Introduction

Heart failure (HF) is defined as a clinical syndrome characterized by symptoms such as dyspnea, orthopnea, and lower limb edema, alongside signs like elevated jugular venous pressure and pulmonary congestion. Identifying the etiology of HF is a critical step in its diagnosis (^{McDonagh et al., 2021}).

This condition is associated with high morbidity and mortality rates. Its prevalence has been rising due to population aging and advancements in the treatment of ischemic heart disease. Consequently, individuals with HF experience prolonged lives but continue to face poor prognoses (^{Emmons-Bell et al., 2022}; ^{Savarese et al., 2023}).

The disease course is variable, often marked by acute decompensations requiring repeated hospitalizations (^{Savarese et al., 2023}). As the disease progresses, functional capacity and quality of life decline (^{McDonagh et al., 2021}). Current American and European guidelines highlight the importance of palliative care (PC) for individuals with HF at all stages of the disease (^{Heidenreich et al., 2022}; McDonagh et al., 2021).

The World Health Organization (World Health Organization) defines PC as an "approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness" (^{World Health Organization, 2020}). The American Heart Association (AHA) emphasizes that PC ensures or enhances the quality of life for individuals with HF, advocating for its integration into a formal system of interdisciplinary care (^{Heidenreich et al., 2022}). Similarly, the European Society of Cardiology (ESC) recommends PC for all individuals with HF, irrespective of the disease stage (^{McDonagh et al., 2021}).

This review aims to map the scientific evidence on PC for individuals with HF in critical care contexts. The research question was framed using the PCC (Person, Concept, Context) strategy: "What constitutes PC for individuals with HF in critical care?" Inclusion and exclusion criteria are outlined in Table 1.

1. Methods

A review protocol was developed and registered on the OSF platform (https://doi.org/10.17605/OSF.IO/7YDJT). This scoping review followed the methodology proposed by the Joanna Briggs Institute (JBI) (^{Aromataris & Munn, 2020}), adhering to the PRISMA-ScR EQUATOR checklist (^{Tricco et al., 2018}).

The research strategy comprised three phases. Firstly, a preliminary search was carried out in the MEDLINE Complete and CINAHL databases (via EBSCO), using natural language terms to identify articles related to the subject under study. Subsequently, the titles, abstracts, and keywords were read and analyzed to identify the most relevant indexed terms for the research.

In the second phase, and with the aim of developing the complete research strategy, comprehensive searches were conducted in databases (MEDLINE Complete, CINAHL, PubMed, Web of Science, and RCAAP), combining natural language and indexed terms using Boolean operators ("OR" and "AND"). These searches were performed on May 20, 2024, and detailed strategies for each database are provided in Annex 1.

In the third phase of the research, the references of the articles selected for this review were analyzed to find complementary studies that could answer the research question.

Articles in Portuguese, English, and Spanish were included, with no restrictions on publication date. References were managed using Zotero®, and duplicates were removed using Rayyan®. Two independent reviewers screened titles and abstracts based on inclusion and exclusion criteria. Conflicts were resolved through discussion or consultation with a third reviewer.

2. Results

A search of the databases yielded 1,674 articles. After removing duplicates, 956 articles remained. Following a review of the titles and abstracts, 939 articles were excluded for not meeting the inclusion criteria, leaving 18 articles for full-text analysis. The full text of one source could not be obtained. After reading the remaining articles in full, 9 were selected for inclusion in this review.

Subsequently, an analysis of the bibliographic references of the included articles identified 4 additional sources of evidence, which were retrieved and considered eligible for full-text analysis. Of these, 3 articles were excluded after detailed review, resulting in 1 additional source being included in the review.

In total, this review included 10 articles. The article selection process is detailed in the PRISMA flowchart (^{Page et al., 2021}) presented in Figure 1.

Figure 1 PRISMA flowchar 

The selected studies were published between 2006 and 2024 with 5 from the United States (USA) (^{Aaronson et al., 2019}; ^{Brady, 2016}; ^{George et al., 2015}; ^{Wiencek & Webster, 2012}; ^{Wingate & Wiegand, 2008}) , one each from Spain (^{López et al., 2016}), Italy (^{Romano', 2019}), Taiwan (^{Chou et al., 2024}), the Netherlands (^{Beuks et al., 2006}), and the United Kingdom (^{Kumar et al., 2009}).

Table 2 shows the content extracted from the sources of evidence.

The analysis of the results obtained allowed them to be aggregated into 2 categories and 8 subcategories, as shown in Table 3.

3. Discussion

People with HF, at some stage of their illness, are admitted to critical care. These care environments (ICU and ED) should be integral to the provision of adequate PC (^{Bierle et al., 2021}).

From the analysis of the results, it is evident that in the category of PC in the ED, the evidence shows that identifying palliative needs is essential for referral to specialized PC services (^{Aaronson et al., 2019}; ^{George et al., 2015}; ^{López et al., 2016}). The ED represents a context that poses challenges to the provision of PC (^{Pereira & Reis-Pina, 2021}). However, individuals with HF have several resources in this context due to the decompensation of symptoms inherent in the disease’s progression. Thus, this setting is crucial for identifying PC needs in people with HF (^{Lipinski et al., 2018}). Identifying unmet palliative needs is a key step in providing PC (^{Heidenreich et al., 2022}; ^{McDonagh et al., 2021}). American guidelines even state that care should not be limited to specialized PC but should encompass all healthcare settings where care is provided to these individuals (Heidenreich et al., 2022). However, clear guidelines for operationalizing early referral are lacking (^{Egídio De Sousa et al., 2021}).

In the PC in ICU category, there are four subcategories (B1, B2, B3, and B6), which align with the AHA guidelines (^{Heidenreich et al., 2022}) and ESC guidelines (^{McDonagh et al., 2021}). Regarding the subcategory of symptom control, most authors agree that symptoms should be managed, although they do not specify pharmacological or non-pharmacological interventions. However, two authors mention interventions to be implemented for symptom control (^{Romano', 2019}; ^{Wingate & Wiegand, 2008}). The ESC guidelines offer clear guidance on symptom management, including specific interventions (McDonagh et al., 2021).

^{Romano' (2019}) highlights thirst and spiritual well-being as often underestimated symptoms that deserve more attention from healthcare professionals. Literature suggests that people with advanced HF experience high levels of spirituality, yet often have unmet spiritual needs. Addressing these spiritual needs can improve quality of life (^{Bierle et al., 2021}; ^{Tobin et al., 2022}). Neither of the guidelines mentioned addresses this category of symptoms (^{Heidenreich et al., 2022}; ^{McDonagh et al., 2021}).

The results obtained in the subcategories of ICD and VADs management and the definition of prognosis align with the two guidelines (^{Heidenreich et al., 2022}; ^{McDonagh et al., 2021}). Two authors even provide clear guidelines and procedures for deactivating ICDs, with specific protocols for device deactivation (^{Brady, 2016}; ^{Romano', 2019}). On the other hand, there seems to be consensus, both in the studies included and in the literature, that HF follows a unique and unpredictable course, making it difficult to predict the disease's progression (^{Bierle et al., 2021}; ^{Egídio De Sousa et al., 2021}).

In the subcategory of the dying process, the choice of place and participants in the dying process proved to be crucial. The literature supports this view, stating that the individual should have the option to choose where and with whom they wish to die. The AD is an essential step in this regard (^{Lee & Hwang, 2022}). As suggested by a study in this review, interventions specific to the ICU can hinder the transfer of these individuals to their homes, and coordination with community care is essential (^{Beuks et al., 2006}). ^{Quinn et al. (2020}) suggest that while most people die in hospitals, PC in end-of-life care can enable individuals to die at home.

Regarding the subcategory of communication, decision-making, and advance directives, it should be noted that the authors do not address the timing of the AD (which is referred to by various authors in different ways but with the same meaning). Furthermore, the two guidelines do not define a specific timeframe either. ^{Lee & Hwang (2022}) propose that care planning should begin early in the illness and continue throughout. During the end-of-life phase, it is suggested that any unresolved AD should be conducted or existing directives should be reviewed. It is important to clarify and affirm the individual's wishes regarding resuscitation efforts, life support measures, and the steps to ensure a dignified death, including decisions on the place and people present during the dying process. Different issues should be addressed at different stages of the illness.

In light of the subcategories discussed, culture emerges as a highly relevant topic, as suggested by three authors (^{Beuks et al., 2006}; ^{Chou et al., 2024}; ^{Romano', 2019}). Traditions and ideologies can significantly influence the acceptance and delivery of PC (^{Hill et al., 2023}). Current clinical consensus indicates that from the first interaction between the patient and healthcare professionals, there should be open communication, validation of the disease's unique progression and often uncertain prognosis, and recognition of the family’s and patient’s values (Hill et al., 2023). These elements can facilitate shared decision-making, as mentioned by some authors in this review ^{(Beuks et al., 2006}; ^{Chou et al., 2024}; ^{Romano', 2019}; ^{Wiencek & Webster, 2012}; ^{Wingate & Wiegand, 2008}). Additionally, it is essential to recognize the roles of family members. Understanding whether they are involved in self-care, adapting to new conditions and limitations, or providing emotional and financial support during the disease’s progression is important (Hill et al., 2023). As noted in some of the studies included in this review, advance directives (^{Beuks et al., 2006}; ^{Chou et al., 2024}; ^{Romano', 2019}; ^{Wiencek & Webster, 2012}; ^{Wingate & Wiegand, 2008}), end-of-life discussions, and decisions regarding the process, participants, and place of death can be addressed not only with the individual but also with significant others (Beuks et al., 2006; Chou et al., 2024; ^{Kumar et al., 2009}; Wingate & Wiegand, 2008). Recent literature supports this view (Hill et al., 2023).

Although PC has been achieved for people with HF in critical care, there are several barriers to its delivery in ICUs and EDs. Clinical decision-making is often made by cardiologists who lack academic training in PC (^{Silva et al., 2024}). Thus, gaps in PC training and the shortage of specialists in this field are significant barriers (^{Romanò, 2020}; Silva et al., 2024). A clinical approach focused on prognosis, coupled with difficulty in establishing it, hinders recognition of the need for PC. Moreover, there is currently a stigma surrounding the implementation of palliative interventions, as PC is often associated with death and the dying process (Romanò, 2020).

The limitations of this review include the fact that studies in languages other than Portuguese, English, and Spanish were not included. Furthermore, no implications for practice can be drawn, as the methodological quality of the included articles was not assessed.

Conclusion

There were no deviations from the protocol during the scoping review.

Although the majority of authors, as well as the two guidelines discussed in this review, advocate for early PC interventions throughout the course of the disease, most of the care discussed pertains to the end-of-life phase. The most prominent early intervention approach is seen in the management of device-related complications (DCI), where it is emphasized that care discussions and planning should occur during the implementation of the treatment. Both the American and European guidelines support the inclusion of PC throughout the disease trajectory. However, only the American guidelines provide clear recommendations for all healthcare settings.

Although no specific recommendations are provided for various care settings, it was found that critical care is a crucial environment for promoting PC and enhancing the quality of life for these individuals. The ED serves as a key setting for identifying the palliative needs of patients with HF who present there. On the other hand, evidence indicates that the ICU has well-defined PC practices that should be considered throughout the illness, particularly regarding ICD deactivation, effective and proactive communication, decision-making, and advance care planning.

Including PC as a topic in the training curricula for nurses and doctors could be beneficial in enhancing their involvement in clinical practice.

Authors' contribution

Conceptualization, F.P; dada curation, F.P.; formal analysis, F.P., L.B. and P.P.S.; investigation, F.P., L.B. and P.P.S.; methodology, F.P., L.B. and P.P.S.; project administration, F.P.; resources, F.P.; supervision, L.B. and P.P.S.; validation, L.B. and P.P.S.; visualization, F.P. and P.P.S.; writing-original draft, F.P.; writing-review and editing, F.P.

Conflict of interest

The authors declare no conflict of interest.