30-Second Takeaway
- Palliative and DNR use in heart failure hospitalizations remains low, even among in-hospital deaths.
- Clinicians often limit nonbeneficial treatments using tacit or silent strategies that diverge from policy guidance.
- End-of-life conversations for dementia in hospital are infrequent and usually initiated by patients or families.
- Targeted questioning and cautious recommendations can improve value-concordant decisions, functional support, and nutrition in serious illness.
- Prevention-focused primary care, geriatric ED models, and caregiver support can reduce acute-care use and ease transitions.
Week ending February 21, 2026
Serious-Illness Communication and Systems-Level Levers in Heart Failure and Dementia Care
Palliative Care and DNR Orders Remain Rare in U.S. Heart Failure Hospitalizations
Among 7,533,995 U.S. heart failure hospitalizations (2016–2022), 1.6% had palliative consultation alone and 3.7% had both palliative and DNR orders. Over 83% of admissions had neither palliative consultation nor DNR status documented. Utilization of palliative care increased modestly from 4.7% to 5.9%, and DNR from 12.4% to 16.6% over the study period. Half of patients who died in-hospital (50.6%) never received palliative consultation, indicating major missed opportunities for serious-illness care. Thirty-day unplanned readmissions were highest when neither palliative care nor DNR was used, suggesting potential system benefits from earlier palliative involvement.
Six Real-World Strategies to Limit Nonbeneficial Life-Prolonging Treatments
Interviews with 101 clinicians at three academic centers identified six approaches to limiting potentially nonbeneficial life-prolonging interventions. Approaches included providing informed choice, making a recommendation to limit, stating a plan to limit, explicitly not offering, and not mentioning interventions. Institutional conflict-resolution processes were used as a rare last resort, despite policy statements emphasizing these mechanisms. Clinicians described system pressures toward life prolongation, challenges with formal shared decision-making, and ethical uncertainty about alternate, less explicit strategies.
End-of-Life and Euthanasia Discussions Are Infrequent for Hospitalized Patients With Dementia
Across 11 Dutch hospitals, end-of-life topics were discussed in only 36% of consultations with patients with dementia, mainly during diagnostic visits. Euthanasia was discussed in 21% of consultations, usually initiated by the patient or family rather than the physician. Physicians acknowledged the importance of timely end-of-life discussions but struggled to initiate them, particularly around euthanasia. They valued family involvement yet had moral concerns and feared euthanasia discussions narrowed attention from other end-of-life options.
References
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Additional Reads
Optional additional studies from this edition.