Imagining the Unimaginable: Video May Help Heart Failure Patients With End-of-Life Decisions

Patients with advanced heart failure who view a video-based decision support tool that discusses options for end-of-life care are more informed about their options, more likely to select comfort care at the end of life, and less likely to select aggressive end-of-life care, according to the results of a study published online in Circulation.  

“Videos can help patients imagine the unimaginable,” lead author Areej El-Jawahri, MD (Massachusetts General Hospital, Boston, MA), told TCTMD. “Advanced illness and medical interventions are quite different in reality than what is portrayed on television. This tool empowered patients and providers to ensure that patients get the right care at the right time on their own terms.”

End-of-Life Care Underutilized 

Despite the fact that heart disease is the leading cause of death in the world, discussions on advance care planning have been slow to come to this area of medicine, El-Jawahri said. “Patients with advanced heart failure have been shown to have lower utilization of end-of-life planning, including things like hospice.”

This may be due, in part, to the prognostic uncertainty of patients with heart failure, and due to advances in therapies available for these patients.

El-Jawahri et al’s randomized controlled trial was designed to test the use of a short video that explained three levels of care—life-prolonging care, limited medical care, and comfort care. The study enrolled 246 patients aged 64 or older with heart failure and a greater than 50% likelihood of death within the next 2 years. Half of the patients were randomly assigned to a video-assisted intervention where they listened to a description of the different levels of care, watched a 6-minute video on an iPad in the presence of a research assistant, received an advance care planning checklist, and were encouraged by the research assistant to discuss any questions with their physicians. Patients in the control arm only listened to the description of the three goals of care.

Better-Informed Patients

More than half of patients in the video-intervention arm selected comfort care as their preferred path, significantly more than the proportion of patients who did so in the control arm (51% vs 30%). By contrast, more patients in the control group selected life-prolonging care (41% vs 22%). A small but significantly higher proportion of patients in the video-intervention group selected limited medical care (25% vs 22%; P < 0.001 for all).

Specifically, despite similar rates at baseline, more patients who watched the care planning video wanted to forgo CPR (68% vs. 35%) and intubation (76% vs. 48%; P < 0.001 for both) after the intervention compared with patients who had a verbal description only.

Finally, the patients who watched the advance-care planning video also had higher mean knowledge scores related to their care options as compared with patients in the control arm (4.1 vs 3.0 on a scale of 0-6; P < 0.001). At both 1-month and 3-month follow-up, patients who viewed the video were more likely to have had goals-of-care conversations with healthcare providers compared with patients given only a verbal description.

Right Care, Right Time

One of the most interesting takeaway messages of these data, according to Eric D. Adler, MD (University of California San Diego School of Medicine), is that they reflect that patients are more interested in less aggressive care then physicians might assume.

“One of the surprising findings is how many more people wanted comfort measures,” Adler told TCTMD. “I think that is higher than most cardiologists would expect.”

This is information that many physicians who treat patients with advanced heart failure are often left without, he added. End-of-life conversations take a lot of time and effort in a busy clinic, and up until recently, physicians were not paid for that time.

“Unlike cancer, which is more of a slow decline, heart failure if more like a roller coaster,” Adler said. “If you do not have upfront discussions as a provider, you may be left at the bedside with an unconscious patient, trying to gather family members to try to make the best treatment decision for the patient.”

According to Adler, a video intervention is an example of the best of both worlds in that it does not require a lot of time from the healthcare system because the video only took a few minutes but, at the same time, it helped to achieve the goal of finding out patient preferences for end-of-life care.

In fact, El-Jawahri said that the most striking finding of the study is that the tool helped to supplement and engage patients and physicians in having an important conversation about end-of-life care.  “When we contacted patients 1 month after the study, 40% of them had conversations with a provider compared with 6% of people randomized to the verbal control arm,” El-Jawahri said.

The use of an aid like this is not specific to cardiovascular disease, she added.

“These are conversations that should be had for patients with end-stage renal disease, with advanced cancer, and others,” El-Jawahri said. “We hope that video decision support tools will provide an avenue for patients, to empower them and their provider, and the healthcare system to ensure patients are able to talk about getting the right care.”


  • El-Jawahri A, Paasche-Orlow MK, Matlock D, et al. Randomized, controlled trial of an advance care planning video decision support tool for patients with advanced heart failure. Circulation. 2016;Epub ahead of print.


  • The study was supported by a grant from the National Heart, Lung, and Blood Institute.
  • El-Jawahri and Adler report no relevant conflicts of interest.

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