Palliative care is an essential component of management in advanced heart failure (HF). As the disease progresses, the focus gradually shifts from life-prolonging interventions toward relief of symptoms and reduction of treatment burden.

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Goals of Care in Advanced Heart Failure

In the advanced stage of HF, the overarching goals are:

• Optimal symptom relief – targeting dyspnea, edema, pain, fatigue and anxiety.

• Support for active self-management – including maintenance of mobility, muscle strength and balance to the extent feasible.

• Avoidance of low-value interventions – limiting investigations and procedures unlikely to change management or prognosis (for example, repeated imaging, invasive procedures, or hospitalizations that do not contribute to patient-defined goals).

• Support for a “good death” – ideally in the patient’s preferred place, with comfort, dignity, and appropriate family and caregiver support.

 

Identifying Patients for a Palliative Treatment Pathway

Patients who may benefit from a predominantly palliative approach include those with:

• Persistent NYHA class III–IV symptoms despite guideline-directed medical and device therapy.

• Recurrent HF hospitalizations or unplanned urgent visits.

• Progressive intolerance of disease-modifying therapies, such as symptomatic hypotension, renal dysfunction, hyperkalemia or bradyarrhythmias.

• Severe frailty or multimorbidity, or explicit patient preference to prioritize comfort and quality of life over life prolongation.
   

For such patients, palliative and end-of-life planning should be integrated with ongoing cardiology care and revisited regularly.

 

Adapting Heart Failure Pharmacotherapy in the Palliative Phase

In advanced HF, pharmacotherapy shifts from long-term prognostic benefit toward immediate symptom relief, reduction of regimen complexity and avoidance of adverse effects. Deprescribing should be deliberate, stepwise, and based on shared decision-making.

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Prognosis-Modifying HF Medications

These include:

• ACE inhibitors (ACEi)

• Angiotensin receptor blockers (ARB) / angiotensin receptor–neprilysin inhibitors (ARNI)

• Beta-blockers

• Mineralocorticoid receptor antagonists (MRA)

• Sodium–glucose cotransporter-2 inhibitors (SGLT2i)
   

These agents improve survival and reduce HF hospitalizations and often contribute to better hemodynamics and symptom control (for example, less dyspnea and edema).

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In systolic HF, these drugs are generally continued while they are well tolerated and clearly contribute to symptom relief and blood pressure control.

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In diastolic HF (HFpEF), antihypertensive therapy can often be simplified:

• Continue treatment if the patient has symptomatic hypertension or markedly elevated blood pressure.

• Consider tapering if blood pressure is low and/or the treatment does not clearly improve symptoms
   

Beta-blockers used primarily for angina should be continued if they clearly relieve chest pain or dyspnea.

MRAs and SGLT2 inhibitors are used alongside ACEi/ARB/ARNI and beta-blockers as disease-modifying therapy and can be managed in a similar way: continued while tolerated and symptomatically useful, with deprescribing when side effects or treatment burden outweigh benefits.

 

When to Taper or Discontinue Prognosis-Modifying Therapy

Gradual tapering and discontinuation should be considered if any of the following occur:

• Symptomatic hypotension or dizziness.

• Advanced renal dysfunction, for example estimated GFR <25 mL/min/1.73 m².

• Recurrent or severe hyperkalemia, for example serum K⁺ >5.5 mmol/L despite optimization.

• Marked bradycardia or conduction disease attributable to beta-blockade.

• Polypharmacy and high treatment burden clearly reducing quality of life.
   

When deprescribing, reduce one agent at a time (often starting with the one most likely to cause side effects, such as MRA or high-dose ACEi/ARB/ARNI) and monitor symptoms, blood pressure and renal function.

 

Symptom-Directed Diuretic Therapy

Loop and thiazide diuretics are the cornerstone of symptom relief in end-stage HF. Their importance increases as HF advances, and they are typically the last HF drugs to be tapered.

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Doses should be adjusted according to congestion, daily weight, renal function and blood pressure. Intensified oral, intravenous or occasionally subcutaneous loop diuretic therapy can reduce dyspnea, edema and the risk of hospitalization.

 

Combination therapy with a loop plus a thiazide-type diuretic can be considered for refractory congestion, with close electrolyte and renal monitoring.

 

Other Medications

Nitrates

Short-acting or long-acting nitrates used primarily for angina should be continued if they clearly relieve chest pain or dyspnea.

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Secondary Prevention of Coronary Artery Disease

Statins and low-dose aspirin used solely for long-term cardiovascular prevention generally provide little symptomatic benefit in patients with limited life expectancy and can often be discontinued by the hospice phase.

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Because current ESC and ACC/AHA acute coronary syndrome (ACS) guidelines recommend at least 12 months of dual antiplatelet therapy and long-term high-intensity statins after an ACS, deprescribing these agents in patients with very recent ACS or coronary stent implantation (particularly within the first 6–12 months) should be approached cautiously and individualized. Outside this early high-risk period, especially when life expectancy is limited and bleeding risk is high, reduction or discontinuation of these preventive therapies may be reasonable.

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Rhythm Control and Atrial Fibrillation

Sinus rhythm maintenance (for example, with amiodarone) should be continued only when suppression of atrial fibrillation or other arrhythmias has a clear symptomatic benefit, such as reduction of palpitations or HF decompensation, which may be particularly relevant in HFpEF.

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For many patients, a simplified rate-control strategy and anticoagulation (if consistent with goals of care and bleeding risk) may be preferable to rhythm-control approaches.

 

Medications to Avoid or Deprescribe

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided because of sodium and water retention, increased blood pressure, and a heightened risk of HF decompensation and hospitalization.
 

Symptom Management

General Principles

Both ESC and ACC/AHA/HFSA guidelines recommend consideration of low-dose opioids (for example, morphine) for refractory dyspnea and pain in advanced HF. HF-specific dosing protocols are not provided, and morphine titration protocols for dyspnea in HF are not well established. Dosing should therefore follow general palliative-care guidance, starting with low oral or parenteral doses and titrating cautiously according to symptom relief and adverse effects, with attention to age, renal function and comorbidities.

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Dyspnea and Congestion

Optimize diuretic therapy as the first step.

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Low-dose opioids (for example, oral morphine) can be used for refractory dyspnea once reversible contributors have been addressed. Evidence is limited but supported by HF and general palliative-care literature.

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Supplemental oxygen should be reserved for patients with documented hypoxemia; it does not consistently relieve breathlessness in normoxemic HF patients.

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For opioid-naïve adults, general palliative guidelines suggest:

• Morphine 5 mg PO every 3–4 hours as needed (2.5 mg in very frail or older adults).

• Morphine 1–2 mg IV every 1 hour as needed.

• Oxycodone 2.5–5 mg PO every 3–4 hours as needed.
   

Doses can be titrated by approximately 25–50% if dyspnea remains uncontrolled.

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For chronic refractory breathlessness, an often-cited regimen is oral morphine 10 mg/day, titrated slowly by 10-mg increments every 7–10 days up to approximately 30 mg/day, based on small trials and observational data. This is derived from general palliative evidence.

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Benzodiazepines (for example, lorazepam) are reserved for clinically significant anxiety or panic associated with dyspnea. Benzodiazepines do not relieve dyspnea per se.

 

Pain

Pain is highly prevalent yet frequently under-recognized in advanced HF, with studies reporting clinically significant pain in 40–70% or more of patients. Routine assessment and systematic management are essential.

 

Pharmacologic treatment

First-line: acetaminophen/paracetamol on a regular or as-needed schedule.

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Opioids (for example, low-dose morphine or oxycodone) are appropriate for moderate to severe pain unresponsive to non-opioid therapy, with careful titration and monitoring for constipation, confusion and respiratory depression.

 

For neuropathic pain, consider gabapentinoids or certain antidepressants (for example, duloxetine), taking into account sedation, dizziness and renal function.

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Avoid systemic NSAIDs because of their deleterious effects in HF; topical NSAIDs may be considered for localized musculoskeletal pain where systemic absorption is limited.

 

Anxiety

Benzodiazepines are directed at anxiety, not dyspnea itself. They should only be added only once non-pharmacologic strategies and opioid therapy for dyspnea have been optimized.

 

A commonly used regimen for anxiety related to dyspnea in non-frail adults, lorazepam 0.5–1 mg PO or sublingual every 4–6 hours as needed can be used for anxiety related to dyspnea, with dose and frequency individualized and the lowest effective dose sought. For frail patients lorazepam 0.25 mg PO or sublingual can be considered.