Integrating a Palliative Approach into Cardiogeriatric Decision-Making for Frail Older Adults with Heart Failure

Background: Advanced heart failure (HF) in very old patients follows an unpredictable trajectory marked by recurrent decompensations, progressive functional decline, and high mortality. In this population, decision-making regarding goals of care and treatment proportionality is particularly complex due to multimorbidity, frailty, cognitive vulnerability, and prognostic uncertainty, and remains insufficiently addressed by conventional disease-centred heart failure pathways. Methods: This narrative review synthesizes current evidence from heart-failure guidelines, geriatric medicine, and palliative care literature to propose a cardiogeriatric framework for end-of-life decision-making in advanced HF. Results: In older adults, functional decline and geriatric vulnerability often progress independently of cardiac parameters, limiting the relevance of prognosis-based thresholds. The palliative turning point should be understood as a multidimensional process resulting from converging cardiological, geriatric, organizational, and patient-reported signals. Therapeutic decisions should be guided by proportionality between expected benefit, treatment burden, and patient priorities. Longitudinal, iterative communication is essential to align care with evolving goals. Conclusions: A cardiogeriatric approach integrating cardiology, geriatrics, and palliative principles supports timely palliative integration, shared decision-making, and coordinated care in very old patients with advanced HF.