Download End Stage Heart Failure

END STAGE HEART FAILURE
Symptom control for patients with end-stage heart failure should continue in conjunction with
optimal heart failure treatment. This is the first step to achieving good symptom control. This may
include diuretics and ACE inhibitors as long as these medications remain appropriate for that
individual.
SYMPTOM RELIEF
Breathlessness
 See general palliative care guidelines
 Consider diuretic adjustment
Pain
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Cough
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See general palliative care guidelines
Non-steroidal anti-inflammatory agents including COX II inhibitors can worsen heart failure
and renal function so should be used with caution. Should only be considered in a terminal care
situation.
Avoid tricyclic antidepressants in view of cardiotoxic side-effects
See general palliative care guidelines
Cough is often attributed to ACE inhibitors. If the patient has been on an ACE for any length
of time then it is very unlikely that this will be the case. Patients should therefore be
assessed for other causes of cough. Prolonged bouts of coughing are exhausting and
frightening.
Nausea and Vomiting
 See general palliative care guidelines
 Avoid cyclizine as this may worsen heart failure.
Constipation
 See general palliative care guidelines
Anxiety
 Drug therapies may be helpful to break the anxiety cycle and restore sleep
o Anxiolytics e.g. Lorazepam 0.5mg sublingually for panic attacks
o Night sedation e.g. Lorazepam 0.5 - 1mg nocte
Depression
 SSRIs are category of choice
 Avoid tricyclic antidepressants
Peripheral Oedema
 Adjustment to diuretics, ACE inhibitors, digoxin
 Possible reduction in dose of beta blocker
 Compression bandaging
END STAGE HEART FAILURE
THE LAST FEW DAYS OF LIFE
It is important to try and recognise patients who appear to be approaching the terminal phase of
their illness. It is more difficult to diagnose dying in heart failure than in most terminal cancer
patients.
Indicators of the terminal phase include:
o No identifiable reversible precipitant
o Receiving optimum tolerated conventional drugs
o Sustained hypotension
o Failure to respond within 2 - 3 days to appropriate change in diuretic or vasodilator
drugs
o Worsening renal function / hyponatraemia
If recovery is uncertain, this needs to be shared with patient and family and the patients wishes
explored in terms of options for care and place of care. It is to be hoped that initial discussions will
have taken place long before the terminal phase is reached
As the patient becomes weaker and has difficulty swallowing every effort should be made to continue
medication providing symptomatic relief. Non essential medications should be stopped.
It is useful to consider 3 levels of treatment
 Drugs with short term symptomatic benefits - e.g. loop and thiazide diuretics, anti-anginals
and digoxin and beta blockers in atrial fibrillation
These drugs should be continued if possible
 Drugs with medium term benefits - e.g. ACE, A2A, beta blockers and spironolactone
The advantages / disadvantages of continuing these medications should be considered on an
individual patient basis.
 Drugs without symptomatic benefit - e.g. statins and digoxin in patients in sinus rhythm
These can be stopped in the terminal phase
 Consideration should also be given to the advantages / disadvantages of continuing drug
treatments of co-morbidities e.g. hypoglycaemics.
 Conversion of oral medication to CSCI via syringe pump may also be indicated. If the patient is
considered to be in the last few days of life conversion of oral analgesia, antiemetics and
anxiolytics to CSCI via syringe pump should be considered with PRN doses also available (see
general palliative care guidelines).
 Addition of an anti-secretory agent should also be considered. (see Breathlessness guidelines)
IMPLANTABLE CARDIOVERTER DEFIBRILLATORS
 If the patient has an implantable cardioverter defibrillator (ICD) it is important to consider and,
where appropriate, discuss with patient and family when would be an appropriate time to have this
switched off by a technician.
 In an emergency situation an ICD can be deactivated by applying a large magnet to the area of
the chest where the ICD has been inserted!!