Palliative Care in the Cardiac Intensive Care Unit

52  Palliative Care in the Cardiac Intensive Care Unit Milla J. Kviatkovsky, Briana N. Ketterer, Sarah J. Goodlin

OUTLINE Burden of Heart Failure, 580 Defining Hospice and Palliative Care, 580 Prognostication, 581 Communication Strategies, 582 Symptom Management in Heart Failure, 584

Discontinuation of Therapies, 584 Implanted Electric Devices, 584 Left Ventricular Assist Devices, 585 Conclusions, 585

BURDEN OF HEART FAILURE

Approximately 5% to 10 % of all patients with HF have stage D disease4; a larger number of patients have stage C HF with significant comorbidities. Patients with American College of Cardiology/American Heart Association (ACC/AHA) stage D HF have refractory HF. These patients experience rest symptoms despite optimal medical management and are refractory to conventional therapy, which may also include advanced treatment strategies, such as inotropes or LVADs.2,4 Patients with ACC/ AHA stage C HF who have significant comorbidities and complications (frailty, COPD, dementia) are also approaching the end of life. Life expectancy is limited for HF patients even when advanced therapies are used. Patients who receive cardiac transplant have an average 10-year survival and about 70% LVAD device recipients survive 2 years, though newer devices may improve length of life. Patients with HF and reduced left ventricular ejection fraction (HFrEF) receiving continuous inotropic support have an average 6-month survival.5–7 Options for an approach to patients in these groups are presented in Fig. 52.2. Comprehensive HF management should weave in palliative interventions throughout the course of care for communication and shared decision making, including advanced care planning, and symptom management. When appropriate, end-of-life care should include hospice care.

The burden of heart failure (HF) includes frequent deteriorations often requiring hospitalization, high mortality, and significant symptoms, reducing the quality of life. HF contributes to more than 10% of deaths in the United States.1 Despite advances in therapy, the number of deaths attributable to HF today is similar to the numbers in 1995.2 Patients who survive a hospitalization for HF have age-adjusted 28-day and 1-year case fatalities of 10.4% and 29.5%, respectively. After three or four hospitalizations for HF, patients older than 85 years and patients younger than 65 years have a 50% 6-month mortality rate.3 Symptoms are prevalent throughout the course of HF; most HF hospitalizations are associated with increased dyspnea, fatigue, or other cardiovascular symptoms. Heart failure patients are predominantly elderly, most of whom have more than four comorbid conditions. Some patients with HF will be hospitalized for unrelated issues and HF management complicates their care. The majority of patients with chronic HF are also frail and may have cognitive impairment, complicating intensive care management. Communication and decision making with the patient and family should acknowledge mortality and address palliation in addition to life extension. This chapter addresses palliative and end-of-life concerns encountered in the intensive care unit (ICU). Care for the patients with advanced HF who are without further options for advanced therapies is specifically addressed. Fig. 52.1 illustrates the trajectory of HF, incorporating palliative and care supportive throughout the course of the illness. HF results in severe impairment of function that might result in cardiac intensive care unit (CICU) admission, but appropriate medications and treatment often can rescue the patient. This chapter is particularly relevant to patients who do not recover with aggressive treatment (see Fig. 52.1, time point 4), or who may no longer have options for advanced therapies (such as left ventricular assist device [LVAD] or transplant).

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DEFINING HOSPICE AND PALLIATIVE CARE Palliative care is a philosophy of care as well as a care delivery system that often employs a multidisciplinary team involving physicians, advanced care practitioners, nurses, social workers, and—most notably—the patient and the patient’s family. All clinicians provide palliative care when suffering and the burden of illness are addressed. Palliative care emphasizes alleviation of physical, psychosocial, and spiritual symptom burden to enhance quality of life. Palliative care should be provided throughout the course of all serious illnesses, and does not necessitate end of



Keywords Palliative care advanced heart failure intensive care unit end of life advance care planning symptom management

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Excellent

Physical function

Palliative and supportive care 2 3

Heart failure care 4

1

5 Death Time Sudden death event Transplant or ventricular assist device

Fig. 52.1  Comprehensive heart failure care. Time point 1 illustrates initial diagnosis of heart failure, in which care emphasizes initiation of evidence-based therapies, education of patient and family about the disease, and how to manage it. Time point 2 is the plateau phase, in which treatment has been initiated and quality of life is improved from initial diagnosis. Patients remain in this stage and benefit from medical management, a variable length of time until time point 3, with oscillating exacerbation and rescue with decline in physical function, increased need for supportive care, and perhaps increasing frequency of hospitalizations. Time point 4 is generally a crossroad phase in which advanced therapies, such as a left ventricular assist device or transplant, may bring patients back to a new plateau. Alternatively, progression of disease to time point 5 occurs, characterized by low function, frailty, and significant need for palliative therapies, with variable length of time until death. (From Goodlin SJ. Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54:386–96.)

life or a set prognosis. Palliative care consultation in the CICU results in increased referrals of patients to hospice.8 Hospice and palliative care often go hand in hand. Hospice is a model of care targeting those in the last 6 months of life, while palliative care is provided at any time and concurrently with life-prolonging treatment. Thus, in the CICU, palliative care and advanced treatment of HF are not mutually exclusive but instead are synergistic and beneficial to all stakeholders (patients, family, providers, and the hospital itself). We recommend early consultation of in-patient palliative care teams for patients with lifeshortening illness. Clinicians based in the CICU provide many components of palliative care; however, when hospice referral is appropriate, palliative care consultants can facilitate continuity of care. Incidentally, ICU palliative care consultations benefit the health care system via reduced length of stay and cost saving of an estimated $7700 per hospitalization for HF.8,9 Hospice care incorporates palliative care and supportive services 24 hours a day, 7 days a week. The majority of hospice care is delivered as intermittent visits in the home or patient’s residence (including long-term care settings). The hospice benefit also includes “general inpatient care” for severe symptoms or crises that cannot be managed in the home, “continuous care” that delivers 8 to 24 hours of skilled care in the home for a few days to manage acute problems or provide training to caregivers, and respite care for the primary caregiver. Physical, social, spiritual, and emotional care are provided via an interdisciplinary team.

Individuals who qualify for hospice have a likely life expectancy of 6 months or less. Patients are eligible for hospice via Medicare (and most other insurers) with two physician certifications of 6 months or less of life if the illness runs its natural course, although patients can be repeatedly certified for the hospice benefit when they live longer than 6 months. The patient must elect the hospice benefit and agree to not be hospitalized for the hospice diagnosis. More information can be obtained at https:// www.medicare.gov. When the hospice diagnosis is HF, the traditional guidelines include HF New York Heart Association (NYHA) class IV with either symptoms at rest or inability to carry out minimal activities due to dyspnea despite optimal medical treatment. These criteria are outdated and serve more as a guideline, as more weight is given to the physician’s statement regarding prognosis based on the complexity of HF, including the number of associated hospitalizations; decline in self-care; frailty; and other comorbidities, such as cancer or markers of disease severity, including hyponatremia, elevated N-terminal prohormone brain natriuretic peptide (NT-proBNP), cachexia, and use of inotropes.

PROGNOSTICATION The American Heart Association/American College of Cardiology (AHA/ACC) 2013 and the European Society of Cardiology (ESC) 2013 HF guidelines recommend ongoing discussion with patients

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Stage D HF or stage C HF with comorbidities: survival <1 year, ± IV inotropes

Transplant candidate? Age <70, no end-organ damage, no significant comorbidities

Yes

No

Referral for heart transplant evaluation

LVAD candidate?

Yes: bridge to transplant and determination

Yes: destination therapy

No: <6 month predicted survival?

Hospice

Fig. 52.2  Decision tree for patients with stage D heart failure or stage C with comorbidities and <1 year predicted survival. HF, Heart failure; IV, intravenous; LVAD, left ventricular assist device.

and families about prognosis for functional capacity and survival, palliative and hospice care, and discussions regarding implanted device deactivation.2 Ideally, these topics should be addressed throughout the course of the patient’s HF progression, and should be readdressed with changes in clinical status. Patients and their families may also request to have these discussions. Fig. 52.2 provides a decision tree, with various branch points when hospice might be considered. Several risk models can assist with prognostication. We suggest that clinicians identify which model is most useful for the specific patient and circumstance at hand, bearing in mind that the tools reflect aggregate data and provide only estimates. Table 52.1 lists prognostic models and their characteristics.3,5,10–14 One out of five patients do not want to know their prognosis; thus it is important to begin communication by asking what the patient wants to know.

COMMUNICATION STRATEGIES Communication with patients and families about prognosis is an important skill for all clinicians. Communication about goals

and end-of-life planning should occur throughout the continuum of care of a patient with HF. HF patients are at risk for rapid deterioration and sudden cardiac death; thus, conversations should occur early in their care and be readdressed on a regular basis. Despite these previous conversations, many patients hospitalized with HF and their families may be surprised that they are at risk of imminent death. One model to approach these patient-centered conversations is “Ask-Tell-Ask” (Table 52.2). This model begins the conversation with asking the patient for the patient’s understanding of the current situation or worries or concerns. Then the clinician shares information. Finally, the clinician asks what the patient or family understood and asks for their questions.15 Table 52.2 provides example phrases to facilitate these conversations. Often, this point in the care continuum presents a crossroad for medical providers. When patients in the CICU are nearing the end of their life or may not have options for advanced HF therapies, the medical team guides shared decision making. This starts by identifying the patient’s values and priorities, then sets joint clinician and patient goals, and assesses how the available

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TABLE 52.1  Outpatient Models for Heart Failure Prognostication Model

Outcome

Seattle Heart Failure Model13

Continuous risk score expressed as predicted life expectancy and percentage chance of survival (1-, 2-, and 5-year mortality)

Heart Failure Survival Score2

All-cause mortality

Variables, Limitations, Advantages Accounts for NYHA functional class, ischemic etiology, diuretic dose, LVEF, SBP, sodium, hemoglobin, percent lymphocytes, uric acid, cholesterol. Not derived from HF population. Most commonly used, validated in HF patients Peak VO2, LVEF, serum Na, mean BP, HR, ischemic etiology, QRS duration/morphology Limitation: difficult to acquire VO2 data

Inpatient Models for Heart Failure Prognostication EVEREST Risk Model29 Combined endpoint Age, DM, h/o stroke, h/o mortality or persistently arrhythmia, BB use, BUN, Na, poor QOL over 6 BNP, KCCQ score months postdischarge EFFECT12 30-day and 1-year Age, SBP, RR, Na, hemoglobin, BUN, mortality h/o CVA, h/o dementia, h/o COPD, h/o cirrhosis, h/o cancer Limitation: no EF requirement ADHERE11

In-hospital mortality

BUN, SBP, serum Cr Limitation: no EF requirement

ESCAPE Discharge14

6-month mortality

BNP, CPR, or mechanical ventilation during hospitalization, BUN, Na, age >70 y, loop diuretic use, BB use, 6-min walk distance

Example Patient

Survival vs. Mortality

65 yo male w/ ischemic cardiomyopathy; EF 30%; NYHA class IV; SBP 90; on ACEi, BB, statin; with ICD in place

1-year mortality, 11%; 2-year, 20%; 5-year, 43%

LVEF 40%; SBP 90; serum Na 135; known ischemic cardiomyopathy; IVCD of 124 ms; resting HR of 90 beats/min (VO2 max not known)

Score: 7.25 Medium risk: 72% predicted 1-year survival

Predicted 30-day survival for 62 yo male, RR, 20 beats/min; SBP, 100 mm Hg; BUN, 30; hemoglobin, 10; serum Na, 132; + CVD + COPD + dementia Mean BUN <43 mg/dL; SBP <115 mm Hg; intermediate risk 3%–5.5% in-hospital mortality Compared to mean BUN >43 mg/dL, SBP <115 mm Hg, serum Cr >2.75 mg/dL 75 yo male, BUN >40, 6-min walk <300 ft, Na >130 mEq, no h/o CPR/mechanical ventilation, on 40 mg furosemide BID, not tolerating BB, with BNP 650 pg/mmol

Score: 122 High risk: 26%–32.7% 30-day mortality

High risk Predicted in-hospital mortality: 21.9%

Score: 5 Predicted 6-month mortality: 66.4%

Commonly used Heart Failure Prognostication models separated by their clinical utility in the outpatient versus inpatient setting. Example patient and associated risk stratification is provided to illustrate differences and guide decisions regarding which model is most suited for specific patient in question. ACEi, Angiotensin-converting enzyme inhibitor; BB, β-blocker; BID, twice daily; BNP, brain natriuretic peptide; BP, blood pressure; BUN, blood urea nitrogen; COPD, chronic obstructive pulmonary disease; CPR, cardiopulmonary resuscitation; Cr, creatinine; CVA, cerebrovascular accident; CVD, cardiovascular disease; DM, diabetes mellitus; EF, ejection fraction; HF, heart failure; h/o, history of; HR, heart rate; ICD, implantable cardioverter-defibrillator; IVCD, intraventricular conduction delay; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVEF, left ventricular ejection fraction; Na, sodium; NYHA, New York Heart Association; QOL, quality of life; RR, respiratory rate; SBP, systolic blood pressure; yo, year old.

treatment options might approach those goals while supporting the patient’s values. It is important to depict what the course might be with each option. Identifying values and aligning treatment options with them limits confusion and avoids care that is not beneficial or may be harmful, while prioritizing the patient and the family.16 In part, this raises an ongoing ethical debate questioning whether just because we can do something we should do it.17 These conversations are challenging for patients and providers. It is important to recognize emotions both on the part of the clinician and the patient and family. Naming

surprise, sadness, anger, and other emotions is essential to being able to conduct a discussion. Voicing “I Wish” statements such as “I wish things were different,” is one way for providers to empathetically align with patients and acknowledge that the outcome is not something anyone desired. Designation of surrogate decision makers and early conversations acknowledging and planning for possible death are important. Planning for “the worst,” including undesired states and death, is often easiest when done as a dichotomous discussion that includes clinicians’ hope for the best outcomes.

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SYMPTOM MANAGEMENT IN HEART FAILURE The most common complaints of end-stage HF patients are dyspnea, depression, pain, edema, and fatigue. Other symptoms also include feelings of uncertainty, anxiety, and worry about what to expect. In assessment and management of symptoms, medications are often added in a stepwise fashion to target specific symptoms (Fig. 52.3). Table 52.3 lists therapies that may be added to assist with symptom management. In advanced HF, one of the most distressing symptoms is dyspnea. Dyspnea is a complex symptom that takes into account pulmonary congestion and neurohormonal activation and renin-angiotensin-aldosterone system (RAAS) disarray, along with increased proinflammatory cytokines.18 Therefore, in addition to decongestion strategies via diuresis and vasodilation, treatment strategies focus on blocking or modifying the neurohormonal and cytokine abnormalities. When at all possible, it is beneficial TABLE 52.2  Examples of “Ask-Tell-Ask”

Strategies in Advanced Heart Failure Ask

Tell

Ask

“Tell me what you understand about your heart failure.” “Tell me how you think things are going.” “Under what circumstances would you not want your life to be prolonged?” “What are you concerned or worried about?” “What is important to you?” “Given everything we have talked about, and that you wish to let death occur naturally, I would like to talk about how to achieve that and manage your symptoms.” “I would like to talk about all of your options so you can make a choice.” “I would like to talk about the plan for turning off the shock function of your cardiac defibrillator.” “I would like to talk about what it would look like if we turned your LVAD off.” or “I would like to talk about what it would be like if we kept your LVAD on.” “Tell me what you understood from our discussion. When you tell your family about what we talked about, what will you tell them?” “What questions do you have?”

LVAD, Left ventricular assist device.

to continue β-blockers and angiotensin-converting enzyme (ACE) inhibitors (or angiotensin receptor blockers [ARBs]). Dose adjustments may be needed in the setting of volume overload, hypotension, and acute kidney injury. The use of “medical air” and fans to stimulate the respiratory centers on the face can aide in alleviating the symptom of air hunger. Use of oxygen is not recommended in patients who are not hypoxemic. Opiates and benzodiazepines can also improve the sensation of dyspnea. Opiates are appropriate at all phases of HF while benzodiazepines have more limited utility, especially in the frail and elderly. Depression in the HF population is present in 9% to 77.5% of patients.19 Depression correlates with decreased quality of life and increased pain, as well as worsened prognosis. Selective serotonin reuptake inhibitors (SSRIs) are the mainstay of therapy, although at low doses, sertraline was not better than frequent phone contact. Depression remission was significantly associated with improvements in Kansas City Cardiomyopathy Questionnaire (KCCQ) scores in particular subscales of physical and mental self-assessment.20 In addition, controlled-release paroxetine in a small population of patients with HF was associated with significant improvement in depression (69% vs. 23%; P = .018) and improvement in psychological aspects of quality of life.21 Overall, this highlights the importance of addressing comorbid depression in HF. In one study, 84% of advanced HF patients had pain.22 Opiates are useful for pain in that they also simultaneously treat symptoms of dyspnea. Topical and nonpharmacologic therapies, including physical therapy and exercise, should be used to manage pain in the CICU. Last, intravenous (IV) inotropes should be considered for palliation of symptoms and improved functional capacity in select circumstances with the caveat that there is increased risk of sudden cardiac death.

DISCONTINUATION OF THERAPIES Implanted Electric Devices Implantable cardioverter-defibrillators (ICDs) do not improve symptoms and should not be implanted when patients approach end of life, for example, when life expectancy is less than 1 year. It is not uncommon for ICDs to fire at the end of life; some studies suggest 10% to 20% of patients receive shocks during the last weeks to months of life.23,24 Deactivation of ICDs should be discussed before implantation and as end of life nears, especially

Responding to Conventional Therapies Diuresis: IV diuretics Vasodilation: ACEi/ ARB, long-acting nitrates, hydralazine β-Blockade Exercise

Increasing Dyspnea, Limiting Hypotension Adjust vasodilators, opiates “Medical air” Thigh muscle strengthening

Refractory Dyspnea Inotropes Adjunct therapies Hospice care (Benzodiazepines)

Fig. 52.3  A summative approach to symptom management in heart failure. ACEi, Angiotensinconverting enzyme inhibitor; ARB, angiotensin receptor blocker; IV, intravenous.

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TABLE 52.3  Heart Failure Symptom Management Medication

Advantages

Cautions

Dosing/Titration

Dyspnea/Pain Morphine

Reduces preload

Low doses often sufficient for dyspnea

Hydromorphone Methadone

Less toxic metabolites GI excretion

Renal excretion, toxic metabolites, delirium Accumulation of metabolites Prolongs QTc interval at high doses

Fentanyl

Hepatic metabolism; no active metabolites; available in oral formulation as lozenges and lollipops Benefit if opiate refractory Oral not recommended, consider topical use Physical therapy, thigh muscle strengthening, getting patients up and out of bed

Transdermal use for moderate to severe pain has long half life

No evidence of harm compared to TCAs

Potential hyponatremia, orthostatic hypotension, some prolong QTc interval QTc prolongation, can prolong RR interval, anticholinergic

Therapeutic benefit may be patient and dose specific

Risk of sudden cardiac death as a result of ventricular arrhythmias

Average life expectancy 6 months

Benzodiazepines NSAIDs Nonpharmacologic: physical therapy, heat/cold therapy, topical analgesics, acupuncture, fan as “medical air” Depression SSRIs: sertraline,21 paroxetine22

TCAs

Should be used by experienced clinician

Functional Decline Inotropes Physical therapy

Titrate to pain or dyspnea Accumulates in tissues; reduce dose/ frequency after 4–5 days Transdermal patch not for opioid-naive patients; require 8 hours to reach dose IV recommended over morphine in ICU patients

Confusion and falls in elderly Sodium and fluid retention, worsening renal function Few to none

ECG and serum level monitoring

Maintain function, reduce deconditioning

ECG, Electrocardiogram; GI, gastrointestinal; ICU, intensive care unit; IV, intravenous; NSAIDs, nonsteroidal antiinflammatory drugs; QTc, corrected QT; RR, respiratory rate; SSRIs, serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.

if patients choose to die naturally. This discussion should be revisited when patients with HF have a change in clinical status or transition to comfort care.10,25 Cardiac resynchronization therapy (CRT) provides symptom relief in HF by pacing the ventricles simultaneously and improving left ventricular ejection fraction. Thus, generally, it should be continued until the end of life. Standard pacemaker function for bradycardia and heart block is also generally continued, but it is appropriate to plan for management of all electrical device functions as the end of life approaches. Unfortunately, many people approach death before they have the opportunity to discuss deactivation of their device.23,24 Hospitals and hospice agencies should have protocols in place for ICD deactivation at the end of life.

that every institution that implants LVADs also have a discontinuation protocol that can be applied and adapted when the need arises. Notably, hospice enrollment for LVAD patients is location and hospice specific, making knowledge of your local hospice agencies and policies key to a smooth transition. LVAD discontinuation can result in rapid decompensation and death at a time when patients are likely awake and alert. The most common triggers for LVAD discontinuation are infection, stroke, cancer, renal failure, and impending pump failure.26 Most patients die within 20 minutes of device deactivation.27 Therefore patients and families should be forewarned and a thoughtful plan for management should be in place.

Left Ventricular Assist Devices

CONCLUSIONS

LVADs are being used more frequently for destination therapy (DT) in addition to bridging therapy. All patients receiving an LVAD should plan for adverse events and undesired outcomes with their family or a designated surrogate in the process of obtaining an LVAD. As more patients undergo DT LVAD implantation, an increasing number will ultimately die. The discussion regarding device-related death should be introduced when first discussing the potential for LVAD placement. We recommend

Comprehensive HF management involves not only care of symptoms but also planning for the future and disease progression. The variable trajectory has notoriously made HF a challenging arena for advance care planning. Individuals with HF are at risk for sudden changes in their disease trajectory with hospitalizations, ICU stays, advanced therapies, and sudden cardiac death. Meanwhile, there are others who live for years with HF symptoms. A palliative care model addresses the patient, the patient’s

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symptoms, the family, and planning for what is to come. Hospice provides respite for caregivers and grief counseling for family after the death of their loved one; some hospice agencies are able to use advanced therapies at home, such as home inotropes or LVADs. Ultimately, the emphasis is shared decision making and symptom management that focuses on patient-centered values and goals. Enrollment in hospice may be appropriate for increasing numbers of patients living with HF, but all CICUs should anticipate death and have plans to manage devices, HF, and other symptoms and to support HF patients and families

who approach the end of life in the CICU. We implore CICU providers to begin the planning process early, engage HF patients and their families often in the decision-making process, and build processes in collaboration with palliative care clinicians and hospice agencies to provide a smooth transition at the end of life. The full reference list for this chapter is available at ExpertConsult.com.



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(Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. J Am Coll Cardiol. 2010;55:872–878. 15. Whellan DJ, Goodlin SJ, Dickinson MG, et al. End-of-life care in patients with heart failure. J Card Fail. 2014;20:121–134. 16. Roeland E, Cain J, Onderdonk C, et al. When open-ended questions don’t work: the role of palliative paternalism in difficult medical decisions. J Palliat Med. 2014;17:415–420. 17. Goodlin SJ, Quill TE, Arnold RM. Communication and decision-making about prognosis in heart failure care. J Card Fail. 2008;14:106–113. 18. Goodlin SJ. Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54:386–396. 19. Selman L, Beynon T, Higginson IJ, Harding R. Psychological, social and spiritual distress at the end of life in heart failure patients. Curr Opin Support Palliat Care. 2007;1:260–266. 20. Xiong GL, Fiuzat M, Kuchibhatla M, et al. Health status and depression remission in patients with chronic heart failure: patient-reported outcomes from the SADHART-CHF trial. Circ Heart Fail. 2012;5:688–692. 21. Gottlieb SS, Kop WJ, Thomas SA, et al. A double-blind placebocontrolled pilot study of controlled-release paroxetine on depression and quality of life in chronic heart failure. Am Heart J. 2007;153:868–873. 22. Goodlin SJ, Wingate S, Albert NM, et al. Investigating pain in heart failure patients: the pain assessment, incidence, and nature in heart failure (PAIN-HF) study. J Card Fail. 2012;18:776–783. 23. Goldstein NE, Lampert R, Bradley E, Lynn J, Krumholz HM. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835–838. 24. Sherazi S, McNitt S, Aktas MK, et al. End-of-life care in patients with implantable cardioverter defibrillators: a MADIT-II substudy. Pacing Clin Electrophysiol. 2013;36:1273–1279. 25. Padeletti L, Arnar DO, Boncinelli L, et al. EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy. Europace. 2010;12:1480–1489. 26. Green CP, Porter CB, Bresnahan DR, Spertus JA. Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure. J Am Coll Cardiol. 2000;35:1245–1255. 27. Bhattacharya S, Abebe K, Simon M, Saba S, Adelstein E. Role of cardiac resynchronization in end-stage heart failure patients requiring inotrope therapy. J Card Fail. 2010;16:931–937. 28. Aaronson KD, Schwartz JS, Chen TM, et al. Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Circulation. 1997;95:2660–2667. 29. Allen LA, Gheorghiade M, Reid KJ, et al. Identifying patients hospitalized with heart failure at risk for unfavorable future quality of life. Circ Cardiovasc Qual Outcomes. 2011;4:389–398.