Palliative Care in Heart Failure

1. Palliative Care in Heart Failure Lizzie Smith Heart Failure Specialist Nurse

2. 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

3. So where did palliative care pop up from? • 1960’s 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…..

4. 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?

5. 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

6. 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

7. One of our vital roles…. • Having the longer view is becoming a rarer gift in today’s NHS • ‘I’ve 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

8. 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

9. 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

10. Social Aspects of care • Preferred place of care- bit of a joke! • If home: bed downstairs, air mattress, O2, commode, bottle • Carers for ADL’s • Free prescriptions • Financial benefits- DLA if <65, need help getting around, help with personal care or help with both • AA if > 65 needs help with personal care • High rate allowance if prognosis less than 6months

11. 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 • Don’t even think about a FENTANYL Patch!!!!!! • Oxygen • GTN spray

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

13. 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

14. 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!

15. 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

16. 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

17. 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

18. Peripheral Oedema • May include arms and genitalia as well as lower limbs • Diuretics • Pruritis/dry skin- aqueous cream + 0.5% menthol

19. Dry Mouth • Assess for underlying cause • Ice Cubes • Chewing gum • Pineapple juice • Oral balance gel

20. 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

21. And always talk • Its ok to talk about uncertainty –they don’t 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

22. Any Questions? Thanks for listening