1. Palliative Management of Heart Failure
Dr Mags Clifford, Consultant in Palliative Medicine
Ciara Wynne, Clinical Nurse Specialist

2. Overview Case presentation – Mrs Begum Audience discussion on case
Approach to care of person with heart failure under headings of WHAT needs to happen / WHEN / WHERE/ and HOW to make it happen
Complete Mrs Begum’s story
Questions and comments

3. Introduction to Mrs Begum
Initially referred to St Josephs Community Palliative Care Team by a Heart Failure nurse due to frequent A+E admissions and need for advance care planning
Mrs Begum had a history of Heart Failure, Pulmonary Hypertension, AF, Metallic Mitral Valve, Chronic Kidney disease stage 3, CVA
Mrs Begum lived with her husband whom had advanced Parkinson’s, and their son whom was main carer to both of them.

4. First visit to Mrs Begum
Initial presentation at first visit:
Mobile with assistance
Slightly breathless on exertion-not using any inhalers/opiates/benzodiazepines
Frequently accumulating oedema usually resulting in hospital admission for diuresis
Episode of cellulitis related to oedematous effect in skin integrity
Difficulty sleeping (was using flat double bed to sleep)
Pruritus
Abdo/Torso pain-sharp stabbing-using oxynorm
Facial swelling, extremely raised JVP
Family report attending A+E approx every 4 weeks

5. Audience Discussion How would you approach this?
What are Mrs Begum’s options for her future care?

6. What should happen? Holistic Assessment :
Social: Are there issues specific to Tower Hamlets.
Spiritual: Consider how Advance Care Planning may be affected
Psychological: Multifactorial
Physical: Just one component
ACP: Do you know what peoples options are?
Palliative approach to care
Quality of Life intended outcome

7. When?

9. Disease Trajectories

10. Where?

11. Where? – “In the bed you’re in” (Dame Barbara Monroe, St Christopher’s Hospice)

12. Can we achieve “palliative care in the bed you’re in” for Heart Failure?
Challenge
Preferred place of care and death
ACP discussions / future planning
Hospital avoidance
Anticipatory prescribing / crisis plan
Home
Support available / DNACPR and other documentation
Care Home
Staff support / Communication
Hospice
Unpredictability / length of stay

13. The reality……. 1,000 deaths per year in Tower Hamlets 59% hospital
7% care homes
10% hospice
24% own home
Cardiovascular disease – 28% of deaths
(Tower Hamlets JSNA 2015 / 16)

14. Physical Symptom Management Heart failure meds Burden vs benefit
Reverse the reversible / Palliate the irreversible

15. How?

16. Symptom Assessment Open-ended Q rather than listing off symptoms
“Popular” versus “orphan” symptoms
Symptom assessment tools (e.g. IPOS)

17. Symptom Prevalence (Solano, Gomes and Higginson. JPSM. Jan 2006)
Heart Failure
Cancer
Breathlessness 60-88%
Breathlessness 10-70%
Fatigue 69-82%
Fatigue 32-90%
Pain 41-77%
Pain 35-96%
Anxiety / Depression 9-49%
Anxiety / Depression 3-79%
Insomnia 36-48%
Nausea 17-48%
Nausea 6-68%
Constipation 38-42%
Anorexia 21-41%
Anorexia 30-92%

18. Breathlessness

19. Pharmacological Opioids
Lower starting doses than pain (e.g. Oramorph 1mg TDS)
Most evidence for Morphine
Benzo’s
Break anxiety spiral
Start with short acting (e.g. Lorazepam)
Oxygen
Only if hypoxic

20. Non-pharmacological Hand-held fan Positioning
Breathing techniques / retraining
Exercise

21. Positioning

22. Breathing Techniques “Just take a nice deep breath” Vs
“When in doubt breathe out”
The “Window” technique
Do not avoid exercise completely

24. Mrs Begum’s symptom management
Oedema -> Frusemide 80mg CSCI / 24 hours
Breathlessness -> Fentanyl patch with PRN Oramorph (supplemented with Alfentanil CSCI in last days of life), occasional Lorazepam, hand held fan
Nausea -> Haloperidol
Insomnia -> Zopiclone / presence of family
Anorexia -> Not an issue!!

25. Psychological Multi-factorial Loss of independence
Loss of role in the family (mother/grandmother)
Communication barrier-Language issues

26. Social
Complexity of living with husband with Parkinson's. Son main carer.
Frequent interruption to daily living because of hospital admissions.
Housing structure: Tower Hamlets specific- Inadequate homes
Financial: Son had concerns as he was main carer to two frail parents-no other earning capacity- wanted to start his own business- sisters had young families- could not be as available as son.

27. Spiritual Devout Muslim faith
Even when so ill she was barely conscious most of the time, would still pray five times a day
Frequent visits from Imam
Sense of “calm” in the room
Died during Ramadan

28. Final part of Mrs Begum’s story
Very prolonged hospice admission
Appeared to be starting to die Jan 2016 – large GI bleed due to gastric varices, not fit for hospital transfer, generalised oedema, breathless, globally deteriorating
Never improved but lived for several months (?? How ??)
Died during Ramadan.

29. Summary Identify when to adopt a palliative approach – SPICT tool
NB A palliative approach does not preclude continuing life prolonging treatments
Diuretics may have a role in symptom management of heart failure up to the end
Unpredictable illness trajectory
Some things are out of our control!!

30. Thank you / Questions