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In March 2020, COVID-19 became a global pandemic. Patients with cardiovascular diseases, mainly heart failure, are disproportionately affected by COVID-19, resulting in increased mortality, a heavy burden on the medical staff, and a significant impact on healthcare resources. On the other hand, in heart failure, the need for palliative care has been increasing, and its importance as a standard of care is gaining attention. A Meta-analysis from 10 randomized trials showing that palliative care, compared with usual care, was associated with a reduction in heart failure hospitalization, and a modest, though significant, improvement of life and symptoms in patients with advanced heart failure [1]. Considering these backgrounds, the question arises as to how best to support patients with COVID-19 and heart failure, and how to deal with death. This narrative review article summarizes what is needed to provide optimal palliative and end-of-life care for patients with heart failure and COVID-19 complications in this COVID-19 pandemic and post-COVID-19 era.

Search strategy

We selected PubMed as the most suitable database to search for articles about the physical examination, as it is easily accessible and widely used. MeSH (Medical Subject Headings) is the National Library of Medicine’s vocabulary thesaurus used for indexing articles for PubMed, and it was frequently used to determine rough annual trends of research topics. Initially, we performed a structured PubMed literature review about palliative care in patients with heart failure in the pandemic of COVID-19 on August 31, 2021, using Google.

Chrome (version 92.0). The search strategies were the following: (("palliative care"[Mesh]) [OR] palliative) [AND] heart failure [AND] (COVID-19 [OR] coronavirus [OR] SARS-CoV2). Reviewing process included only the publication which describes the palliative care for heart failure in the pandemic of COVID-19. After excluding nonrelevant and non-English manuscripts, 4 of the total 17 articles were considered relevant.

In August 2021, there is no evidence showing the clinical and social benefits of palliative care for patients with heart failure and COVID-19. However, a recent editorial provides clinical guidance on supportive care for patients with COVID-19 and a recent update on the management of palliative care needs of patients with HF [2]. Common symptoms associated with COVID-19 are fever, cough, breathlessness, and myalgia. COVID-19 can lead to decreased diffusion capacity of the lungs, resulting in severe hypoxia and the need for high-flow oxygen therapy. Surprisingly, some patients exhibit "asymptomatic hypoxia," in which there is little shortness of breath despite significant hypoxemia. In addition to respiratory failure, the experience of shortness of breath is also influenced by the degree of ventricular dysfunction, as well as by psychological, environmental, and sociocultural factors. In a systematic review with 12 papers, cough, breathlessness, fatigue, and myalgia were significant symptoms in patients hospitalized with COVID-19, and dyspnea was the most significant symptom in dying [3]. The mode of death was predominantly through respiratory of heart failure [3]. A multidisciplinary, holistic approach is needed for optimal management. Pharmacotherapy, such as the use of morphine, remains appropriate [4,5], but given the risk of viral spread, caution should be exercised in the use of previously advocated non-pharmacologic therapies. Chest discomfort may be accompanied by breathlessness and requires prompt examination and treatment if the patient shows findings of acute coronary syndrome or has a history of coronary artery disease [6].

In the COVID-19 pandemic, good communication between healthcare workers and patients and their families is critical [7]. Due to the mandatory wearing of personal protective equipment (PPE) to prevent the spread of infection, hospitalized patients are unable to read the smiles and facial expressions of health care workers and get the comfort of empathic touch without gloves. Therefore, it is important for health care providers to frequently address the patient by name and provide verbal encouragement and reassurance when necessary. Particularly in COVID-19 patients with concomitant heart failure, all involved health care professionals must adopt a palliative approach that combines objectivity, compassion, and truthfulness, recognizing that heart failure is more difficult to predict than malignancy, and that difficult conversations about end-of-life [8]. Emotional and sociocultural barriers may have to be overcome to facilitate effective shared decision-making about future interventions [8]. Discussions about the discontinuation of palliative care or treatment should take into account the patient's current physiological state, existing quality of life, advance directives, and personal wishes and values, including cultural norms and spiritual beliefs [7].

Patients with COVID-19 often require clinical isolation for preventing the spread of infection, and the most demanding element of this is not being able to be with their loved ones when they die [7]. Such a situation goes against the normative perception of a good death, where the family can comfort their relative and say "goodbye. They can attend to the patient so that he or she does not die alone, but they cannot comfort the grieving family. Likewise, relatives, community, and faith leaders may be denied access to practices and rituals that some cultures and religions require before and after death, and funeral rites may be truncated, with only a limited number of mourners allowed to attend. The sight of multiple coffins in a temporary mortuary or strangers wearing PPE carrying the body to the cemetery can be disconcerting for anyone. In such situations, people trying to come to terms with the premature loss of a family member or close friend may exhibit persistent, complicated bereavement with long-lasting negative effects. Palliative care can also support these people [7].

There is also a need for psychological support for healthcare professionals involved in the treatment of COVID-19 [7]. Unfortunately, as a result of the extraordinary increase in the number of intensive care unit (ICU) beds for patients requiring invasive ventilation, health care providers may have to make on-the-spot ICU admission decisions based primarily on the ethical concept of distributive justice, prioritizing the allocation of this constrained resource to patients who are considered to have the best chance of survival [9]. In addition, many health care professionals caring for patients with COVID-19 have been reassigned from their normal clinical work environment and are working outside of their usual areas of expertise. Some staff may feel conflicted that being reassigned to support COVID-19 patients may compromise the patient care for which they are normally responsible [7]. It is important to ensure that there is a professional support system in place for health care providers.

In this narrative literature review, we reviewed palliative care for patients with heart failure and COVID-19. Although there is no evidence showing the clinical and social benefits of palliative care for patients with heart failure and COVID-19, we summarized what is needed to provide optimal palliative and end-of-life care for patients with heart failure and COVID-19 complications in this COVID-19 pandemic and post-COVID-19 era.

All authors confirm that there is no conflict of interest.