Statement Highlights:
- Palliative care is specialized medical care focused on easing symptoms, addressing psychological and spiritual needs, and helping patients and caregivers make critical decisions aligned with their personal beliefs and values.
- Palliative care practices can be integrated by cardiovascular clinicians and by, or in collaboration with, palliative care interdisciplinary teams and specialists for all stages of care for people with cardiovascular disease, including individuals hospitalized for acute medical crises, patients in cardiac intensive care units and those receiving outpatient care.
- The new scientific statement reviews how palliative care can be integrated into treatment for people with critical cardiovascular conditions, identifies challenges and ethical considerations to accessing palliative care, and highlights the need for palliative care education for all cardiovascular clinicians.
DALLAS, May 15, 2025 — Palliative care may help relieve symptoms and improve quality of life for people with cardiovascular disease and ensure that treatment is aligned with the patient's personal beliefs and values throughout all stages of illness, whether they are hospitalized in a cardiac intensive care unit or receiving outpatient care, according to a new American Heart Association scientific statement published today in the Association's flagship, peer-reviewed journal Circulation.
The new scientific statement, "Palliative and End-of-Life Care During Critical Cardiovascular Illness," suggests strategies to integrate palliative care principles into the management of patients with critical cardiovascular illness. Palliative care aims to improve quality of life; to minimize physical, emotional and spiritual distress; to facilitate complex discussions regarding prognosis and goals of care; and to provide emotional and psychosocial support to patients, family members and caregivers throughout all stages of illness, not just at the end of life. Currently, palliative care is most widely used caring for patients with cancer.
"We need to better understand the benefits of palliative care in a broad range of cardiovascular conditions and particularly for patients with acute, critical illness," said volunteer Chair of the scientific statement writing group Erin A. Bohula, M.D., D.Phil., an assistant professor of medicine at Harvard Medical School and critical care cardiologist at Brigham & Women's Hospital, both in Boston. "People with a variety of heart conditions face increasing symptoms, functional limitations and a need to align care with their personal preferences, beliefs and values – whether that's to do everything possible or to prioritize comfort and quality of life. A patient-centered approach needs to be considered, particularly when making decisions about available and sometimes invasive care options as their condition advances."
Palliative care for specific cardiovascular conditions
The statement authors emphasize that palliative care can be provided in addition to evidence-based treatments at any stage of a person's illness, from intensive care to outpatient care. However, providing palliative care for cardiovascular disease can be challenging because the progression of the illness can be unpredictable, and there may be sudden, urgent situations requiring hospitalization and/or admission to the cardiac intensive care unit. These can result in new symptoms such as loss in physical function and may lead to unexpected end-of-life situations that necessitate more intensive support from cardiology and palliative care professionals.
In addition, many patients admitted to cardiac intensive care units are older (with a median age of 65 years), more frail and critically ill, with advanced and complex cardiovascular conditions, and they may also have multiple non-cardiac conditions. Palliative care health professionals need to be knowledgeable about the medical prognosis and quick decision-making required in cardiac intensive care units, including the management of life-sustaining technologies and advanced cardiac interventions.
Palliative care can be integrated into care to manage symptoms and improve quality of life for patients with different types of cardiovascular disease:
- Heart failure (weakening of heart muscle so it is unable to pump enough blood and oxygen to meet the body's needs): Symptoms can include persistent shortness of breath and fatigue. Treatment options may include inserting a device to help the heart pump, or a heart transplant. The guideline for the management of heart failure recommends incorporating palliative care to all patients with heart failure. Current evidence indicates that incorporating palliative care into heart failure management is associated with better outcomes, including improved quality of life and symptom management, better physical function, lower rates of depression and anxiety, better use of advanced care directives, lower health care utilization, lower hospital admissions, shorter length of hospital stay and lower costs of care.
- Coronary artery disease (build-up of plaque in arteries feeding the heart muscle): Symptoms include persistent and severe chest pain that limit a patient's quality of life and ability to function, which may contribute to additional symptoms, such as depression, anxiety and fatigue. Palliative care may be helpful in relieving symptoms for patients with end-stage coronary artery disease who are not candidates for revascularization surgery (to restore blood flow to the heart). However, current research indicates that only 15% of patients with end-stage coronary disease are referred for palliative care.
- Peripheral artery disease (also called PAD, narrowing of arteries carrying blood away from the heart to the extremities): Symptoms can include pain that makes it difficult to walk and significantly limits quality of life. Treatment options may include medications or procedures to restore blood follow, or in severe cases, amputation may be the best option. Previous studies have found that palliative care for patients with peripheral artery disease improved caregiver and family satisfaction, better end-of-life communication and hospice referrals.
- Adult congenital heart disease (heart problems in adulthood related to being born with a structural heart defect): Due to advancements in the care of patients with congenital heart defects over the last few decades, survival rates have greatly improved. Currently, more than 97% of children with congenital heart disease can be expected to reach adulthood. This has resulted in an increasing number of adult patients who are at high risk for heart failure, arrhythmia (irregular heartbeat) and/or vascular disease. Palliative care may be helpful to provide emotional and social support for patients and their families, improve quality of life, mental health and functional status, and to facilitate discussions about goals of care as the disease progresses. However, only 10-15% of patients with congenital heart disease report receiving referrals for palliative care.
- Valvular disease (one or more heart valves that don't open or close properly, creating blood flow problems): Symptoms can include shortness of breath and chest pain. Treatment options may include open heart or less-invasive surgery to replace or repair a valve that isn't functioning properly. Palliative care may help assess the patient's goals of care; the most common goal reported by patients with advanced heart valve disease is symptom relief rather than prolonging life. More than 5 million people in the U.S. are diagnosed with heart valve disease each year, and the prevalence is expected to increase due to the aging population and improvements in diagnostic strategies.
- Arrhythmias (abnormal or irregular heartbeats): Patients who have implantable cardiac defibrillators may experience psychological stress or anxiety due to receiving sudden, unexpected shocks from the device, which can affect their quality of life. Palliative care can assist with aligning patient values and goals for invasive procedures and device management, specifically implantation, replacement, removal or deactivation. However, only an estimated 9-14% of patients with implantable cardiac defibrillators receive palliative care consultation.
- Post-cardiac arrest (a life-threatening emergency in which the heart suddenly and unexpectedly stopped pumping): Lasting symptoms after cardiac arrest may include significant brain injury, physical fatigue, muscle weakness, chest pain, shortness of breath, changes in vision or speech, problems with fine motor skills, memory loss and emotional challenges such as post-traumatic stress disorder. Early referral for palliative care consultation can help patients after cardiac arrest with navigating challenging discussions, assisting in complex decision-making, and providing ongoing support for families, caregivers and care teams.
Accessibility challenges and ethical considerations
Despite the growing evidence about the benefits of palliative care, many people with cardiovascular disease have limited access to palliative care specialists. Rates of referral to palliative care for patients with cardiovascular disease are low and often delayed compared to patients with cancer.
Due to delayed referrals and the scarcity of palliative care resources, it can be difficult for individuals with cardiovascular disease to access outpatient palliative care. Inpatient palliative care services may also be limited in settings outside of large hospitals. The statement suggests integrating palliative care services into heart failure clinics and post-discharge services for patients recently hospitalized in the cardiac intensive care unit, creating a transition from inpatient to outpatient care.
There are also complex ethical considerations for patients with advanced cardiovascular disease, particularly in relation to life-sustaining interventions. Medical codes of ethics emphasize promoting patient well-being, avoiding harm and respecting patient autonomy; however, these can sometimes seem at odds in the setting of the cardiac intensive care unit or treating a patient with end-stage cardiovascular disease. For example, deactivating the shocking function of an implanted cardiac defibrillator may increase the risk of death if a fatal arrhythmia occurs, while at the same time minimizing a patient's pain by avoiding the delivery of multiple shocks.
A separate, recently published American Heart Association scientific statement on palliative care and advanced cardiovascular disease highlights the importance of shared decision-making involving the patient and family as the disease progresses. When a patient's symptoms become more severe and difficult to manage, discussions about changing or discontinuing certain treatments may be necessary based on the patient's personal preferences, quality of life, prognosis and advanced care documents.
Education for cardiovascular specialists
While palliative care is not a recognized subspecialty of cardiology, its approaches can be offered by cardiovascular clinicians with specialized training in palliative care and in consultation with palliative care specialists. However, only a small fraction of health care professionals who complete a cardiology fellowship receive either required or elective training in palliative care.
The scientific statement identifies several basic palliative care competencies needed by cardiovascular specialists:
- ability to manage common symptoms of various cardiovascular conditions, such as pain, fatigue, nausea and shortness of breath, and address the emotional, psychological and spiritual needs of patients and their families;
- skills in discussing prognosis, treatment options and goals of care with patients and families, with sensitivity to cultural, religious and personal values that may influence patient preferences and decision-making;
- ability to collaborate in a multidisciplinary team and coordinate care across different settings to ensure continuity of care; and
- understanding of the ethical issues involved in advanced cardiovascular care, including end-of-life decisions, informed consent and advance directives.
"It is critical that all cardiac intensive care unit and acute care professionals have the tools and knowledge to provide the basic tenets of palliative care, such as symptom management and ensuring that care is appropriate and aligns with the patient's personal choices. As the field of cardiac critical care advances, incorporating palliative care principles ensures a holistic approach to providing care and addressing the complex needs of these patients during a health care crisis or at the end-of-life," said Bohula.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology, and the Council on Cardiovascular and Stroke Nursing. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.
Co-authors are Vice-Chair Abdulla A. Damluji, M.D., Ph.D., M.B.A., FAHA; Michael J. Landzberg, M.D.; Venu Menon, M.D., FAHA; Carlos L. Alviar, M.D.; Gregory W. Barsness, M.D., FAHA; Daniela Crousillat, M.D.; Nelia Jain, M.D., M.A.; Robert Page II, Pharm.D., M.S.P.H., FAHA; and Rachel Wells, Ph.D., M.S.N. Authors' disclosures are listed in the manuscript.
