What is known
Patients with advanced heart failure experience severe physical and psychosocial symptoms. Psychosocial issues include the experience of social isolation, fear, loss of control, life disruption, uncertainty about prognosis, and difficulty in accessing and dealing with information about their condition and in navigating the health system. [1-2] The benefit of involving social workers in addressing these problems has been identified. 
Depression was present in 21.5% of patients with heart failure in a meta-analysis (33.6% if screened with questionnaires, 19.5% by diagnostic interview) – with higher rates of death and trends to increased hospital service use in depressed patients. This relationship appeared to be strong and consistent.  Psychosocial factors that contribute to quality of life in this population are being explored, including the issue of 'hope / hopelessness'  and the effect of social support and spiritual beliefs on coping.  The evidence suggests that psychosocial and spiritual distress are a significant problem in advanced cardiac failure. Assessment and management of these sources of distress should be a priority. 
The commonest physical symptoms that affect patients as heart failure progresses are shared with both far advanced cancer and with other end-stage non-malignant conditions – pain, fatigue and shortness of breath. [6-8] In addition, cachexia  and insomnia  also affect many heart failure patients. It has been argued that this constellation of symptoms is a final common pathway of many conditions as patients approach the end-of-life. 
Implications for practice
- Meticulous assessment of symptoms, including both physical and psychosocial aspects of the patient’s experience, should be a routine part of care in advanced heart failure.
- As patients progress through the palliative phase, goals of care gradually shift from attempting to stabilise physical parameters, to maximising comfort.
- Assessment tools for pain, distress, and other symptoms as used by palliative care services are available to monitor symptom burden and effects of treatment in heart failure, and can be used to supplement routine cardiological monitoring.