Living and dying with heart failure: it's time to talk.

Dramatic advances in the care of heart failure (HF) patients have emerged over the last two decades, resulting in an improvement in survival after diagnosis. With the development of novel therapies, the number of patients living with HF has increased. Unfortunately, HF is a disease associated with high symptom and co-morbidity burden, resulting in repeated hospitalizations. This emerging epidemic of HF hospitalizations has placed an enormous economic burden on the healthcare system in many countries. In an era of increasing focus on patient-centred medicine, the matching of patient preferences to resource use becomes of mounting importance in caring for our ageing population. However, assessment and knowledge of patient preferences regarding treatment and end of life care remain suboptimal. Brunner-La Rocca and colleagues report provocative findings from an analysis of patients enrolled in the Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-CHF), which compared symptom-guided with N-terminal pro brain natriuretic peptide (NT-proBNP)-guided medical therapy. Among the 622 HF participants, elicited end of life preferences revealed a predilection for quantity of life over quality of life, though there was little association between patient preference for longevity and mortality. These results challenge conventional beliefs that HF patients would trade time alive for an improvement in health status, and prompt further investigation into the factors contributing to patient preferences, including their understanding of their own prognosis. Brunner-La Rocca et al. gathered information on time trade-off and resuscitation preferences at enrolment, 12, and 18 months among patients with active HF and a recent HF hospitalization. In contrast to most trial populations, TIME-CHF participants more closely mirrored community HF patients, as they were quite elderly (mean age 77 years), frequently female (41%), and had a high burden of co-morbidities, making generalization of their findings to the representative European communities less problematic. The authors found that three-quarters of patients were not willing to trade any time alive for an improved quality of life at enrolment, and only one-third of participants expressed a willingness to trade longevity for improved quality of life at any point in the study. While some independent predictors of willingness to trade were identified, including older age, female sex, a lower activity level, and higher depression scores, they exhibited a poor ability to predict end of life preferences (Model C-statistic 0.710). A minority (39%) of patients did not wish to be resuscitated, though the proportion approached 50% in those aged 75 and older. Perhaps most intriguingly, there was no correlation between patient preferences regarding time trade-off or resuscitation and all-cause mortality. The literature investigating end of life preferences in HF patients is sparse. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a multicentre study enrolling patients with one of nine high-mortality conditions. Of the 936 participants with HF, 23% did not want to be resuscitated, and 19% of patients changed preference after 6 months. Physicians incorrectly perceived patients’ preferred resuscitation status 24% of the time. The most powerful predictor of physician belief that a patient would not want to be resuscitated was the physician’s personal preference for resuscitation if they were placed in similar circumstances. Similar to the TIME-CHF analysis, these results underscore the dynamic nature of patient end of life preferences, and highlight the need for recurring patient– physician discussions on end of life care. However, it is alarming that there was a disconnection between physician perception and patient preference for resuscitation even after patient–provider discussions occurred, calling into question whether medical training has provided physicians with the skills necessary to elicit patient preferences accurately regarding end of life care. The time trade-off utility was also administered in patients hospitalized with HF enrolled in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheter Effectiveness (ESCAPE) trial. In contrast to the study of Brunner-La Rocca