Some services differ by area. Select your area so we can show you the most relevant information to you.

Borough selection

Identification of end stage heart failure: Information for clinicians

The following are triggers to consider a referral to palliative care in heart failure:

Clinical symptoms and and signs:

  • Worsening breathlessness at rest and often at night when lying flat (New York Heart Association class IV)
  • Increasing oedema limiting function and requiring increasing diuretics
  • Frequent admissions to hospital with fluid overload
  • Reduced mobility, weight loss, poor sleep and reduced appetite (cardiac cachexia) 
  • Nocturnal dyspnoea

Metabolic indicators:

  • Progressive deterioration in estimated glomerular filtration rate (eGFR) , creatinine and potassium levels
  • Hypotension limiting the use of drug treatments
  • Serial increases in Beta natriuretic peptide (BNP)
  • Albumin as a marker of cachexia 

Why is it important to identify

  • As an opportunity to discuss future care and wishes
  • Plans to avoid admission e.g. flexible PRN diuretic plans - oral or subcutaneous
  • Referral to palliative care
  • Prioritise symptom relief for breathlessness, oedema, insomnia and nausea
  • Diuretic review e.g. switching from furosemide to bumetanide which is better absorbed if extensive oedema present (40mg PO furosemide is equivalent to 1mg PO bumetanide)
  • ICD deactivation if relevant

Recommended Resources

NICE CKS - Heart failure - chronic

Published 1st September 2025

Share

Related Services

Heart failure services

British Heart Foundation
Close

British Heart Foundation

T. 0300 330 3322

W. https://www.bhf.org.uk/

The British Heart Foundation provides information on heart and circulatory diseases.

Patients and carers can get support through the online support groups and communities, advice and guidance about heart and circulatory conditions and managing risk factors.

Pumping Marvellous - Heart Failure Charity UK
Close

Pumping Marvellous - Heart Failure Charity UK

W. https://pumpingmarvellous.org/

Pumping Marvellous offers support to help people live well with heart failure, to recognise the early symptoms and self-interventions through their community hub.

Palliative care advice lines

NCL Palliative Advice Team
Close

NCL Palliative Advice Team

T. 020 8152 3252

W. https://northlondonhospice.org/get-support/out-of-hours-telephone-advice

The North Central London Palliative Advice Team is a telephone service providing palliative care patients, families, carers, and healthcare professionals (in NCL ICS boroughs) with out of hours advice and support.

The telephone service is available 8.00pm to 8.00am, seven days a week.

Community palliative care teams

Palliative Specialist Community Care
Close

The Community Specialist Palliative Care team provides specialist palliative and end-of-life care in the community to patients with life-limiting illness for residents in South Camden, North East Westminster and Islington.

Please contact the team between Monday to Sunday 9.00am to 5.00pm and Monday to Sunday 5.00pm to 8.00pm call the switchboard on 020 3456 7890 and ask for air-call palliative care team.

Palliative Specialist Community Care - North Camden
Close

Palliative Specialist Community Care - North Camden

T. 020 7830 2905

W. https://www.royalfree.nhs.uk/services/palliative-care?q=%2Fservices%2Fservices-a-z%2Fpalliative-care%2F

The Community Specialist Palliative Care team in north Camden provides specialist palliative and end-of-life care in the community to patients with life-limiting illness, as well as offering support to families and carers.

Please contact the team between Monday to Friday 9.00am to 5.00pm. On weekends and bank holidays, call the switchboard on 020 7794 0500 and ask for air-call palliative care team.

St John's Hospice Inpatient unit
Close

St John's Hospice Inpatient unit

T. 020 7806 4040 / 07725 258767

W. https://www.stjohnshospice.org.uk/our-care/inpatient-care

St. John's Hospice provides inpatient palliative care services to the residents of Brent, Central London and West London.

This is an inpatient unit with 18 beds

Please contact for admissions for advice and Community Specialist Palliative Care.

The office hours are Monday to Friday 8.30am to 4.30pm. Referrals received in the morning are triaged the same afternoon, and those received in the afternoon are triaged the following working day.

If urgent, please follow up the referral by calling us on 020 7806 4040. Out of hours, urgent referrals will be discussed with the consultant on call.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4.2 (DOCX)

Related Articles

19th February 2026

Advance care planning: Information for clinicians

3rd December 2025

ICD deactivation towards the end of life: Information for clinicians

Feedback