Examples of what has been done

Personalised care plans for advanced heart failure to help patients make their own choices for end-of-life care


The end-of life HF care pathway is an NHS Improvement project involving an integrated approach to the care of patients with advanced heart failure in Brent, London, to ensure better identification, palliation of needs and choices at the end of life.

What they did

The NHS Improvement National Heart Failure Project set up an end-of-life HF care pathway in Brent 1, England, to improve the accessibility of end of life care for advanced HF patients in hospital and community settings.


The programme involved 1:

  • improving communication between HF and palliative nurses
  • developing a tool to identify end-of-life HF patients
  • involving patients and their carers in decisions regarding their end-of-life care preferences and providing ‘Red Folders’ containing the palliative care plans to take home
  • identifying the patient’s care needs and improving referral to palliative care by developing a patient and carer assessment tool
  • improving communication between community and hospital staff regarding advanced HF cases by setting up meetings in an ‘Advanced Heart Failure Forum’

Resources and other practical implications

In order to provide optimal end-of-life care for HF patients, a multidisciplinary approach is needed that enables communication and coordination between different HF and palliative care teams, different health care settings and the patient and their carers.

Links, references, and key reading

  1. NHS Brent. Developing an end of life heart failure care pathway in Brent.