Palliative Care in Heart Failure

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Palliative Care in Heart Failure

• Lizzie Smith
• Heart Failure Specialist Nurse

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Introduction

• Consider this to be a malignant condition of the
  heart
• Most people with heart failure do not
  understand the cause or prognosis of their
  disease and rarely discuss end of life issues
  with their carers Murray 2003

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So where did palliative care pop up from?

• 1960s lots of free love and painful dying
• Focused on cancer and the emergence of
  independent hospices
• Now recognised medical speciality since 1987
• Holistic care for patients and families
• Covering a wide range of illnesses..

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Sounds great but

• Reality is that it is cancer, cancer and a bit of
  MND and HIV
• Many reasons why this is political and clinical
• Is that fair?

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What research is telling us

• John Hinton 1960
• Regional study of the care of the dying 1990
• Loads of similar studies
• The symptom burden is very similar to that of
  many common cancers
• The prognosis is often worse than many common
  cancers
• These patients should have access to P.C

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When do we think palliatively?

• Illness trajectories Major problem in predicting
  the future
• One week they look awful, then they perk up for a
  bit
• Grade II one month, grade IV the next

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One of our vital roles.

• Having the longer view is becoming a rarer gift
  in todays NHS
• Ive known him for 3 years
• It requires experience in looking after heart
• failure patients to spot the subtle shift in
  condition or symptoms , when it might be time to
  think beyond the blood tests or the drugs

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A few helpful markers

• Previous hospital admissions
• No identifiable reversible precipitant
• Already on full cardiac drugs
• Deteriorating renal function
• Failure to respond within 2-3 days with diuretics
  etc

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What to do?

• Talk about it as a team and with the patient and
  their family
• They have probably already guessed something is
  up and are quite frightened by this
• Then divide the tasks medical, nursing, social

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Social Aspects of care

• Preferred place of care- bit of a joke!
• If home bed downstairs, air mattress, O2,
  commode, bottle
• Carers for ADLs
• Free prescriptions
• Financial benefits- DLA if lt65, need help getting
  around, help with personal care or help with both
• AA if gt 65 needs help with personal care
• High rate allowance if prognosis less than
  6months

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Breathlessness

• Consider causes of breathlessness other than
  heart failure e.g BB, Anxiety
• Pharmacological management
• Low dose oramorph
• Morphine excreted renally
• Consider uses of laxatives
• If they find it bombs them out use oxynorm liquid
  2.5mg 4 hourly its twice as potent so be careful
• Dont even think about a FENTANYL Patch!!!!!!
• Oxygen
• GTN spray

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• Non- Pharmacological management
• Breathing techniques
• Psychological support
• Relaxation
• Complementary therapies

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Cough

• May be due to underlying heart failure rather
  than ACE I, do not discontinue
• If having difficulty expectorating Saline nebs
  2.5mls PRN
• Cough suppressants simple linctus 5-10mls,
  codeine linctus 5-10mls
• Consider low dose oramorph- start 2mg prn
• Consider diuretic increase

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Pain

• 78 of heart failure patients experience pain
• Need to consider psychological, emotional and
  spiritual aspects, what pain signifies e.g
  progression of illness
• Need full assessment of pain site e.g other
  causes than heart failure
• Analgesic Ladder
• Step one Non opioid (e.g Paracetamol)
• Step two Weak opioid /- step one analgesia
• Step three Strong opioid step one
• Remember- Non steroidal anti-inflammatory agents
  worsen heart failure!

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Nausea and Vomiting

• Patients with advanced heart failure have
  multiple causes of nausea and vomiting
• Consider drug cause
• If constant nausea, renal impairment or renal
  failure use Haloperidol 1.5-3mg orally
• If related to meals, early satiety, vomiting of
  undigested food or hepatomegaly
• Metoclopramide 10mg po
• Domperidone 10mg tds
• Low-dose levomepromazine 3-6mg od may have
  anxiolytic effect
• Avoid cyclizine as this may worsen heart failure
• If patient nauseated much of the time may
  consider alternative route such as subcutaneous,
  as oral anti emetics may not be being absorbed

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Cachexia and Anorexia

• Patients with heart failure have poor appetite
  and lose significant amounts of weight.
• Focus of earlier dietary advise may need to be
  revised
• For cachectic patients consider high calorie,
  high protein with no added salt
• Patients may develop low cholesterol levels and
  in these circumstances consider stopping statin
• Fat-soluble vitamins
• Referral to dietician

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Psychological issues

• Low mood, depression, insomnia, anxiety, fatigue
  and lethargy
• Antidepressants avoid tricyclic
• Sertraline 50mg is suitable for first line
• Unless anxiety depression citalopram 10-20mg od
• Night sedation- lorazepam 0.5 1mg nocte or
  temazepam 10-20mg od
• For anxiety lorazepam 0.5-1mg esp panic
  attacks
• Diazepam 2mg po for anxiety
• Explore what preventing them from sleeping or
  making them anxious

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Peripheral Oedema

• May include arms and genitalia as well as lower
  limbs
• Diuretics
• Pruritis/dry skin- aqueous cream 0.5 menthol

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Dry Mouth

• Assess for underlying cause
• Ice Cubes
• Chewing gum
• Pineapple juice
• Oral balance gel

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If admitted to hospital

• Talk about resuscitation with the hospital team
• Phone palliative care/ heart failure service
• Consider converting to S/C
• May need to consider switching off of ICD
• Syringe drivers invaluable when swallowing a
  problem
• Look after skin, hygiene

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And always talk

• Its ok to talk about uncertainty they dont
  always loose respect
• Is there anything they really want to achieve?
• Have they written a will?
• Talk about goals and how realistic they may be
• Phone HFS or Palliative care
• 01452 389494
• 08454 223447/225179

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Any Questions?

• Thanks for listening