Fast Fact and Concept #144: Palliative Care Issues in Heart Failure

Authors: Gary M. Reisfield, M.D. and George R. Wilson, M.D.

The physical and psychological symptom burden in the dying heart failure (HF) patient is similar to that in the dying cancer patient. Symptom prevalence data in HF includes: pain (78%), dyspnea (61%), depression (59%), insomnia (45%), anorexia (43%), anxiety (30%), constipation (37%), nausea/vomiting (32%), fatigue, difficulty ambulating and edema. The Fast Fact reviews domains of medical management common to most end-stage HF patients.

General Symptom Management

• Pain. Common causes include: peripheral edema, arthritis, diabetic neuropathy, and post-herpetic neuralgia. NSAIDs are generally contraindicated because they antagonize the effects of diuretics and ACE inhibitors, promoting fluid retention while decreasing glomerular filtration and impairing renal function. Opioids are the agents of choice for nociceptive and neuropathic pain because of efficacy, rapidity of onset and potential to relieve dyspnea. See Fast Facts: #18, #28, #53, #54, #72.
  
• Dyspnea. Reassess/optimize HF medications and assess for reversible causes, e.g. pleural/pericardial effusions, dysrhythmias, COPD exacerbation. See Fast Fact #27.
  
• Depression. Short-term psychotherapy can be helpful for mild-moderate depression, but patient participation and logistical issues can be problematic. SSRIs are the antidepressants of choice because they preserve ejection fraction, lack hypotensive/dysrhythmogenic effects, and have few drug interactions; sertraline may be the agent of choice in HF patients. Psychostimulants (Fast Fact #61) may accelerate the treatment response to SSRIs. Note: As there exists no data on the safety of psychostimulants in HF, therapy should be initiated with caution.

Heart Failure Pharmacotherapy. Optimal drug use can improve symptoms and should be continued until the burden of administration outweighs benefits. Diuretic therapy can be crucial, but diuretic resistance is common. The following strategy can help overcome diuretic resistance:

• Optimize dose of oral loop diuretic (e.g. furosemide). Doses of up to 4000 mg/day have been found to be safe and effective.
• Change to iv/sc route. Intravenous boluses can produce symptom relief within minutes. Continuous infusions (3-200 mg/h; 10-20 mg/h in most patients) provide increased efficacy.
• Add a prn oral thiazide diuretic (e.g. hydrochlorothiazide, 25-100 mg/d or metolazone 5-20 mg/d). This can reestablish diuresis in a loop diuretic-resistant patient. Note: High dose/combination diuretics can result in electrolyte imbalances; consider electrolyte monitoring if death is not imminent.

Intravenous inotrope therapy (dobutamine, milrinone, dopamine) has a substantial record of use but a paucity of data in the home setting. Data suggests these agents may improve symptoms, but with an increased risk of dysrhythmic death. In hospitalized inotrope-dependent HF patients, discharge on inotropes may provide the opportunity for death to occur at home if desired by patient/family.

Device therapies. Decisions regarding previously implanted device therapies should be made in the context of goals of care. See Fast Fact #111, #112 for full discussion of implantable devices and issues surrounding deactivation.

Prognostic Uncertainty Accurate prognostication is virtually impossible in HF (Fast Fact #143). While this uncertainty is frustrating for physicians, it provides a basis for initiating end-of-life discussions. Clinicians can best help their patients by:

• Initiating advance care planning discussions before a crisis or following HF hospitalization (which triples one-year mortality).
• Educating patients and families about the unpredictable, but usually terminal nature of HF, and the ever present danger of sudden cardiac death (even when feeling well).
• Ascertaining specific goals of care (e.g. quality of life vs. length of life, living/dying at home vs. hospital) and assessing options for achieving these goals (e.g. initiating/handling device therapies (when/if to turn off), hospice vs. serial hospital/CCU admissions, resuscitation preferences.

Note: A free advance care planning packet for HF patients is available through the Heart Failure Society of America website (www.hfsa.org).

References:

1. Albert NM, Davis M, Young J. Improving the care of patients dying of heart failure. Cleveland Clinic Journal of Medicine 2002;69(4):321-328. Algorithm for managing dyspnea due to pulmonary edema.
2. Alvarez W, Pickworth KK. Safety of antidepressant drugs in the patient with cardiac disease: a review of the literature. Pharmacotherapy 2003;23(6):754-771.
3. Berger JT. The ethics of deactivating implanted cardioverter defibrillators. An Intern Med 2005;142(8):631-634.
4. DeBruyne LKM. Mechanisms and management of diuretic resistance in congestive heart failure. Postgrad Med J 2003;79:268-271.
5. Ward C. The need for palliative care in the management of heart failure. Heart 2002;87:294-298.
6. Braun TC, Hagen NA, Hatfield RE. Cardiac pacemakers and implantable defibrillators in terminal care. J Pain Symptom Manage 1999;18(2):126-131.

C opyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Reisfield GM and Wilson GR. Fast Facts and Concepts #144; Prognostication in Heart Failure. October, 2005; revised October 2006. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge and Patient Care

Keyword(s): cardiac diseases and heart failure

Specific Disease and Organ System Category(s): Cardiac diseases & heart failure