Aggressive Symptom Management in Advanced Heart Failure
Patients who have end-stage heart failure experience multiple symptoms that require frequent and ongoing assessment and evaluation of interventions for effectiveness. Both drug and nondrug approaches are used. Patient and family support and education are critical, and the plan of care is coordinated with members of the interdisciplinary team. In contrast to treatment for patients who are dying from cancer, aggressive medical treatment, including infused inotropes and pacemaker placement, continues to be applicable in patients who have end-stage heart failure. However, diagnostic tests and medical interventions that do not contribute to comfort are generally not included in the plan of care.
General palliative recommendations include activity as tolerated, a diet with mild salt restriction, fluid restriction, and protection from infection. Patients are more comfortable when the symptoms of heart failure are well managed, and medications are continued as long as the patient is able to tolerate them. The following medications may be prescribed (see Table 3 for commonly used medications from each class): diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers, beta-blockers, spironolactone, and digoxin. Spironolactone is recommended for patients who have refractory symptoms and have recently been hospitalized. Careful monitoring of serum potassium is done to avoid development of hyperkalemia associated with spironolactone.
In one investigation of patients with end-stage heart failure, 88% reported breathlessness, 75% reported pain, and 69% identified fatigue as troublesome symptoms. Dyspnea can be particularly bothersome to patients and their families; orthopnea and paroxysmal nocturnal dyspnea may also be present. Dyspnea associated with volume overload is managed with diuretic and vasodilator therapy.[2,5] Opioid therapy provides relief because these medications reduce preload and after load; opioids have also been found to improve breathlessness, possibly because of action in the midbrain centers. Nonpharmacologic treatment for fluid retention includes a mild salt restriction, possible fluid restriction, elevation of the lower extremities and the head of bed, and avoidance of nonsteroidal anti-inflammatory drugs and calcium channel antagonists. Patients may also benefit from use of supplemental oxygen by way of a nasal cannula, fans and fresh air, or a cool fan across the cheeks and face. In patients whose fluid retention and dyspnea persist despite these therapeutic approaches, discussion of intravenous (IV) infusion of inotropes may take place. The decision about IV infusion therapy is made with careful consideration of the burden to the patient and family.
The pain experienced by patients who have end-stage heart failure can result from cardiac and noncardiac sources; it is often reported as pain all over the body. Common causes of cardiac pain include angina and edema, whereas noncardiac pain results from comorbidities and medical interventions. Generally speaking, opioids are recommended for the relief of pain regardless of its etiology. Nonsteroidal anti-inflammatory drugs are not recommended in heart failure because these medications reduce the benefits and effectiveness of diuretics and ACE inhibitors. Nonpharmacologic approaches to pain management are also part of every patient's treatment plan. Such approaches include repositioning, relaxation, distraction, and alternative approaches, including pet therapy, music therapy, and aromatherapy.
Fatigue is also commonly reported in patients who have end-stage heart failure; this symptom is in turn related to functional impairment. Fatigue results from heart failure itself, comorbidities, including anemia, infection, and nutritional deficiencies, and/or medications.[5,21] Fatigue is also related to psychological and situational factors. Management of fatigue is challenging and requires multidimensional strategies.
One additional symptom that is underrecognized and underreported in end-stage heart failure is depression.[2,9] Medications to help treat depression include selective serotonin reuptake inhibitors; tricyclic antidepressants are avoided because of the potential for hypotension and arrhythmias in this population. Nonpharmacologic interventions include psychosocial and spiritual support, including involvement of social services and pastoral care. A recent prospective observational study assessed the relationship of depression to death or hospitalization in patients who have heart failure. The results suggested an increased risk of death and cardiovascular hospitalization in patients with increased depressive symptoms. Thus, it is imperative that patients with heart failure be screened for depression and that it be managed appropriately. 
As the patient nears death, progressive withdrawal occurs; patients generally experience increasing weakness, less interest in eating, and less interest in interacting with people and the environment. Comfort measures are provided, including repositioning and skin and mouth care, while attempts to aggressively control symptoms continue. Signs of approaching death include further changes in the level of consciousness, diminished urine output, changes in the breathing pattern, and progressive coolness in the extremities. During this time, family members are supported by members of the hospice and palliative care team.
Journal of Hospice and Palliative Nursing. 2008;10(2):100-105. © 2008 Lippincott Williams & Wilkins
Cite this: Providing Palliative Care in End-stage Heart Failure - Medscape - Mar 01, 2008.