Advanced Heart Failure

Palliative Care Considerations

• Heart failure symptoms at the end of life may include hypotension, volume overload, edema, and fatigue. Patients should be assessed to confirm symptoms are related to heart failure rather than other disease states to ensure appropriate treatment

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• The goals for advanced heart failure treatment will differ from traditional heart failure management. Drug therapy will be focused on symptom management rather than improving mortality. Prevention of cardiovascular disease through cholesterol reduction is no longer necessary at this point.

Nonpharmacologic Treatment in Palliative Care

• Patients should be maintained in a comfortable position with feet elevated to minimize lower leg fluid accumulation.

• Patients should minimize high-salt foods to reduce fluid accumulation associated with a failing heart.

• The patient should not over exert during physical activity. At this stage in heart failure, comfort becomes the primary initiative.

Pharmacotherapy in Palliative Care

• If patient becomes symptomatic of hypotension, reduce dose of angiotensin-con-verting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), and/or P-adrenergic blocker. For P-adrenergic blockers, in particular, this should be done gradually to avoid significant clinical deterioration.

• If volume overload occurs or persists, consider tapering off P-adrenergic blocker therapy.

• If the patient is fatigued while taking a P-adrenergic blocking agent and their heart rate does not increase with exertion, consider tapering down the dose of P-adrener-gic blocker.

• If patient's renal function deteriorates (e.g., cardiorenal syndrome), consider discontinuing the ACE inhibitor (or the ARB).

• If the patient restricts sodium and water intake, consider reducing the dose of diuretic or potentially discontinuing therapy.

• Digoxin toxicity is common; therefore, patients should be carefully monitored, and therapy adjusted or discontinued as appropriate. Monitoring should include complaints of anorexia, nausea and vomiting, visual disturbances, disorientation, confusion, or cardiac arrhythmias.

• Hydroxymethylglutaryl coenzyme-A (HMG-CoA) reductase inhibitors (and other cholesterol lowering medications) 2 are likely to have a long-term effect rather than a palliative effect; consider discontinuing therapy.

• Figure 4-2 provides a list of agents that improve functional status in advanced heart failure patients.

OUTCOME EVALUATION

® Involving the patient and caregivers in the development of the therapeutic plan demonstrates responsible palliative medicine. Before the implementation of drug therapy, the patient and caregiver should be involved with the decision-making process. The practitioner should ensure that his or her understanding of the patient's goals are being addressed.

Assessing positive therapeutic outcomes includes resolution of symptoms while minimizing adverse drug events. Resolution of symptoms is very important to patients and their caregivers. The hallmark of palliative medicine is specializing in symptom management while preventing adverse drug events. Cultural diversity is an extremely important consideration when establishing goals. Various cultures may perceive some symptoms as more or less important and the practitioner should be aware of those differences.

Nearly all physical symptoms are exacerbated by humanistic suffering. Patients with life-limiting diseases have emotional and spiritual issues that deserve attention by trained professionals. Addressing these concerns and providing support and coping skills can dramatically reduce the medication requirements for symptom control. Psychosocial and spiritual support is not only directed toward the patient in palliative care, but also supports the family during the time of the illness and after the death of their loved one. This bereavement support of the family is mandated under the Medicare Hospice Benefit and is unique to hospice care.

® Patient and caregiver education is vital to ensuring positive outcomes. If the patient and caregiver are unaware of the purposes of the strategies used in palliative medicine, adherence to regimens will be hindered and outcomes will be compromised. Practitioners who are challenged in the area of palliative medicine are greatly rewarded through achieving positive outcomes and observing immediate results of good decision making.

Patient Encounter 3

TT, a 76-year-old white female, presents to the outpatient clinic with a complaint of nausea and occasional vomiting. Her nausea started approximately 2 weeks ago and has progressively worsened. The patient also has a recent complaint of constipation (the past few weeks). The patient has a past medical history of non-small cell lung cancer (completed last chemotherapy regimen 3 weeks ago), osteoarthris, and hypertension. The patient has smoked one pack per day for the past 20 years and drinks occasional alcohol. The patient's family history is unknown. The patient reports an allergy to morphine.

Meds: Naproxen 500 mg every 6 hours as needed for osteoarthritis pain (started 4 weeks ago); enalapril 10 mg twice daily; celecoxib 100 mg twice daily; acetaminophen 500 mg every 6 hours as needed for pain; hydrocodone/acetaminophen 5/500 mg two tablets every 6 hours as needed for cancer pain; ginseng (the patient takes as needed for energy)

What potential drug-drug interactions exist in this patient?

What medications could be discontinued and/or changed?

How does the patient's allergy to morphine impact potential treatment options?

How could this patient's pain regimen be improved? Should the different types of pain the patient is experiencing be managed differently?

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