Highlights
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Specialty palliative care is often introduced late in advanced heart failure.
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Embedding palliative care within clinics enables earlier goals-of-care discussions.
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Training specialists in serious illness communication reduces care fragmentation.
Advanced heart failure (HF) is characterized by high morbidity and mortality, yet palliative care is frequently delayed or underutilized. While prior studies support earlier use of palliative services, outpatient models incorporating structured goals-of-care discussions within advanced HF and transplant evaluation remain limited. We describe a clinician-led, embedded approach within a multidisciplinary HF clinic at a tertiary care center, in which HF providers trained in serious illness communication conduct advance care planning as part of routine evaluation for transplant and left ventricular assist device (LVAD) candidacy. Since implementation in January 2023, three HF clinicians have completed formal communication training, and approximately 324 patients have been evaluated using this model. Documentation of serious illness discussions and advance care planning occurred in all eligible patients, with medical decision-making preferences addressed at each visit and caregiver involvement encouraged when appropriate. By integrating these discussions into existing clinical workflows, this model supports timely, continuous, and disease-specific communication without reliance on external referral. In conclusion, embedding palliative care within advanced HF teams is a practical and scalable strategy that may improve alignment of care with patient goals during complex treatment decision-making.
Advanced heart failure (HF) carries a profound symptom burden and high mortality despite optimal medical therapy. Patients frequently experience dyspnea, fatigue, and depression, while caregivers face significant emotional and logistical strain. The 2022 AHA/ACC/HFSA Heart Failure Guidelines emphasize integration of palliative and supportive care throughout advanced HF to address multidimensional needs and facilitate shared decision-making. Yet, specialty palliative care (SPC) remains underutilized and is often introduced late in the disease course.
Evidence supports earlier use of multidisciplinary palliative services. The PAL-HF randomized trial demonstrated that structured SPC embedded within an advanced HF clinic improved quality of life, mood, and spiritual well-being without shortening survival or increasing hospitalization rates. Systematic reviews have confirmed that team-based palliative interventions reduce symptom burden and caregiver distress while improving patient satisfaction. , Although emerging models have explored telehealth and social worker–facilitated interventions, , and inpatient models with embedded approaches have been described, outpatient programs that embed structured serious illness communication directly within advanced HF and transplant evaluation remain limited.
At Baylor University Medical Center (BUMC) in Dallas, Texas, SPC is embedded within the Baylor Scott & White Advanced Heart Failure Clinic as part of a multidisciplinary team that includes advanced HF cardiologists, surgeons, nurse practitioners, nutritionists, social workers, and pharmacists. In contrast to referral-based models, structured serious illness conversations and advance care planning are conducted by advanced HF clinicians who participate directly in transplant and left ventricular assist device (LVAD) evaluation.
Advanced HF clinicians complete Serious Illness Conversation training at BUMC, equipping them with structured tools to conduct values-based discussions regarding prognosis, goals of care, acceptable tradeoffs, and end-of-life preferences. Because the clinicians leading these discussions are disease-specific experts involved in transplant and LVAD candidacy assessment, conversations regarding procedural risks, contingency planning, and postoperative expectations are incorporated into routine clinical appointments.
The program was implemented in January 2023. Since inception, three advanced HF clinicians have completed Serious Illness Conversation training. Between 2023 and 2026, approximately 324 patients undergoing transplant evaluation were assessed through the embedded model. Ongoing advanced care planning and structured serious illness conversations were documented in all patients. Medical Power of Attorney is addressed at each serious illness conversation, with caregiver participation encouraged in accordance with patient preferences.
Embedding serious illness communication within the HF team provides structural advantages compared with referral-based approaches ( Table 1 ). Because the clinician conducting palliative discussions is an advanced HF provider directly involved in transplant and LVAD evaluation, discussions occur with full knowledge of disease trajectory, selection criteria, and longitudinal management strategies. This allows disease-specific counseling and iterative conversations as clinical status evolves.
Table 1
Comparison of embedded vs referral-based specialty palliative care models in advanced heart failure treatment
| Feature | Embedded model | Referral-based model |
|---|---|---|
| Understanding of HF treatment & prognosis | Conducted by HF clinician directly involved in transplant/LVAD evaluation with detailed knowledge of candidacy and disease trajectory | Conducted by external palliative clinician with indirect familiarity with transplant selection and HF management |
| Therapeutic alliance | Occurs within established HF clinician–patient relationship | Requires introduction of separate consulting clinician |
| Communication | Shared workflow, documentation system, and clinic space facilitate direct coordination | Communication occurs across distinct services |
| Patient experience | Single clinical setting reduces logistical barriers and confusion | Separate appointments and clinic locations |
| Efficiency of care | Conversations triggered in real time by changes in candidacy or clinical status | Dependent on formal referral process |
| Timing of serious illness discussions | Integrated early during transplant/LVAD evaluation | Often initiated later in disease course |
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