Ethical decisions and end-of-life care in older patients with cardiovascular disease

Cardiovascular disease disproportionately affects older adults. Advanced transcatheter and surgical interventions and implantable devices have changed the course of coronary artery disease, valvular disease, and advanced heart failure. Such interventions are increasingly applied to older and more medically complicated patients. However, prognostication and outcomes can be unclear in older patients due to the nature of cardiovascular disease and the presence of comorbidities. Decisions should account for patients’ goals and preferences. Treatment of older patients with cardiovascular disease requires addressing many ethical and end-of-life issues, including assessment of decision-making capacity, surrogacy and advance directives, decisions related to cardiopulmonary resuscitation, and management of cardiac devices at the end of life. Meeting the needs of patients with heart disease and stroke in advanced stages may require multidisciplinary teams including palliative care. As the population ages and technology advances, issues of distributive justice and access to care will challenge health systems worldwide.