Existential Pain
Spiritual well-being is an important component of holistic care. Though often equated to faith, spirituality is a broader term that refers to the way that a person views the meaning of their life in terms of their own values.38 Objective spirituality scoresinclude meaning of life, peace, purpose, and faith.39 Higher spirituality scores appear to confer some degree of protection against the development of depression.40 Clinicians can identify spiritual beliefs and sources of support by simply asking “What gives you hope and where, or how, do you find support in your life?” The FICA questions (see Table 2) can also help guide discussions about spirituality.41
Cognitive Impairments with Heart Failure
Cognitive impairment at the end of life is extremely prevalent in patients with HF and can impair a patient’s ability to interact with family and friends as well as impair 
independence.42 Patients with decompensated HF can experience difficulty with short-term memory, working memory, executive control and processing speed. Executive dysfunction and memory problems interfere with self-care and problem-solving, though many patients seemingly converse normally despite moderate-to-severe impairment. Cognitive function can improve with improved volume status, but is unlikely to resolve. Exercise has been shown to improve vascular dementia.43 While many patients retain the ability to discuss options and may express their preferences, it is important to include their designated surrogate decision-makers in planning care.
Functional Management
The functional decline towards death is often slow and lasts many years. Patients and families need additional support such as assistance with medication management, self-care, home care, and activities of daily living (ADLs) as they approach the end of life. Attention to functional needs of the patient is important for both patients and care-providers who may experience significant care-giver fatigue and burnout.44 Knowledgeable home health providers can help patients to avoid hospitalizations. Physicians caring for HF patients should develop a network of skilled community partners with whom to work. It can be difficult to estimate when HF patients have a 6-month life-expectancy, but the combination of HF with several other significant medical problems, or recurrent volume overload and a decision to not be hospitalized again are some indicators of hospice appropriateness. Because HF care differs significantly from cancer care, which is what hospice care is modeled on, it is important to build HF care with one or more hospice companies.