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Addressing ‘the elephant on the table’: barriers to end of life care conversations in heart failure – a literature review and narrative synthesis

Momen, Natalie C.; Barclay, Stephen I.G.

Current Opinion in Supportive and Palliative Care: December 2011 - Volume 5 - Issue 4 - p 312–316
doi: 10.1097/SPC.0b013e32834b8c4d
Cardiac and circulatory problems: Edited by James Beattie

Purpose of review Heart failure is a life-limiting illness, but with great uncertainty over its prognosis. Policy increasingly states the importance of discussions about end of life care between patients and their clinicians. This study reviews the extent to which there is evidence that these conversations occur for heart failure patients in practice.

Recent findings Although several opinion pieces and guidelines on this topic have emerged in recent years, little new empirical data have been published. Papers publishing empirical data since 2005 and other literature suggest that these conversations rarely occur. Many clinicians feel uncomfortable or lack confidence; and there is uncertainty whether patients want such discussions. Barriers and facilitators for discussions with heart failure are identified, regarding the nature of the disease, resource constraints and attitudes. The consequence is that disempowered patients rarely have such discussions: the ‘elephant on the table’ is rarely addressed.

Summary The wide range of barriers identified all hinder conversations about the end of life with heart failure patients. Individual patient preferences for the timing and content of such conversations must be respected, including the wish of some not to have such conversations at all.

University of Cambridge, Institute of Public Health, Cambridge, UK

Correspondence to Natalie C. Momen, BSc, MSc, CLAHRC End of Life Care Research Assistant, University of Cambridge, Institute of Public Health, Robinson Way, Cambridge CB2 0SR, UKTel: +44 1223 330300; e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.