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Learning objectives Cardiovascular disease remains a leading cause of death internationally despite decades of advances in medical, surgical and device therapy. Our armament of treatments may support heart function, correct valvular dysfunction, ameliorate arrhythmias and delay death while improving functional status. However, none of these treatments are curative, and each carries at least a small risk of unintended negative consequences, including causing or prolonging suffering. Cardiovascular disease manifests in a variety of clinical profiles, ranging from a previously healthy person with an acute myocardial infarction to a middle-aged individual with an inflammatory cardiomyopathy to a teen with a Fontan repair of single ventricle disease. Their disease experiences and deaths may look very different from one another, but they can all benefit from the incorporation of palliative care. This article provides a description of palliative care as it applies to cardiology, including tools to facilitate the use of primary palliative care by cardiovascular clinicians. Palliative care is a specialised type of medical care that focuses on improving communication about goals of care (GOC), maximising quality of life and reducing symptoms.1 2 It is patient-centred and family centred care that is appropriate at any age and at any stage of a serious illness. In the past, it was often used synonymously with hospice, particularly in end-stage cancer, and gained a reputation as ‘doing nothing’ or ‘giving up’. However, palliative care is better seen as an ‘interventional’ specialty because of its focus on GOC that frame the appropriateness of therapies and its use of measures to ameliorate suffering. Palliative care should be applied alongside usual care in acute and chronic …

A 68-year-old man with ischaemic cardiomyopathy presents with acute on chronic systolic heart failure with severe mitral regurgitation. He has a history of coronary artery disease status post-coronary artery bypass surgery, stage 3 chronic kidney disease and diabetes. He is deemed high risk for surgical valve replacement and is being evaluated for transcatheter mitral valve intervention. In a goals-of-care discussion, he expresses that it is important to him to be functional and independent in his daily activities, and he wishes never to be placed on dialysis. His independence is more important to him than longevity at all costs. He is unsure how he feels about mitral valve intervention. His son, who is his healthcare power of attorney, is in favour of the intervention because he wants his father to live as long as possible, even if he is not as independent as he would like to be. They ask you how they should proceed. Cardiovascular disease is a chronic illness with periods of acute exacerbation and intense decision-making. Our therapies are not curative, and they carry the potential to be burdensome to the patient if used unwisely. Palliative care (PC) is an approach to medical care that focuses on managing symptoms, providing emotional and spiritual support, promoting communication …

Once the focus of medical treatment transitions away from life-prolonging care, implantable cardioverter-defibrillator (ICD) shocks no longer serve their intended purpose. In this situation, device deactivation may be appropriate. The potential unwanted consequences of having an ICD at the end of life are rarely addressed, although their life-saving benefits until that point are widely recognised. In their Heart paper, Stoevelaar and colleagues1 share insight from patients’ expressions of their thoughts and experiences related to advance care planning surrounding ICD deactivation. Five focus groups were held with 41 participants, exploring patient attitudes towards ICD deactivation and delivery of information and communication about ICDs towards the end of life. Using thematic analysis, the authors present results centred about three major themes: (1) reflection on wishes and preferences, (2) discussing preferences, and (3) recording and reviewing preferences. Participants had widely differing opinions about ICD deactivation, ranging from equating deactivation with euthanasia to fearing shocks more than death. One was even unaware of the option to deactivate their ICD. Living with compromised quality of life was deemed undesirable, and several participants cited suffering from non-cardiac disease as a reason to deactivate the ICD. Others felt no need to even think about future ICD deactivation, instead preferring to focus on life. While some participants desired conversations about ICD deactivation with healthcare providers, few had done so, and this served as a source of discontent for some. Strikingly, there was no consensus as to the optimal timing for …