Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Cough 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!!