• heart failure
• quality and outcomes of care
• educational goals and objectives
• palliative care

The rising prevalence of heart failure in response to changing demographics and the modified natural history of disease in response to effective treatments is well described. For the individual and family, heart failure has a wide-reaching personal impact, with reduced quality of life and function within society, and a prolonged dependence on healthcare services. This high cost to the individual and to healthcare services is projected to increase further, yet there is little emphasis in practice on solutions to prevent or manage its implications. A recently published systematic review of studies from 10 countries across Europe and North America investigating cost-of-illness in heart failure presented important concerns.1 During the course of heart failure, the costs of medical care are largely driven by hospital admission and are highest in the year after diagnosis and in the last 6 months of life. The most common predictors for higher care costs are comorbidity (the cause of around three-quarters of readmissions in people with heart failure) and advanced stage of disease. Management of people with New York Heart Association Class IV heart failure accounts for 70% of total annual heart failure costs.1

While the first peak in costs following diagnosis is intuitively appropriate, the second peak at the end of life raises important concerns about inappropriate admissions and the use of invasive, burdensome and futile interventions. People with advanced disease are in double jeopardy: if inappropriate care is being received, they may not receive the care which would be helpful to them and their families. Evidence-based practice consists of three pillars: the best quality relevant research evidence, clinician expertise and patient values. Prioritisation of clinical service time for life-prolonging interventions to the exclusion of an assessment of patient and family …