The SUPPORT study has shown us that the clinical course of dying from congestive heart failure is quite different from dying of lung cancer. Patients with lung cancer begin a visible, predictable decline several weeks before death that usually evident to experienced clinicians. Patients with congestive heart failure, however, experience periods of fairly good function alternating with decompensation right up until death, and the terminal event for these patients is often sudden. This pattern of decline is not usually labeled by patients or physicians as "dying." The unpredictable course has resulted in very few hospice referrals for patients with end-stage congestive heart failure.
Case 2 Discussion
The best care plan in this situation would be based on a discussion with Angela about what kinds of contingency plans should be in place if she has a severe, possibly fatal decompensation (see Advance Care Planning). Some medical centers are developing Palliative Care or Comfort Care services to try to better match the needs of patients with less predictable end-stage illnesses.
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