1. Palliative Care In Heart Failure Dr Chi-Chi Cheung Consultant in Palliative Medicine 19 th March 2015

2. Overview When does heart failure become palliative? Heart failure therapies Cardiac devices Pharmacological management Prescribing at the end of life

3. Follow the general principles Palliative Care Holistic care and support Sensitive discussions about now and the future Symptom control

4. Heart failure admissions Represent 5% of all emergency admissions High readmission rate 1.8% total NHS budget 70% of cost of heart failure care = hospital admissions 33% mortality at 1 year (NYHA III/IV) 15% mortality within 30 days of hospital admission (9% in hospital, 6% post-discharge)

5. End stage disease trajectory Contrasting Dying Trajectories for (A) Obvious late decline of cancer; (B) End stage heart or lung disease with episodic crises; and (C) Dwindling course of dementia

6. Predictors of Poor Prognosis NYHA grade Blood pressure Diuretic resistance Poor exercise tolerance Inability to take ACE or ARB Hyponatraemia Uraemia Renal failure

7. Advanced Heart Failure Management Optimising Medication Device therapy Ultrafiltration Surgical techniques Circulatory support Transplant consideration Palliative approach +/- specialist referral

8. Significant conversations Transition towards end of life DNACPR Preferences and wishes, including place of care Ceiling of treatment, incl. OOH plan

9. Cardiac Device Therapy CRT-D (D=defibrillator) ICD (implantable cardiac defibrillator) CRT-P (P=pacemaker) CRT = cardiac resynchronisation therapy

10. Deactivating ICD/CRT-D devices

11. But…

12. Medication For improving survival Beta-blockersACEI/AR blockers Mineralocorticoid antagonists For improving symptoms DiureticsDigoxinMorphine If rationalising meds in final phase of life, consider stopping: Statins Anti-platelet agents Ca channel blockers Nitrates Consider switching furosemide to bumetanide, or combining loop with thiazide

13. Renal Failure and Heart Failure 17% of patients with Heart Failure have CKD stage 1 (GFR>90mls/min) 27% have CKD stage 2 (GFR 60-89mls/min) 40% have CKD stage 3 (GFR 30-59mls/min) 16% have CKD stage 4 or 5 (GFR<30mls/min) Circulation. 2004;109:1004-1009. A 30% rise in creatinine is expected with diuretics and ACE inhibitors A 50% rise in creatinine may be satisfactory An even greater fall in GFR is expected Therefore seek cardiology advice if uncertain

14. Common Symptoms Breathlessness Fatigue Oedema Postural hypotension Pain Poor appetite Depression Poor energy levels Nausea Cough Fear Syncope NB Treat cause where possible

15. Specific symptoms Breathlessness: Morphine (reduce dose or frequency in renal impairment, e.g. oramorph 2.5mg tds instead of 4 hourly) Pain: Avoid NSAIDs, pregabalin, TCAs Nausea/vomiting: Avoid cyclizine Depression: Avoid TCAs, venlafaxine Remember non-pharmacological modes of treatment Remember laxatives with opioids!

16. End of life prescribing Notes: 1. Opioid analgesic, sedative, anti-emetic, antisecretory 2. Range for 24hr CSCI drugs 3. PRN drugs mirror CSCI drugs 4. PRN opioids are usually ⅙ of 24hr dose – reduce frequency in renal impairment 5. Subcutaneous furosemide may be an option

17. Take home messages General principles Specific to Heart Failure Discussions re deactivation of ICD, CRT-D (but not pacemakers or CRT-P) Avoid cyclizine, TCAs, venlafaxine, pregabalin where possible HF meds may be useful for symptom control Key discussions re transition, future care, preferences etc. Assess symptoms and treat cause where possible Optimise medications