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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Palliative care advice lines

24 hour Advice Line Michael Sobell Hospice
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24 hour Advice Line Michael Sobell Hospice

T. 0203 824 1268

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

It is also an Advice Line for patients and families who live in Hillingdon and need advice on any aspect of palliative care. 

The Advice Line is answered by hospice nurses in the Inpatient Unit and queries are escalated to the on-call palliative medical team if needed.

24/7 Your Life Line 24/7 Hillingdon (YLL)
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24/7 Your Life Line 24/7 Hillingdon (YLL)

T. 0800 328 5697

W. https://www.cnwl.nhs.uk/services/community-services/your-life-line-team-hillingdon

The team is made up of clinical nurse specialists and health care assistants (HCA) who can support patients with complex needs at home in the last weeks and months of their life (with any diagnosis). 

The service is open 24 hours a day, 365 days a year, and can offer advice.

 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.

Speak to your GP or district nurse to be referred to the service.

Heart failure services

British Heart Foundation
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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.

Hillingdon Community Heart Failure Nursing Service
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Hillingdon Community Heart Failure Nursing Service provides specialist nursing advice and management of adult patients with a diagnosis of heart failure.

Pumping Marvellous - Heart Failure Charity UK
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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.

Community palliative care teams

Hillingdon Community Palliative Care Team
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Hillingdon Palliative Care Team (hosted by NHS CNWL) provides specialist advice and visiting to palliative care patients living in Hillingdon. Each GP practice has their own named Clinical Nurse Specialist ( CNS ). A Triage CNS manages calls and referrals each day and they have the option to escalate to consultants if needed.

They can be contacted Monday to Friday 8.00am to 4.30pm excluding bank holidays.

Out of hours phone Michael Sobell Hospice 24 hour Advice Line on 020 3824 1268

Referral form for clinician use only.

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

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