Palliative Care in Heart Failure

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• Palliative Care in Heart Failure

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Palliative Care

• The active total care of patients whose disease
  is not responsive to curative treatment. Control
  of pain, of other symptoms, and of psychological,
  social and spiritual problems is paramount.
• WHO (1990)

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Why involve palliative care?

• The National Service Framework for Coronary Heart
  Disease (DOH 2000)
• identifies the need to ensure that
• People with unresponsive heart failure and
  other malignant presentations of coronary heart
  disease receive appropriate palliative care and
  support

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Why involve palliative care? 2

• The palliative needs of patients and carers
  should be identified ,assessed and managed at the
  earliest opportunity
• Patients with heart failure and their carers
  should have access to professionals with
  palliative care skills within the heart failure
  team
• The opportunity to discuss issues around
  uncertainty and sudden death should be available
  at all stages of care
• NICE Guidelines-Chronic heart failure (2003)
  section 1.7

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Unmet needs

• There is substantial evidence for considerable
  unmet palliative needs of patients with heart
  failure and their informal carers The main areas
  of need include symptom control, psychological
  and social support,planning for the future and
  end of life care.
• Management of chronic heart failure in
  adults in primary and secondary care. (National
  Institute for Clinical Excellence July 2003)

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Symptoms of worsening disease

• Increasing shortness of breath
• Fatigue (profound weakness)
• Worsening renal function
• Pain (Physicalpsychologicalspiritual aspects)
• Low mood
• Loss of appetite (cardiac cachexia)
• Incontinence
• Immobility
• Confusion, sleep disorders
• Poor response to medication

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Managing Breathlessness

• Optimum palliation of symptoms of heart failure
  often depends on concordance with medication
  especially diuretics
• Consider possible causes of breathlessness other
  than heart failure such as co morbidity or
  psychological factors

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Managing Breathlessness

• Detailed history
• Thorough assessment --?sudden onset
• Chest examination/x-ray if indicated
• Treat underlying cause (recent MI, arrhythmia,
  infection, anaemia, pleural effusion,
  thyrotoxicosis,)
• Diuretic adjustment

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Managing Breathlessness

• Trial of low dose opiates . Immediate release
  oral morphine preparations e.g. oramorph 2.5 mg 4
  hourly as needed and tolerated.(Sedation and
  accumulation may occur as most HF patients have a
  degree of renal failure, may need reduced dose or
  alternative opioid such as oxycodone 1-1.5mg)
  Consider prophylactic laxative.
• GTN Spray if appropriate(has this helped
  previously)
• Sublingual lorazepam 0.5mg may provide rapid
  relief of anxiety associated with breathlessness
• ( Avoid Diazepam long half life)

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Managing Breathlessness

• Advise on non-pharmacological management ( see
  dyspnoea management model)
• Involve other experts to ensure a holistic
  approach
• Lifestyle adjustment
• Equipment e.g. fan backrest
• Oxygen Therapy

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Depression

• Assess for depression/anxiety
• Negotiate management with patient
• Consider trial of antidepressants (liaise with
  heart failure teams/pharmacist SSRIs may be
  safest )
• Assess for social isolation and acknowledge
  impact of disease on QOL
• Refer to psychologist
• Consider CBT

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North Tyneside Palliative Care TeamDyspnoea
Management Model
PHYSIOTHERAPIST
NURSE SPECIALIST
Breathing Techniques

Anxiety Management
Pacing
Symptom Control
Provision of Walking Aids
Listening
Psychological Support
Relaxation
Energy Conservation
Refer to other Services
Panic Attacks
Managing Activities of Daily Living
Advise Primary Healthcare Team
Practical Support
Carer Support
Exercise Advice
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Managing Fatigue

• Accurate assessment
• Treat reversible causes
• Assess for depression
• Allow opportunity to express feelings about
  impact of illness
• Refer to occupational therapist for equipment to
  reduce exertion e.g.stairlift, bath lift
• Advise on pacing (encourage gentle activity)
• Cognitive Therapy
• CLIP ACTIVITY Sheet

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Oedema

• Early detection important
• Diuretics are a palliative measure
• Combination diuretic approach may be required
• Salt/fluid restriction
• Positioning /elevation (not excessive do not
  elevate the foot of the bed!)
• Pressure Care
• Skin care

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Cough

• Consider possible causes of cough other than
  heart failure e.g. infection, pulmonary oedema
• Do not immediately ACE inhibitors if patient has
  been taking for a long time
• If recently started on ACE inhibitor and when
  cough commenced discuss with Heart Failure Team
• Simple linctus 5mls qds
• Is related to difficult expectoration consider
  nebulised saline 2.5 mls prn

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Pain

• Assess pain
• Consider causes other than heart failure such as
  musculoskeletal pain, neuropathy.(Up to 70
  patients report non cardiac pain)
• Treat Cardiac pain conventionally
• Consider psychological, spiritual and emotional
  aspects
• Involve other team members as appropriate e.g.
  OT, Chaplain
• WHO Analgesic Ladder (Caution in renal failure)
• Extreme caution with NSAIDS ( Renal
  Failure/Fluid retention)

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Nausea and Vomiting

• Consider drug causes e.g. digoxin
• Overwhelmed by amount of medication?
• Explore biochemical causes ( constant nausea due
  to severe renal impairment may respond to
  haloperidol 1.5 mgs)
• Hepatomegaly or early satiety consider
  prokinetic before meals
• Small portions
• May need antiemetics administered via non oral
  route

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Cardiac Cachexia

• Cardiac cachexia is linked to raised plasma
  levels of tumour necrosis factor alpha and other
  inflammatory cytokines. The degree of body
  wasting is strongly correlated with neurohormonal
  and immune abnormalities. The available evidence
  suggests that cardiac cachexia is a
  multifactorial neuroendocrine and metabolic
  disorder with a poor prognosis. A complex
  imbalance of different body systems may cause the
  development of body wasting

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Cardiac Cachexia

• Patients may have poor appetite and lose
  significant amounts of weight
• Many patients have congestive gastrointestinal
  oedema causing impaired nutrient absorption
• Congestive hepatic enlargement may cause anorexia

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Cardiac Cachexia Management

• Attention to detail, may be overlooked due to
  appearance of oedema
• Referral to dietitian
• Low sodium high calorie, high protein
  supplements
• EPA Fish oils if tolerated
• Low Cholesterol levels may developstop statins
  if this occurs
• Discuss possibility of megestrol if severe (may
  affect blood sugar)

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Dry Mouth

• Assess for underlying Cause
• May be due to oxygen therapy
• Is patient dehydrated? Diuretics fluid
  restriction
• Oral infection or oral Thrush?
• Routine mouth care
• Sucking ice
• Sugar free gum
• Oral balance gel
• pilocarpine is contraindicated in severe
  cardiac disease

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Constipation

• Risk factors
• Reduced fluid intake, opioids for breathlessness,
  inactivity, dietary
• Stool softener e.g. docusate (should be commenced
  prophylactically)
• Co-danthramer if severe
• Advise to avoid straining
• Extreme caution with movicol

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Treatment agenda vs. support agenda

• Treatment agenda up titration of drugs,
  exercise, daily weight, ongoing investigations
• Support agenda adjustment to illness, coping
  with symptoms, uncertainty, fear of dying

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Why do Heart Failure Patients end up dying in
hospital?

• Uncertainty about prognosis and whether all
  options exhausted
• Communication death not discussed or anticipated
• Carers (including GP ) exhausted
• Co-morbidity
• No proactive management strategies
• PANIC !!! Unresolved anxiety

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Palliative Care in Heart Failure
Diagnosis
Death
Heart Failure
Bereavement care
Active care
Palliative care
Cancer
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Partnership

• The key to a coherent joined up approach to
  managing End stage Heart Failure is partnership
  between primary and secondary care, and
  collaboration with nursing staff, medical staff
  and allied health professionals.

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Developing palliative care skills

• Skilling up the generalists Good quality
  palliative care can be delivered by many
  practitioners - not exclusively by the specialist
  palliative care team
• Sensitive honest open communication is
  essential
• Discuss treatment options and care options on a
  regular basis

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End of Life Concerns (Staff)

• Should we mention the chaplain?
• Its a shame he has to die on an acute ward
• Is he in pain or is he agitated?
• Do we continue 4 hourly observations
• Should the cardiac monitor be discontinued
• Should we stop IV Fluids?
• What do I say when his wife asks if he is dying?

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• The terminally ill fear the unknown more than the
  known, professional disinterest more than
  professional ineptitude, the process of dying
  more than death itself
• Derek Doyle (1986)

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LCP for last 48 hours

• Team decision that patient is dying and
  communicating this to the family
• Establishing a DNR order
• Stopping non-essential drugs
• Stopping inappropriate interventions e.g. blood
  tests
• Prescribing guidelines for managing pain,
  agitation, nausea, respiratory secretions