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

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T. 0203 824 1268

Offers support and advice on palliative care issues to GPs, Care Homes, District Nurses and hospital doctors.

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 Urgent night visits  are available to patients already referred to the service.

If you have already been referred to this service, you will have been given a direct contact number.

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Referral form for clinician use only.

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