Recognizing advanced heart failure: How hospice supports better outcomes for patients and care teams

By Heather Veeder, MD, Regional Medical Director, VITAS Healthcare

Heart failure is one of the most common and clinically complex serious illnesses in the United States. Even with advances in medical therapy, many patients experience escalating symptoms, declining function and repeated hospitalizations as they move into the advanced stages of the disease. These challenges place significant strain on clinicians, patients and caregivers.

As a hospice physician, I frequently see patients referred late in the course of heart failure, often during the final days of life. Earlier recognition of advanced decline and earlier hospice involvement can make a meaningful difference. It can stabilize symptoms, reduce avoidable utilization and improve the patient and family experience.

This article summarizes key insights from our recent VITAS Healthcare webinar, Matters of the Heart: Beyond Survival in Advanced Cardiac and Hospice Care, and offers practical guidance for clinicians who care for patients with progressive heart failure.

Patients with heart failure are underrepresented in hospice

Despite the prevalence of heart failure, hospice utilization for these patients remains significantly lower than for those with cancer and other advanced illnesses. The pattern is well known. Patients cycle through the hospital with more frequent exacerbations, appear stable for short periods and then decline quickly.

Several factors contribute to late or no referrals:

• Difficulty predicting prognosis
• Misconceptions about hospice eligibility
• Misconceptions about the need to discontinue disease-modifying therapies
• Lack of clarity about how hospice manages complex cardiac needs
• The false belief that patients must be DNR to receive hospice care

When hospice is added earlier, patients gain access to patient-centered interdisciplinary support that aligns with their goals while reducing the burden on families and the healthcare system.

Common cardiac diagnoses seen in hospice

Although heart failure takes many forms, the most common diagnoses seen in hospice include:

• Heart failure with preserved ejection fraction
• Heart failure with reduced ejection fraction
• Cardiomyopathy
• Atrial fibrillation with rapid ventricular response
• Hypertensive heart disease

Most patients present with multiple comorbidities such as COPD, hypertension, chronic kidney disease and cognitive impairment. These conditions complicate management and often accelerate the transition into the advanced stages of heart failure.

Recognizing clinical indicators of hospice eligibility

Heart failure symptoms can be subtle and easy to minimize. Early recognition of these signs can help clinicians identify patients who may benefit from hospice before crisis moments occur.

Key indicators include:

• Dyspnea with minimal exertion or at rest
• Profound fatigue that limits basic daily activities
• Recurrent hospitalizations or emergency visits
• Hypotension or intolerance to guideline-directed medical therapy
• Weight loss, muscle wasting or declining appetite
• Increasing dependence on caregivers
• Frequent fluid retention requiring IV or high-dose diuretics
• Anxiety or distress caused by breathlessness

These patterns reflect the transition into advanced heart failure, when the goals of care often shift toward comfort, stability and quality of life.

How hospice supports heart failure patients and care teams

Hospice provides a level of home-based support that can be difficult to deliver in traditional outpatient settings. At VITAS, our cardiac trained teams assist patients and partners by:

• Managing complex symptoms such as dyspnea, fatigue and anxiety
• Providing subcutaneous or IV diuretics when indicated
• Supporting oxygen use and other respiratory therapies
• Monitoring symptoms during periods of instability
• Offering 24/7 clinical access to prevent avoidable hospitalizations
• Collaborating closely with cardiologists and heart failure teams
• Educating caregivers on what to expect and how to respond to changes

This approach helps stabilize patients in their preferred care setting and reduces the uncertainty clinicians often face when deciding whether a patient is ready for hospice.

AHA Certification

The value of AHA Heart Failure Certification

VITAS has earned the American Heart Association (AHA) Palliative/Hospice Heart Failure Certification across all 15 states in which it operates. VITAS extends AHA-certified, guideline-directed medical therapy across the care continuum, addressing the clinical, emotional and psychosocial needs of patients with advanced cardiac disease and their families.

This certification reflects our commitment to clinical excellence and ensures that our teams:

• Receive structured, ongoing heart failure training
• Align care plans with AHA best practices
• Support patient and caregiver education
• Maintain strong care coordination across settings
• Offer rapid, consistent access to clinical support

For referring clinicians, this certification provides confidence that their patients are receiving high-quality, cardiac focused end of life care.

Partnering for better patient experiences

Clinicians do not have to manage advanced heart failure alone. Hospice can be an extension of your care, helping patients remain comfortable and reducing the emotional and physical strain on caregivers.

Referring earlier helps patients more, supports families more and gives clinicians the assurance that their patients are receiving the right care at the right time.