Key messages (this topic is currently under review)
- Heart failure is an eventually fatal condition which is becoming more prevalent, and is associated with severe symptom distress and high rates of mortality
- Patients with advanced heart failure benefit from receiving, in parallel, active disease management and a personalised palliative approach to their care
- Palliative care
- affirms life and treats dying as a normal process;
- neither hastens nor postpones death;
- provides relief from pain and other distressing symptoms;
- integrates the physical, psychological, social, emotional and spiritual aspects of care, with coordinated assessment and management of each person’s needs;
- offers a support system to help people live as actively as possible until death; and
- offers a support system to help the family cope during the person’s
illness and in their own bereavement.
Source: Department of Health Palliative Care webpage
Heart failure is the only cardiac disease which is increasing in prevalence. This is largely due to the long-term effects of common conditions that affect the heart’s pump function – particularly hypertension and coronary artery disease.  Improving long-term survival from cardiac conditions and also from heart failure itself has increased the numbers of people living with the condition, and changed its demography. It is now a disease mainly of older people, especially of older women, and it is estimated to affect at least 10% of Australians aged 65 years and older.  Survival ranges from 80% at 2 years for those without fluid overload, to less than 50% survival at 6 months for patients with refractory symptoms. 
Despite continuing improvements in treatment which can prolong and improve the lives of heart failure patients, it remains a terminal condition with a heavy burden of symptoms, especially in the advanced stages. There are many different trajectories which range from sudden cardiac death at any point during the illness (decreasing due to ICDs and beta blockers), 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.  Mortality and severity of symptoms in advanced heart failure are comparable to those in cancer [4, 5] although this is generally not understood by either patients or clinicians. Hence the palliative care approach is not always identified as an essential part of the continuum of care for patients with heart failure [4, 6] - although this is now starting to change. 
A palliative approach systematically addresses issues that are important for patients with a terminal disease  such as:
- providing timely prognostic information to help patients and families plan for their future and deal with end of life issues
- referring to and integrating palliative care with usual care
- providing holistic supportive care for disabling and distressing symptoms
- providing carer support
- reducing unnecessary or unwanted hospitalisation and
- individualised consideration of the benefit versus burden of any interventions that are offered. 
Approaches to end-of-life care, including how and when to de-escalate treatment and inactivate devices, as well as treatment of refractory symptoms, are particularly important in the palliative management of heart failure patients.
Topics to be covered here summarise the current evidence about the palliative care of patients with advanced heart failure. They are:
Symptoms & Patients’ Experiences
Carers and Families
Active research areas/controversies
- Predicting prognosis continues to be an area of research interest. The information needs of patients and carers in relation to prognosis are also being explored.
- Shortness of breath affects palliative care patients with a range of conditions, including advanced heart failure. Issues that are being explored in various studies include the use of opioids for dyspnoea (efficacy and titration of different opioids), and the role of oxygen in managing dyspnoea in non-hypoxic patients. Measuring dyspnoea is a methodological problem for researchers which is also being studied. [9, 10]
- Improvements in the medical management of heart failure continue to be relevant in the palliative phase, and new treatment modalities are evolving – these include cytokine and immunomodulation therapies  calcium sensitizers  and cell based therapies. 
- Many different populations are affected by heart failure, and they may have very different needs. Little specific research is available to improve the care of Indigenous patients, of those from different cultural backgrounds or of women as specific needs groups. The elderly in particular are usually excluded from clinical trials, despite being the most common age group affected by heart failure.