2025 AHA科学声明：重症心血管疾病期间的姑息治疗和临终关怀

PALLIATIVE CARE IN NON-CVD

Palliative care is most widely used in the care of patients with oncological disease. More than a third of patients

with cancer report significant and severe symptoms, in cluding pain, nausea, depression, anxiety, dyspnea, and fatigue. 37 Evidence from randomized clinical trials and observational studies suggests that early integration of palliative care provides a range of benefits, including improved symptoms, mood, and quality of life; increased likelihood of discussing and documenting end-of-life preferences; and improved satisfaction with the care provided. 3,38 Thus, current guidelines from the American Society of Clinical Oncology recommend early palliative care referral for patients with advanced cancer within 8 weeks of diagnosis. 38 The guidelines recommend us ing criteria for early palliative care consultation based on prognosis, functional decline, number of admissions, need for complex care, as well as other concomitant fac tors such as metastatic disease, cardiac arrest history, limited social support, and need for home oxygen.

PALLIATIVE CARE IN CVDs

Heart Failure

The most robust guidance for palliative care integration in CVD exists for patients living with heart failure, for whom recommendations are based on a growing body of evi dence that incorporation of palliative care into heart failure management is associated with better outcomes, includ ing improved quality of life and symptom (dyspnea, pain) management, better functional class, lower rates of de pression and anxiety, better use of advanced care direc tives, lower health care use, lower hospital admissions, shorter length of stay, and lower cost of care. 39–42 There fore, heart failure guidelines from major scientific societies have evolved from recommending palliative care referral for patients with stage D heart failure to recommending palliative care to all patients with heart failure. 43,44 Howev er, rates of referral for palliative care in patients with heart failure remain suboptimal, and referral is often delayed for patients with heart failure compared with patients with cancer. 1,45 Such delays and lower adherence to recom mendations may be explained by several factors, includ ing inconsistent and limited education in palliative care for cardiovascular health care professionals; insufficient sup ply of palliative care specialists, particularly those trained in cardiovascular palliative care, relative to the growing population of patients with heart failure; and challenges in identifying patients who are likely to benefit from pal liative care. 42 A recent Delphi study provided major criteria from expert consensus for palliative care referral in heart failure. 46 These included a combination of patient features (severe left ventricular dysfunction, cardiorenal syndrome, cardiac cachexia), treatment features (inability to toler ate goal-directed medical therapy, need for mechanical circulatory support, frequent readmissions, consideration for advanced therapies), symptoms (severe physical or emotional symptoms, significant functional limitation), and

social/psychological features (difficult decision-making, poor social support, mental health challenges, advanced care planning). 46 Although limited, the available evidence also supports palliative care interventions at the time of acute heart failure hospitalization, in addition to during the chronic phase of disease. 41,42

Other CVD States

More recently, there is a call for expansion of the under standing and application of cardiovascular palliative care beyond heart failure to include non–heart failure CVDs as well (Figure2). 1 Although the evidence base is limited for the use of palliative care for non–heart failure critical cardio vascular illness in the CICU, it is helpful to briefly consider the specific challenges experienced by patients who have each of these diseases and opportunities for palliative care integration to further optimize care for these populations.

End-Stage Coronary Artery Disease

Patients with nonrevascularizable end-stage coronary artery disease may have persistent and severe angina in the face of limited tolerability/efficacy of antianginal medication (attributable to comorbidities, frailty, or base line hemodynamics). 9 Refractory angina significantly limits quality of life and functional status and frequently contributes to additional symptoms such as depression, anxiety, and fatigue. 47 Despite these challenges, only a small proportion of patients with end-stage coronary dis ease are referred for palliative care, with a significant dis proportion compared with patients with heart failure. 1,48

Valvular Heart Disease

Despite the high prevalence of valvular heart disease (VHD) in the aging population, referral to palliative care in VHD remains low. 49,50 In the current era, management of VHD has been revolutionized by percutaneous thera pies, but despite the advances, VHD continues to carry high morbidity and mortality. 50 For example, patients in the high-risk category who undergo transcatheter aor tic valve replacement still have a $47\%$ mortality rate at 2 years in the face of advanced age, multiple comorbidi ties, and frailty, and $17\%$ of the survivors continue to have New York Heart Association class III symptoms. 51,52 Thus, there appears to be a meaningful role for palliative care in the population with advanced VHD in terms of assessing goals of care according to the patients’ individual values and in the context of procedural interventions because the procedure itself may be a way to palliate symptoms of dyspnea and angina, in addition to a potential bene fit in survival. 50 This is a key factor to consider because the most common goal reported by patients undergoing transcatheter aortic valve replacement is symptom relief rather than prolongation of life. 53 In addition, palliative care can assist in navigating code status considerations dur ing the periprocedural period, particularly because there

is significant variability in clinical practice with this issue. 54 In many institutions, it is common to involve geriatricians in the care of older patients with advanced CVD care (eg, high-risk transcatheter aortic valve replacement). In these situations, geriatricians often focus on management of multiple comorbidities and maintaining functional inde pendence, in addition to providing primary palliative care. A palliative medicine specialist can play a complementary role, offering additional support around alleviating symp toms, clarifying goals and care, and providing emotional and spiritual support alongside the geriatrician.

Refractory Arrhythmias

Patients who experience shocks from their implantable cardioverter defibrillator may face significant psychologi cal suffering, including posttraumatic stress disorder. The sudden and unexpected nature of device shocks may in tensify fear and anxiety and profoundly affect quality of life and well-being for patients. Palliative care can assist with alignment of patient values and goals with complex care decision-making surrounding invasive procedures and de vice management, specifically implantation, replacement, removal, or deactivation, as well as the pursuit of advanced therapies such as neural blockade and radiation therapy. Data suggest that implantable cardioverter defibrillator de activation occurred in only $30\%$ to $40\%$ of patients with terminal disease with $10\%$ to $20\%$ of patients receiving an implantable cardioverter defibrillator shock in the last month of life. 30,55 Use of palliative care consultation is low, with $9\%$ to $14\%$ of patients with implantable cardioverter defibrilla tors receiving palliative consultation before death. 30,55

Adult Congenital Heart Disease

As the care of patients with congenital heart disease has advanced in the last decades and patient survival has improved, there is an increasing number of adult patients living with congenital heart disease who are at high risk for advanced heart failure, severe arrhythmia, pulmonary and systemic arterial vascular disease, and subsequent decline in function and greater mortality. 56 A particularly challenging aspect for patients, families, and health care professionals is the chronicity of disease and relatively young age at which complications occur, resulting in sig nificant emotional, social, and economic distress for all involved. It has been recommended that palliative care be involved in the care of these patients by 18 years of age to provide support and to discuss goals of care, quality of life, mental health, functional status, advanced care planning, prognosis, disease progression, and pre pregnancy counseling, among other topics. 57 Despite this recommendation, cohort series document that only $10\%$ to $15\%$ of these patients acknowledge receiving referral to palliative care, highlighting existing gaps in palliative care use not only during times of acute crisis but also throughout the course of chronic disease man agement. 58–60

Cerebrovascular Disease

Cerebrovascular disease carries significant morbidity and mortality, being responsible for ${>}5\%$ of all deaths in the United States and causing significant disability. 61 Accord ingly, both the American Heart Association and American Stroke Association recommend a patient-centered and family-centered approach that includes integration of palliative care with longitudinal care to assist with esti mating prognosis, setting goals of care, and establishing strategies aimed at reducing disease burden and con trolling symptoms in these patients. 61

Peripheral Arterial Disease

The presence of peripheral artery disease portends a high morbidity and mortality, with significant limita tions on quality of life in the face of pain (claudication) or amputations with restricted ambulation and mobility. Furthermore, patients with peripheral artery disease fre quently have vascular disease in other arterial beds and therefore are at increased risk of myocardial infarction, stroke, and cardiovascular death. Although evidence on the use of palliative care in this population is limited to small, retrospective studies, they have found improved caregiver and family satisfaction with the palliative care, as well as better end-of-life communication, hospice re ferral, and out-of-hospital death. 62

After Cardiac Arrest

Mortality rates for patients admitted after cardiac arrest are on the order of $50\%$ to $80\%$ ; a further $8\%$ to $10\%$ will survive but will have at least moderate residual disabil ity. 63,64 In addition, initial neuroprognostication identifying which patients will have a good neurological outcome is challenging and imperfect and often requires a compre hensive multidisciplinary assessment. The sudden, often catastrophic nature of cardiac arrest and the associated uncertainty about neurological prognosis may be an op timal context for palliative care integration to support caregivers and surrogate decision-makers in complex decision-making. Although palliative care use rates were low in this population at $16.7\%$ in 2013 in a National In patient Sample database survey, they had increased by >10-fold compared with the preceding decade. 65 Early implementation of palliative care consultation in patients after cardiac arrest can help navigate challenging discus sions, assist in complex decision-making, and provide lon gitudinal support for families, caregivers, and care teams.

PALLIATIVE CARE IN THE INTENSIVE CARE UNIT

Palliative care delivery in the modern intensive care unit (ICU) setting is borne, at least in part, to early investi gation demonstrating poor recognition and adherence to end-of-life goals, treatment modalities, pain management, and code status desires. 66 End-of-life considerations and

care affect a large proportion of patients admitted to the ICU setting, where the onset of acute life-threatening ill ness or the exacerbation of chronic disease is often asso ciated with a rapid initiation and escalation of potentially life-sustaining therapies. Although most patients would choose to die at home or in familiar surroundings if of fered the opportunity, 2 those with critical cardiovascular illness are often not availed of that comfort because of practical logistic and support issues. Approximately $30\%$ of hospital ICU admissions occur at the end of life accom panied by high rates of distressing symptoms, including thirst, dyspnea, delirium, pain, and anxiety. 67 Palliative care in the ICU serves to contextualize these often invasive and potentially painful therapies to alleviate symptoms, to reduce suffering, and to promote improved quality of life for patients, families, and caregivers, albeit within a much condensed time frame than described for patients in the outpatient and non-ICU setting.

Experience in Noncardiac ICU

Palliative care interventions in the ICU may include both primary and secondary or consultative palliative care models, as well as inclusion of the chronic care health care team who have the benefit of longitudinal care in volvement. 68 Unfortunately, the impact of palliative care interventions and the optimal setting or practice model remain understudied and poorly substantiated. However, a few randomized studies have documented benefit for a subset of patients and palliative care ICU interventions to decrease in-hospital resource use, to improve patient quality of life and symptoms, and to lead to better family and care team satisfaction. 69

An area of focus in ICU-based research relates to the burden placed on surrogate decision-makers. Because of their critical illness, patients in the ICU frequently have impaired decision-making and are unable to make deci sions about the course of care. In these cases, there is a heavy reliance on surrogate decision-makers to make critical and time-sensitive decisions about the immediate plans and overarching goals of care, which can result in significant short- and long-term psychological burden for surrogates. 70 The PARTNER trial (Pairing Re-Engineered ICU Teams With Nurse-Driven Emotional Support and Relationship-Building) studied the impact of a nurse-led, multicomponent family-support intervention for families of patients who were incapacitated and were deemed to have a poor prognosis. 71 The intervention, in which trained nurses met with families on a daily basis and arranged clinician-family meetings early and at regular intervals, did not reduce the burden of psychological symptoms rela tive to standard care but did improve surrogate satisfac tion with the quality of communication and family-centered care and decreased the length of stay, predominantly in nonsurvivors. Although the intervention did not improve the psychological toll for surrogates, it did demonstrate

the importance of improved communications on the family experience and the potential to decrease goal-discordant care. Similarly, although this study did not address the impact of the intervention in care team outcomes, includ ing moral distress or emotional burden, which are linked to wellness and burnout, it is possible that such a proto colized family support intervention may have an impact on health care professional experience as well.

Another study, the PCPlanner trial (Palliative Care Planner), evaluated whether a pragmatic, automated, timeline-driven mobile application (app) could improve the family experience during the care of critically ill patients through standardized collection of family-reported needs using the Needs at the End-of-Life Screening Tool and prompting the ICU attending physician to address these needs with scripted behaviors or interventions. 72 Although the intervention did not alter family psychologi cal distress symptoms at 3 months, the intervention did result in a greater improvement in family-reported needs at days 3 and 7, lending support for an automated digital mechanism for targeting the application of primary pallia tive care to support families in a need-specific manner. 73

Consistent with these findings, collaborative ICU family-centered care guidelines 74 promote routine interdisciplin ary family conferences to enhance satisfaction, along with proactive palliative care consultation to decrease ICU and hospital length of stay, in select high-risk patients. 74 Therefore, the acute care/CICU team should take a caregiver- or surrogate-centered approach that aims to ensure frequent longitudinal bidirectional communica tion to allow the caregiver the opportunity to convey their interpretation of the patient’s wishes while remaining well informed of the treatment options and prognosis.

For patients for whom there is significant uncertainty about the benefit of or desire for escalation of care, a time-limited trial can be considered whereby the clinicians, the patient, and the family agree on the use of specific interventions for a specified duration with establishment of the next steps in the case of improvement, deteriora tion, or maintenance of the status quo. Such an approach may also facilitate navigating the challenges of potentially inappropriate interventions by using a goal-directed rather than an intervention-directed approach and ensuring frequent communication with reassessment of goals of care. 75 A bundled approach, anchored around the use of time-limited trials, was studied in a specific subset of criti cally ill patients who were felt to be at risk for nonbenefi cial ICU treatments (category 3 according to the Society of Critical Care Medicine guidelines). 76 Health care profes sionals were trained to facilitate early family meetings to explain medical conditions and prognosis, to elicit patient values and preferences, and to establish a time-limited trial of care based on improvement or worsening accord ing to predetermined clinical parameters and timeline. In the postintervention phase, mortality rates were stable, but family meetings were earlier and more frequent, length of

stay was shorter, and procedural interventions were fewer (particularly in nonsurvivors). These findings suggest that a time-limited trial can be a useful approach to help patients, families, and clinicians agree on a plan of care that limits nonbeneficial interventions by focusing on quality com munication and allowing sufficient time for processing. To assist clinicians in operationalizing time-limited trials, the American Thoracic Society created an expert consensus reference document that outlines the essential elements for conducting a time-limited trial in critical care, which are summarized in 4 sequential phases: consider (goals, priori ties, and prognosis), plan (trial guidelines, including dura tion and criteria that represent a change in clinical status), support (disseminate plans to care team and update patient and surrogates), and reassess (patient’s response to therapy and focus of future care). 77

Last, a randomized trial of provision of formal advance care planning from a trained facilitator (nurse or allied health worker) using the Respecting Patient Choices model compared with standard of care in 309 hospital ized patients increased the rates of advanced care plan ning. 78 In patients who died during the 6-month follow-up period, end-of-life wishes were more likely to be delin eated and followed in the intervention group, and caretak ers had significantly less stress, anxiety, and depression, highlighting the benefits of a structured and deliberate approach to advanced care planning in hospitalized patients. Advanced care planning is ideally initiated in the outpatient setting with multidisciplinary coordination for outpatient palliative care consultations (eg, palliative care embedded in heart failure or other high-risk population clinics); however, these data support the implementation of routine, formal advanced care planning in the setting of acute decompensations and hospitalizations.

Experience in the Cardiac ICU

Despite the perceived utility of formal palliative care involvement for patients and families cared for in the CICU, uptake remains ${<}5\%$ to $10\%$ with significant variation at the patient and hospital levels, even among the highest-risk cohort of patients with acute myocar dial infarction complicated by cardiogenic shock. 79 In a large contemporary CICU registry experience, $10\%$ of patients died in the CICU, the vast majority of whom were transitioned from “full code” status at ICU ad mission to “comfort measures only” within 24 hours of death, many after a prolonged course of intensive care therapies. 80 Palliative care consultation was offered to fewer than half of those who died, and although the timing for palliative care consultation was not recorded, the median time from admission to comfort measures only status was 3.4 days (interquartile range, 1.2–7.7 days). This is in direct contradiction to generally stated goals; family satisfaction is known to decrease with in creased CICU length of stay and shorter time frame

between care de-escalation and death, likely reflecting dissatisfaction with fewer care conference opportuni ties in this cohort. 81,82 Although the use of palliative care consultative services is slowly increasing among the underresourced population of patients with car diogenic shock in the CICU, there is still need to im prove disparities in this domain. 83,84 This underscores the importance of recognizing the persistently poor short- and long-term outcomes in this cohort and the decreased resource use associated with formal pallia tive care access. 79,85

SUGGESTIONS FOR INTEGRATION OF PALLIATIVE CARE IN THE CICU

Although clinical presentations with a more predictable natural history such as chronic heart failure are amenable to initiation of palliative care interventions in an ambula tory setting, a significant proportion of CICU admissions such as for cardiogenic shock complicating acute myo cardial infarction or cardiac arrest represent unexpected cataclysmic events for the patient, family members, and caregivers. Advances in temporary and durable mechani cal circulatory support, structural and coronary interven tion, and electrophysiological procedures have expanded the therapeutic armamentarium available to the practi tioner in the CICU. Although these resource-intensive and often highly invasive interventions have the potential to mitigate and reverse life-threatening cardiovascular conditions, thereby extending the duration and quality of life for select patients, several factors emphasize the importance of incorporating palliative care into routine CICU care. These include high in-hospital mortality and morbidity, the heterogeneity of disease presentation and trajectory, the lack of robust predictors of futility or suc cess, the competitive risk from comorbidities, the aging and frailty of the population, and the duty to preserve patient autonomy.

The following are suggestions, based primarily on expert consensus, for strategies to integrate palliative care into the acute management of our critically ill car diovascular population. Although it is recognized that team and institutional capabilities may vary, for example, in terms of training and competency accrual within the primary team and access to specialty consultative ser vices, the optimal model will often be based on a hybrid of primary and secondary (specialty) palliative care, as well as involvement of health care professionals with longitudinal involvement, 68 especially as it pertains to advanced care planning initiated before ICU admis sion. Alternative palliative care delivery models continue to evolve, including CICU rounding-team integration of palliative care members, especially those with additional training and targeted knowledge base (eg, cardiovascu lar critical care).

Role of the Primary CICU Team

In the CICU, the primary team (or the acute care team with primary clinical care responsibilities) often comprises phy sicians, trainees, advanced practice professionals, nurses, social workers, pharmacy, clergy, and care managers (Fig ure1). The primary CICU team is frequently supported by non–palliative care consultative specialty services, includ ing cardiovascular (eg, advanced heart failure, intervention al cardiology, or electrophysiology) and noncardiovascular (eg, nephrology, pulmonary medicine, and geriatrics) ser vices. These services can play a critical role in the provision of palliative care, particularly with respect to informing the patient, caregivers, and primary team about treatment op tions and framing expectations about prognosis.

In general, the primary team should aim to recognize and initiate basic management of pain and symptoms ( Supple mental Table 1 ), to facilitate early and iterative discussions about prognosis, to elicit the patient’s and family’s wishes with respect to the basic goals of treatment, and to discuss and recommend limits, if any, to life-sustaining therapies to help navigate the formalities of determining a code status that best aligns with the care goals and values. To achieve these aims, it is important to invest in early efforts that will provide the framework to ensure a well-informed, patientcentered, goal-concordant plan of care throughout the patient’s course. This includes developing an understanding of the patient’s prehospital functional status, quality of life, support structure, and belief system in order to help contex tualize the prognostic and practical implications of their cur rent presentation (Figure3). Furthermore, the primary team should seek to understand the results of prior discussions about goals of care to ensure that the current care plans are consistent and concordant with previously expressed patient values and priorities. Early and regular care health care professional communication with the patient and caregivers allows transmission of the best available infor mation on feasible treatment options and best, worst, and most likely prognosis; this provides an iterative framework to align patient and caregiver values and short- and longerterm hopes with care planning and expectations. Models that have been proposed suggest routine early and regular family meetings for high-risk patients and the inclusion of the “family meeting plan” in the daily ICU bundle. 71,86

In addition to ensuring regular communication, the ICU bundle can be used to increase the likelihood that other basic palliative care elements are attended to on a regu lar basis. 86 For example, the ICU bundle can include pain and other symptom management, delirium management, a review of the current goals of care, and whether it is reason able to engage specialty palliative services. The last—recog nizing when to engage specialty palliative care consultative services—is an important function of all members of the pri mary CICU team (Figure3). Existing ICU scoring systems such as the Behavioral Pain Scale, Critical Care Pain Obser vation Tool, Faces Anxiety Scale, Confusion Assessment

Method for the ICU, and Respiratory Distress Observation Scale can be used for objective assessment of symptom burden. 87–91 These tools could be routinely captured and incorporated into the ICU bundle to aid in determining when to escalate primary palliative care interventions or to con sider specialty palliative care consultation.

Role of Specialty Palliative Care Team in the CICU

As described previously, implementing a tiered structure to palliative care intervention requires a systematic approach to screening for palliative care needs and triaging based on cardiovascular complexity to ensure that patients at high risk for palliative care needs are identified and have access to optimal management. Thus, it is reasonable to define a set of clinical scenarios or triggers that identify high-risk patients who warrant secondary palliative care consultation (Figure3). Generally accepted criteria include refractory symptoms or complex psychosocial or family dynamics. De pending on the institutional resources, palliative care con sultation could be triggered on the basis of clinical situations with a high a priori estimation of morbidity and mortality, which in the CICU could be according to disease state (eg, cardiogenic shock, cardiac arrest, severe stroke), risks fea tures and scores (eg, age, frailty, Sequential Organ Failure Assessment, IABP-SHOCK II [Intraaortic Balloon Pump in Cardiogenic Shock II] score, Society of Cardiovascular An giography and Interventions shock stages), trajectory (eg, escalating need for advanced ICU therapies, expectation of prolonged ICU length of stay, or repeat ICU admission), or consideration of high-risk procedures or advanced inter ventions (eg, advanced heart failure therapies). Additional potential triggers for specialty palliative care involvement are situations that evoke significant moral or emotional dis tress in caregivers or health care professionals. 92 Examples might include young patients or those with young families, patients with acute de novo decompensations that preclude prior advanced care planning, individuals with catastrophic events or complications leading to a guarded prognosis, patients with complex psychosocial issues, or cases with conflict among health care professionals or between fami lies and health care professionals. The last situation is most commonly encountered when there is disagreement about the utility of offering or continuing potentially inappropriate care. In these cases, ethics consultation may also be con sidered along with palliative care. Similarly, the incorpora tion of other disciplines such as social workers, addiction medicine specialists, psychiatry, psychotherapists, and spiri tual care (clergy) consultants may provide important input in supporting specific populations facing a poor prognosis and supporting care team members involved in the care of these patients. Last, palliative care can assist with the facilitation of end-of-life planning and care, including exploration of out-of-hospital care options, hospice referral, the potential for organ donation, and bereavement services.

Areas for Comanagement Across Teams

All teams involved in the provision of palliative care should help patients and family consider reappraisal of the goals of care when appropriate. In addition, it is reasonable to ensure that the goals of care remain consistent on consideration of advanced or high-risk disease-directed interventions such as high-risk percu taneous coronary intervention or ventricular tachycardia ablation. In cases with uncertainty about whether esca lation of treatment is desired or will be of benefit, the broader team can consider the use of a time-limited trial approach, with agreement on the duration of treatment and response to improvement or lack thereof, and serial and prompt reassessment of goals of care according to the therapeutic response. 77 Last, navigating discrepan cies between a poor prognosis or high symptom burden and a patient’s reluctance to engage palliative services requires clear communication, shared decision-making, and a multidisciplinary approach to ensure patient au tonomy while aligning care with realistic outcomes.

OPEN QUESTIONS AND ONGOING CHALLENGES IN THE DELIVERY OF PALLIATIVE CARE IN THE CICU

Although the benefits of palliative care are increasingly well documented in other disease states and care set tings, there remains a paucity of high-quality evidence guiding the implementation, timing, practice, and ben eficial clinical outcomes associated with palliative care interventions in the CICU. Although the clinical purpose of palliative care in this setting is to enhance patient and caregiver well-being through the establishment of goals of care and the promotion of psychosocial and spiritual support, data showing a cause-and-effect relationship in patients with critical cardiovascular illness are currently lacking. A significant need remains for further research to advance our understanding of best ways to use pallia tive services during acute cardiovascular illness. In par ticular, future studies in the CICU environment should focus on randomized trials of pragmatic models of pal liative care delivery, evaluating the impact of palliative care integration on patient-centered outcomes (quality of life, symptom burden, satisfaction with care), health care use (length of stay, readmission), and overall sur vival. Furthermore, the impact of palliative care delivery on health care professional satisfaction, burnout preven tion, and well-being has not been rigorously evaluated. In addition, given the call for increased facility of acute cardiovascular practitioners to provide primary palliative care, further research is needed into the effectiveness of educational interventions, for both trainees and practic ing clinicians, in terms of the impact on patients and the sustainability of knowledge and skill acquisition for the health care professionals.

In addition, despite the recognized importance of pal liative care in CICU, several practical barriers to adop tion still exist. These challenges can be categorized into 3 key areas: (1) There is an urgent need for bidirectional education between CICU clinicians and palliative care professionals. On one hand, CICU clinicians require spe cialized training in the principles and application of pallia tive care, especially in navigating complex conversations about goals of care, symptom management, and end-oflife decisions. Conversely, palliative care clinicians need to be equipped with knowledge of the nuances and rapid decision-making processes inherent in modern CICU care, including the management of life-sustaining technologies and advanced cardiac interventions. Targeted educational programs and cross-disciplinary training initiatives are critical to bridging this gap. (2) The mismatch between the growing need for palliative care and the limited availability of trained palliative care clinicians represents a significant barrier. Most health care institutions face a shortage of palliative care specialists, leading to strained services and limited availability for patients in the CICU. This supplydemand mismatch is projected to worsen with the increas ing complexity and volume of critical cardiovascular cases. Creative solutions such as expanding palliative care edu cation among non–palliative care clinicians, leveraging telemedicine services, and integrating palliative care into multidisciplinary CICU teams could help mitigate this chal lenge. (3) Ensuring the continuity of palliative care after CICU discharge is an underexplored yet essential compo nent of patient care. Many patients who survive their CICU course continue to experience significant symptoms and care needs, which could be better addressed with outpa tient palliative care services. Outpatient palliative care ser vices are often difficult to access, with long wait times and limited infrastructure. One potential solution is to integrate palliative care into post-CICU or heart failure clinics, creat ing a transition from inpatient to outpatient care.

CONCLUSION

In the CICU, palliative care remains underused for patients with critical cardiovascular illness. The unpredictable na

Disclosures

ture of terminal decline in patients with CVD remains a sig nificant challenge, complicating efforts to introduce timely palliative care. This unpredictability underscores the impor tance of a more proactive, adaptable approach to palliative care integration across the continuum of CVD. Integration of palliative care principles in the routine cardiovascular care is necessary to address the complex needs of these patients during a health care crisis or at the end of life. Palliative care principles empower patients and family and enhance shared decision-making because it pertains to their values and preferences and attends to physical and psychological suffering. As the field of cardiac critical care advances, incorporating palliative care principles ensures a holistic approach to providing care and navigating the com plexities of critical cardiovascular illness.

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or poten tial conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Spe cifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

Writing Group Disclosures

| Writing group member |Employment|Research grant| other research support | speakers' bureau/ honoraria | expert witness | Ownership interest | Consultant/ advisory board |other| |---|---|---|---|---|---|---|---|---| |Erin A. Bohula| Brigham and Women’s Hos- pital and Harvard Medical School | Amgen (grant to institution for trial that she is a co-Pl on)t; Merck (grant to insti- tution for trial that she is a local site PI on)t |none|none|none|none|none|none| | Abdulla A. Damluji | Johns Hopkins Medicine Inova Center of Outcomes Research |none|none|none|none|none|none|none|

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 25, 2025, and the Ameri can Heart Association Executive Committee on April 2, 2025. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@ wolterskluwer.com

The American Heart Association requests that this document be cited as follows: Bohula EA, Landzberg MJ, Menon V, Alviar CL, Barsness GW, Crousillat DR, Jain N, Page R 2nd, Wells R, Damluji AA; on behalf of the American Heart Association Acute Cardiac Care and General Cardiology Committee of the Coun cil on Clinical Cardiology; and Council on Cardiovascular and Stroke Nursing. Palliative and end-of-life care during critical cardiovascular illness: a scientific statement from the American Heart Association. Circulation . 2025;151:e•••–e•••. doi: 10.1161/CIR.0000000000001334

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guide lines & Statements” drop-down menu, then click “Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and dis tribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/ statements-and-policies/copyright-request-form).

Writing Group Disclosures Continued

| Writing group member |Employment|research grant| other research support | speakers' bureau/ honoraria | expert witness | Ownership interest | Consultant/ advisory board |other| |---|---|---|---|---|---|---|---|---| | Carlos L. Alviar |New York University|Baxter Medical*|none|Zoll Medical|none|none| Zoll Medical corp* |none| |||||corp*||||| | Gregory w. barsness |Mayo Clinic| AliveCor (PI for institutional research grant)* |none|none|none|none|none|none| |Daniela R.|University of South Florida|none|none|none|none|none|none|none| |Crousillat||||||||| |Nelia Jain|Devoted Health|none|none|none|none|none|none|none| |Michael J.| Brigham and Women’s and Children’s Hospitals |none|none|none|none|none|none|none| |landzberg||none||||||| |Venu Menon|Cleveland Clinic||none|none|none|none|none|none| |Robert Page II| University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences |none|none|none|none|none|none|none| |Rachel Wells| University of Alabama at Birmingham | NIH/NINR (PI of a funded ROO examining the individu- al contributions of palliative care intervention compo- |none|none|none|none|none|none| ||| nents on the quality of life of older adults with advanced heart failure)* Rita and Alex Hillman Foundation (co-PIl) of pilot study to develop a palliative care pain interven- tion for Black adults with |||||||

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (b) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. \*Modest.

†Significant.

Reviewer Disclosures

|reviewer|Employment|Research grant|Other research support| speakers' bureau/ honoraria | expert witness | Ownership interest | consultant/ advisory board |other| |---|---|---|---|---|---|---|---|---| | Mauricio G. Cohen | University of Miami Miller School of Medicine |none|none| Boston Scientific*; Abbott Medical*; Cordis* |none| Accumed Radial Systemst |none|none| | lan C. Gilchrist | M.S. Hershey Medical Center |none|none|none|none|none|none|none| | Jason Neil Katz |NYU Langone|none| Abbott (nonfinancial research support)*; Abiomed (research support)* |乙ol*|none|none|none|none| | Jon R. resar | Johns Hopkins University School of Medicine | Medtronic (PI for multiple TAVR studies)t |none|none|none|none|none|none| | Sean van diepen | University of Alberta (Canada) |none|none|none|none|none|none|none|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (b) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

\*Modest.

†Significant.

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