Background: There are no evidence-based practice guidelines for integrating a Heart-failure (HF) specific medication regimen for those HF patients approaching end-of-life (EOL). This article is a retrospective look at symptom occurrence in EOL patients with cardiovascular disease (HF, atrial fibrillation, and CAD) among subgroups of patients that had their cardiac medications continued through EOL versus those patients that had their cardiac medications stopped either before they arrived to the palliative care unit or once they were admitted.
Design and Participants: Retrospective chart review of patients admitted to a palliative care unit at a large quaternary care academic center in a NY suburb. Patients were admitted between 2019 and 2020 and had a cardiac diagnosis (HF, AF, CAD) and died within 14 days of admission. There were four cardiac medication discontinuation categories: 1) completely stopped prior to PCU admission; 2) stopped before and during PCU admission; 3) mixed cessation pattern, where some cardiac medications were stopped and some remained; 4) all cardiac medications continued. Various demographic data elements collected including illness severity. Symptoms assessed included pain and air hunger using opiate usage, pain assessment, respiratory distress. Primary outcome analyses included: 1) Chi-square tests for categorical variables (respiratory distress and pain scales); 2) Kruskal-Wallis tests for oral morphine equivalents (OME) comparisons; 3) Wilcoxon Signed-Rank tests for within group OME comparisons.
Results: There were no significant demographic differences between the four medication discontinuation groups. After controlling for demographic and clinical characteristics, patients with HF showed stronger associations between early discontinuation and increased opioid requirements compared to those without HF (B=0.196, P=0.028). Multivariate analysis identified initial OME, medication discontinuation status, and pain scores as significant predictors of final opioid requirements. The model revealed a significant interaction between HF status and discontinuation patterns suggesting a stronger effect of medication discontinuation on symptom burden in HF patients compared with those with AF and CAD (B=0.224, 95% CI (0.052, 0.404), P=0.012). Patients who discontinued medications before or during PCU stay experienced higher rates of severe pain (37.2%) compared to patients in the other three medication discontinuation groups. (RR=9.79, 95% CI 2.47-38.82). Interestingly, LOS did not significantly vary among the four discontinuation groups.
Commentary: This article is important because it challenges the common practice (at least in our hospital) of clinicians discontinuing cardiac medications at EOL, i.e. when GOC is changed to “comfort care.” There exists a concern among our clinicians that continuing these medications prolongs the patient’s suffering. This article challenges this, in that continuing cardiac medications did NOT significantly prolong survival but did result in improved symptom management and comfort at EOL. Limitations of this study is that it was performed at one large academic hospital center outside of New York City, in a unit specifically designed for palliative care. I would question how generalizable the findings would be for outpatient EOL cardiac patients and for those inpatients that are not specifically on a palliative care unit (where ostensibly the nurses’ training is focused on palliative/EOL care). And it may not be generalizable to hospice patients. Consequently, especially since was a retrospective study, it would be helpful to construct similar studies in other EOL settings as I noted above (outpatient home, home hospice, inpatient non-palliative-care settings).
Bottom Line: When HF patients are approaching EOL, consider continuing their cardiac medications for improved symptom management and comfort.
Source: Saunders, Steven, MD et al, “Cardiac Medications Continuation Versus Discontinuation at End-of-Life: A Retrospective Analysis of Clinical Outcomes”, American Journal of Hospice and Palliative Medicine 2025, Vol 0(0) 1-10, DOI: 10.1177/10499091251369010.
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