Recommendation 168: We recommend that patients with known or suspected HF should be assessed for multimorbidity, frailty, cognitive impairment, dementia and depression, all of which may affect treatment, adherence to therapy, follow-up or prognosis (Strong Recommendation, High Quality Evidence).

• Depression in older patients with HF should be suspected when chronic physical complaints persist despite optimal HF therapy.
• Measuring orthostatic vitals may identify individuals at risk of falls.
• Managing fall risk related to orthostatic hypotension:
  • Minimize diuretics and other vasodilators by optimizing first-line HF therapy;
  • Consider a medication review with a pharmacist; and
  • Promote physical activity, which may reduce the risk of orthostatic hypotension.
• Screening, prevention and management of delirium is a standard of care for all acutely ill older patients, including those with HF.
• Cognitive impairment, even when mild, may interfere with HF self-care.
• Patients with HF over the age of 65 years should be screened for cognitive impairment.
• If cognitive impairment is identified, a capable substitute decision-maker should be designated.
• HF therapies in frail or older patients should be similar to those in younger patients,
• In frail older patients, HF medications may be introduced at lower doses and titrated more slowly.
• Clinicians should be alert for drug-drug, drug-disease interactions, and therapeutic competition, where the care of one comorbidity is exacerbated by the care of another.
• For patients prescribed many medications or those with cognitive impairment, consider adherence aids, such as “blister packs”, to reduce medication errors.

Recommendation 169: We recommend that clinicians caring for patients with HF should initiate and facilitate regular, ongoing and repeated discussions with patients and family regarding advance care planning (Strong Recommendation, Very Low Quality Evidence).

Recommendation 170: We recommend that the provision of palliative care to patients with HF should be based on a thorough assessment of needs and symptoms, rather than on individual estimates of remaining life expectancy (Strong Recommendation, Very Low Quality Evidence).

Recommendation 171: We recommend that the presence of persistent advanced HF symptoms despite optimal therapy be confirmed, ideally by an interdisciplinary team with expertise in HF management, to ensure appropriate HF management strategies have been considered and optimized, in the context of patient goals and comorbidities (Strong Recommendation, Very Low Quality Evidence).

• The timing of ACP discussions should consider the high mortality rate in the year following a first HF hospitalization.
• The substitute decision-maker should be involved ACP discussions.
• Engage patients and families in open and honest discussion about the prognosis of HF, including possible modes of death (sudden, progressive HF, or from a comorbidity).
• Care preferences and goals of care should be regularly discussed with patients and documented, with emphasis shifting from quantity to quality of life.
• As HF symptoms advance, ACP should be reviewed, and the possible deactivation of implantable defibrillators or cessation of invasive therapies such as MCS or hemodialysis discussed, particularly when these no longer align with goals of care.
• Symptoms and psychosocial burden (e.g., depression, fear, anxiety, social isolation, home supports and need for respite care) should be regularly evaluated, and a palliative care referral considered.
• Informal caregivers of patients with advanced HF should be evaluated for coping and degree of caregiver burden.