What is known
Predictors of survival of six months or less include increased dependency in activities of daily living, number and severity of co-morbidities, worse nutritional status and weight loss, abnormal vital signs and laboratory investigations.  Anaemia has been identified in a meta-analysis as associated with more advanced disease (NYHA stage III or IV) and as an independent risk factor for death and hospitalisation in heart failure. 
Predictors that suggest that death is imminent include advanced age, recurrent hospitalisation for decompensated chronic heart failure and / or a related diagnosis, NYHA class IV symptoms (fatigue, palpitations or shortness of breath occurring at rest), poor renal function, cardiac cachexia, and / or low sodium concentration and refractory hypotension necessitating withdrawal of medical therapy.  In addition, persistent oedema, fatigue, and anorexia also suggest the onset of the terminal phase. 
Recognising the significance and irreversibility of multi-organ failure occurring in the terminal phase of heart failure is important because inappropriate investigation and management of this problem can contribute significantly to patients’ and families’ distress around the time of death. 
Implications for practice
- The best practice recommendations of the National Heart Foundation of Australia are for 'integration of a palliative approach into CHF multidisciplinary care for patients facing the strong possibility of death within 12 months and who have advanced symptoms that are resistant to optimal pharmacological and non-pharmacological therapies.' 
- The framework suggested by the Heart Failure Association of the European Society of Cardiology  relates measures of disease severity for heart failure to palliative care needs and goals of care:
- Stage 1: Chronic disease management phase: (NYHA I–III)
- Stage 2: Supportive and palliative care phase: (NYHA III–IV)
- Stage 3: Terminal care phase.
- Prognostic assessment is therefore important because it should trigger a review of the patient’s goals of care, and discussions with patients and families about these, and it may suggest the need for advance care planning, and / or referral to a specialist palliative care service.
- Prognostic conversations and advance care planning require high levels of communication skill and cultural sensitivity. Specific training to improve clinicians’ communication skills and their comfort with discussing goals of care is available.
- For patients identified as entering the terminal phase, and who are approaching death, end-of-life care pathways have been developed that help guide care. These clinical pathways ensure that physical comfort and the psychosocial care of the patient and their family and loved ones are the main focus of care during this time, and provide guidance on symptom management in the terminal phase.