Integrating palliative care into outpatient heart failure services: an interdisciplinary model
E Villegas, A Tsui, J Kaplan-Lyman, T Suboc, N Kramer, K Marinescu, G Nair, M Colbert, J Rura, K Shanklin, D EchevarriaAbstract
Background
Advanced heart failure (AHF) is associated with high symptom burden, prognostic uncertainty, and complex treatment decision-making. Heart failure guidelines recommend early integration of palliative care; however, outpatient AHF services frequently lack the time and interdisciplinary structure required to deliver guideline-recommended supportive care early in the disease trajectory.
Purpose
To implement and evaluate a structured, interdisciplinary outpatient AHF–palliative care clinic as a pragmatic service delivery model integrating palliative care into routine heart failure management, with the aim of improving advance care planning, prognostic understanding, and alignment of treatment decisions with patient values.
Methods
A structured AHF–palliative care clinic was established in March 2025 within an existing outpatient AHF service. Patients with AHF (NYHA class III–IV or stage C/D, including those receiving inotropic therapy or undergoing evaluation for advanced therapies) were arranged extended, one-hour, joint appointments. Visits were delivered by a multidisciplinary team comprising heart failure advanced practice providers, a palliative care physician associate, and a palliative care social worker (Fig 1). A retrospective review of clinic encounters between March and December 2025 assessed key process and outcome measures, including prognostic communication, family-inclusive goals-of-care discussions, and documentation of advance care planning (healthcare proxy and resuscitations preferences).
Results
Forty-four patients were reviewed. Discussions regarding advanced therapies occurred in 82% of clinic appointments. Following clinic participation, 26 patients engaged in advance care planning, including discussion of a healthcare proxy, of whom 13 (50%) completed new documentation during the clinic visit. Additionally, resuscitation preferences were revised following structured discussions with 7 patients. Several hospice referrals were initiated when clinically appropriate (Fig 2). The integrated clinic model enhanced continuity between inpatient and outpatient services, strengthened multidisciplinary collaboration, and enabled consistent delivery of palliative care alongside disease-directed AHF management.
Conclusions
Early, structured integration of palliative care within outpatient AHF services is feasible and supports systematic implementation of guideline-recommended supportive care. This interdisciplinary model improves advance care planning, facilitates timely goals-of-care discussions, and promotes alignment of treatment decisions across care settings. Embedding extended, team-based consultations within existing clinic infrastructure offers a scalable and reproducible approach for heart failure programmes seeking to operationalise early palliative care.Figure 1- Process MapFor image description, please refer to the figure legend and surrounding text.Figure 2 - Topics AddressedFor image description, please refer to the figure legend and surrounding text.