Palliative care for heart failure patients. Susan Addie

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Vincent Johns
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1 Palliative care for heart failure patients Susan Addie

2 Treatments The most common limiting and distressing complaint is of fatigue and breathlessness. Optimal treatment strategies relieve symptoms, improves prognosis progression is slowed not halted Based on combinations of drug therapy, incrementally increased balance between benefit and adverse effects Treat co-morbidities anaemia, renal disease, COPD, cognitive dysfunction, depression, diabetes, peripheral vascular disease, stroke

3 Symptoms in CCF patients during the last 6 months of life Symptom (%) n=80 Breathlessness 88 Pain 75 Fatigue 69 Anxiety 49 Limitation in physical activity 49 Nausea 48 Ankle swelling 44 Constipation 42 Anorexia 41 Sleeplessness 36 Cough 35 Confusion 29 Dizziness 21 Urinary incontinence 20 Orthopneoa 19 Diarrhoea 12 Pruritis 12 Depression 9 Thirst 9 Palpitation 5 Nocturia 4 L. Nordgren, S.Sorensen, Eur J of Cardiovascular Nursing 2:213-7, 2003

Triggers for Palliative Care http://www.spict.org.uk/the-spict/ The Supportive and PalliativeCare Indicators Tool General Indicators of poor or deteriorating health Unplanned hospital admission(s).

4 Triggers for Palliative Care The Supportive and PalliativeCare Indicators Tool General Indicators of poor or deteriorating health Unplanned hospital admission(s). Performance status is poor or deteriorating, with limited reversibility.(eg. The person stays in bed or in a chair for more than half the day.) Depends on others for care due to increasing physical and/or mental health problems. The person s carer needs more help and support. The person has had significant weight loss over the last few months, or remains underweight. Persistent symptoms despite optimal treatment of underlying condition(s). The person (or family) asks for palliative care; chooses to reduce, stop or not have treatment; or wishes to focus on quality of life. Heart/Vascular Disease Heart failure or extensive, untreatable coronary artery disease; with breathlessness or chest pain at rest or on minimal effort. Severe, inoperable

5 Pain Pain is very common, especially in the terminal stages. One common cause is stretching of the capsule of the liver. Managed in the usual way for palliative care except that NSAIDs should be avoided. Opioids may be of value for both pain and dyspnoea.

6 Pain Up to 78% in some studies WHO analgesic ladder Regular paracetamol Start morphine at lower doses 2.5mg 4hrly Diamorphine 1-2.5mg sc 4 to 6 hrly

7 Marie Curie Glasgow Conversion Chart This is advice on conversion factors and dose equivalents. It is not a guideline on using opioids. If converting in the opposite direction multiply rather than divide. *When changing to a different opioid it is usual to reduce the final opioid dose by one third: vigilance for opioid toxicity and provision for breakthrough pain is advised at this time. Contact Palliative care team for advice. ORAL MORPHINE Contact palliative care team Divide by 2 Divide by 3 Divide by 2* Divide by 7.5* SUBCUTANEOUS MORPHINE SUBCUTANEOUS DIAMORPHINE ORAL OXYCODONE ORAL HYDROMORPHONE Equivalent* Divide by 2 Divide by 2 FENTANYL PATCH microgram/hr Contact palliative care team SUBCUTANEOUS OXYCODONE SUBCUTANEOUS HYDROMORPHONE Divide by 10* SUBCUTANEOUS ALFENTANIL Breakthrough pain: For same opioid & route divide 24 hour opioid dose by 6 For ACTIQ: start at lowest dose and titrate up For Fentanyl: divide patch strength (microgram) by 5 to get breakthrough diamorphine SC dose (mg) J Adam May 2005

8 Nausea and Vomiting Haloperidol 1.5-3mg oral/sc at night in renal impairment or renal failure If related to meals, early satiety, hepatomegaly metoclopramide10mg oral/sc three times daily Low dose levomepromazine 3-6mg daily

9 Breathlessness sublingual lorazepam 500 micrograms -1mg if required to max 4g per day Diazepam 2mg orally Low dose oral Nebulised saline +/-bronchodilators Low dose opioids Reduce respiratory sensation and may reduce pulmonary ventilation Centrally acting drugs on the CO 2 sensitive medullary respiratory centre Other possible site are opioid receptors in airways May also help in heart failure by virtue of its vasodilator action, which reduces the load on the heart Has important cortical sedative action thus reducing the perception of dyspnoea Decrease pulmonary artery pressure

10 Depression Depression may occur in about a third of patients and is often overlooked. Regular assessment and review Exercise/activity Relaxation CBT Sertraline 50mg daily (Mirtazapine 15 30mg at night) Avoid TCAs

11 What should be avoided? Tricyclic antidepressants (interactions/anticholinergic effects) Gabapentin preferred choice for any neuropathic pain NSAID (fluid retention) Cyclizine (hypotension) Domperidone (QT prolongation)

12 Diuretics Furosemide can be given by CSCI to manage decompensated heart failure in community setting. Start with same dose as oral dose Incompatible with most other SC medications and would need to be infused with separate syringe pump.

Just in Case Medication-Background The Scottish Palliative care action Plan (Living and Dying Well, 2008) requires NHS boards to use anticipatory

13 Just in Case Medication-Background The Scottish Palliative care action Plan (Living and Dying Well, 2008) requires NHS boards to use anticipatory prescribing (including Just in case boxes) to enhance patient care and aid the prevention of unnecessary crises and unscheduled hospital admissions.

14 Why? Improve the care of patients as they approach the end of their lives Reduce instances where DNs must contact GPs at short notice and often considerable distance to obtain scripts and then SEARCH for pharmacies with stocks of medicines, even more challenging and time consuming OOH Prevent crisis hospital admissions Minimise OOH call outs Continuity of care Supports patients achieving their Preferred Place of Care

15 Consider NHS GGC Palliative Care Guidelines: Last days of Life What symptoms? Possible choice of medicines? Pain / breathlessness Opioid (diamorphine/morphine) Anxiety / agitation/breathlessness Nausea / vomiting Respiratory secretions Midazolam (10mg/2ml used in palliative care) Tailor to individual need consider levomepromazine if no previous oral anti-emetic Hyoscine butylbromide (Buscopan) Sublingual route for breathlessness / anxiety Lorazepam 1mg (blue scored tablets)

Renal Palliative Care Last Days of Life

Renal Palliative Care Last Days of Life Introduction This guideline is an aid to clinical decision-making and good practice for patients with stage 4-5 chronic kidney disease (egfr