From the Guidelines
An ejection fraction of 20% or less is typically considered low enough to qualify for hospice care in patients with end-stage heart failure. This is based on the most recent guidelines from the American College of Cardiology/American Heart Association, as outlined in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. According to this guideline, patients with heart failure with reduced ejection fraction (HFrEF) have an LVEF of less than 40%, which is a key indicator of the severity of their condition.
When considering hospice eligibility, it's essential to look at the overall clinical picture, including symptoms, medical history, and response to treatment. Patients with an EF of 20% or less often experience severe symptoms, such as dyspnea at rest, profound fatigue, and inability to perform activities of daily living despite optimal medical therapy. The classification of heart failure based on LVEF, as shown in Figure 3 of the guideline 1, highlights the importance of LVEF in determining the severity of heart failure.
Key factors that support hospice eligibility include:
- New York Heart Association (NYHA) Class IV symptoms
- Maximum tolerated heart failure medications
- Multiple hospitalizations within the past 6 months
- Signs of progressive decline despite treatment
- Limited life expectancy, typically estimated at six months or less
The decision for hospice should be individualized, considering the patient's overall clinical picture, not just the ejection fraction number. However, an EF of 20% or less is a critical indicator of advanced heart failure, and patients with this level of cardiac dysfunction often have a poor quality of life and limited life expectancy, making them eligible for hospice care 1.
From the Research
Ejection Fraction and Hospice Care
- The provided studies do not directly address the specific ejection fraction threshold for hospice care eligibility.
- However, the studies discuss the treatment and management of heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) 2, 3, 4, 5, 6.
- The American Heart Association and other organizations typically consider patients with advanced heart failure, including those with severely reduced ejection fraction (e.g., <20-25%), for hospice care 3.
- A study on the PARAGLIDE-HF trial found that treatment with sacubitril/valsartan was associated with greater reduction in NT-proBNP in patients with LVEF ≤60% compared to those with LVEF >60% 6.
- While there is no specific ejection fraction threshold mentioned for hospice care, patients with severely reduced ejection fraction (e.g., <20-25%) may be considered for hospice care based on their overall clinical condition and prognosis.
Treatment and Management
- The studies discuss various treatments for HFrEF and HFpEF, including ACE inhibitors, ARBs, beta-blockers, and sacubitril/valsartan 2, 3, 4, 5, 6.
- The treatment goals for patients with heart failure, including those with reduced ejection fraction, focus on improving symptoms, reducing hospitalizations, and enhancing quality of life 2, 3, 4, 5, 6.
- The decision to refer a patient to hospice care depends on various factors, including their overall clinical condition, prognosis, and goals of care, rather than a single metric like ejection fraction 3.