce congestion.  There is limited evidence to support the use of oxygen in non-hypoxic patients, although patients may report feeling better with oxygen in situ and some patients with advanced heart failure will experience hypoxia.  A recent systematic review of oxygen use in heart failure found limited evidence to support the use of oxygen in advanced heart failure. 
Due to the complex nature of heart failure a non-pharmacological approach to management may be beneficial. In general these interventions focus on physical activity (such as exercise), breathing techniques and technology, such as hand held fans.  These techniques supported by multidisciplinary palliative care may be useful. [15,16]
Anxiety and Depression
Anxiety and depression are common symptoms in advanced heart failure.  Managing these symptoms in the advanced phase of the illness can be important, as they are sometimes seen as lower priority compared to cardiac symptoms.  Chronic or acute dyspnoea can contribute to anxiety and therefore managing dyspnoea may improve anxiety levels.  Treating depression with standard approaches in heart failure patients is appropriate. [4,17] A recent review comparing standard treatment options in depression found there was some benefit in exercise training and cognitive behavioural therapy over medication therapy but too little difference to make a recommendation for practice. 
Cessation of Treatment
As advanced heart failure progresses continuing treatments which minimise symptoms and focus on comfort is often the primary goal of care.  Potential treatment options for heart failure patients such as non-invasive ventilation and left ventricular assist devices may be part of the spectrum of palliation for some patients, and shared protocols for managing such treatments and negotiating goals of care are needed. The use of implantable cardioverter defibrillators (ICD) raises the issue of deactivation to prevent ICD storm in a dying patient, where the device repeatedly shocks a person and can be very painful.  It is estimated that over 30 percent of patients with ICDs will experience one or multiple discharges (or shocks) in the last 24 hours of life.  A recent review established that conversations with patients about deactivating their ICD were uncommon.  There is a lack of knowledge for both patients and heath care professionals about the effects of ICDs in the last day of life and the significant discomfort they can cause. [2,10,18]
- Prognostic tools that assist in the recognition of the need for referral to palliative care continues to be an area of research interest. Further definitions separating advanced heart failure and end stage heart failure may be useful. 
- Specific guidance on best practice interventions in managing pain and dyspnoea in advanced heart failure are needed. 
- The development of specialised roles to support people with advanced heart failure are in the early stages of implementation and further research is needed to establish their utility in the clinical setting.
- Protocols for the deactivation of ICDs in end stage heart failure are required as well as guidelines to assist in communication with patients about deactivation.