From the Editorial Team Lead of the Geriatric Cardiology Section:

The discussion of end-of-life care between physicians and their older adult patients with end-stage heart disease is a very personal conversation and considered a difficult task. It has been suggested that this talk perhaps be delegated to experts in the field of palliative care. However, we in the geriatric cardiology community believe that this privileged dialogue is best started by the patient's cardiologist or advanced cardiovascular nurse practitioner. The inherent reasoning being, that this group of clinicians have an up-to-date knowledge about the current cardiovascular health and an established relationship with the patient. To this extent, I have asked Dr. Esther Pak, Dr. Elizabeth S. Menkin and Dr. James N. Kirkpatrick to share their knowledge and experience in this area to enable cardiologists and advanced practitioners to be comfortable in starting "the conversation."
– Ashok Krishnaswami, MD, MAS, FACC

A 73-year-old man with ischemic cardiomyopathy, status post cardiac resynchronization and implantable cardioverter-defibrillator (ICD) therapies is in clinic after his most recent hospitalization, his third within the last 2 months. During his last admission, he was found to have a decrease in ejection fraction to 15% and worsened renal function with a rise in his creatinine level to 1.8 mg/dL. He initially required inotropic support, which was successfully weaned. A furosemide drip was employed for diuresis, and he was transitioned to twice a day oral diuretics. His shortness of breath and edema have improved, but he continues to be dyspneic at rest. Due to his prostate cancer and lack of social support after his wife's death two years prior, he is deemed as not a candidate for advanced therapies such as destination therapy left ventricular assist device (LVAD). His medications include lisinopril 5 mg, carvedilol 3.125 mg every 12 hours, digoxin 0.125 mg, furosemide 80 mg twice daily with an additional 40 mg depending on his daily weights, aspirin 81 mg, and atorvastatin 40 mg. On physical examination, he catches his breath while walking to the examination table. Vital signs show a heart rate of 85 bpm, blood pressure 100/65 mm Hg, and oxygen saturation of 95% on room air. His weight is 189 lbs, near his dry weight of 183 lbs. His jugular venous pressure is 8 cmH2O. His lungs are clear. Cardiac examination reveals a holosystolic murmur at the apex. A 12-lead electrocardiogram shows biventricular paced rhythm. Since discharge, he has been receiving home hospice services. The hospice team has recommended that defibrillator function be deactivated. The patient wants to get input for device management prior to his appointment with an electrophysiologist. He has never received a shock from his ICD. He wishes to die at home and remain comfortable.