When planning care for an advanced heart failure patient, with whom should end-of-life discussions most appropriately occur?

• A. With the patient and family, guided by patient preferences
• B. Only with the cardiology team in hospital
• C. With the patient's attorney only
• D. Not discussed unless patient requests

Answer: (A)

End-of-life planning should be patient-centered, beginning with the patient and family and guided by the patient’s own preferences. This approach honors autonomy and ensures that care goals reflect what is most important to the patient, whether that means focusing on comfort, pursuing disease-modifying therapies, or a combination of both. In advanced heart failure, where prognosis can be uncertain and trajectories can shift, involving the patient and family in conversations about goals of care, the desired level of intervention, and plans for advance directives or hospice ensures that subsequent treatment choices—including medications, escalation or de-escalation of therapy, and hospital vs. palliative care options—are aligned with the patient’s values.

Relying solely on the cardiology team, involving only medical-legal professionals, or waiting for the patient to request discussion undermines patient autonomy and can miss expressed preferences. These conversations are most effective when they are ongoing, revisited as the situation evolves, and supported by the broader care team to provide consistent, compassionate guidance that centers the patient’s wishes.