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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Community Palliative Care Team - based at Meadow House Hospice
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The Community Specialist Palliative Care Nurse Team provides advice and visiting to palliative care patients in Ealing and Hounslow. The team are based at Meadow House Hospice.

The team will visit patients with progressive life limiting illness in their own homes. They provide specialist advice around pain and symptom control and support for patients, their families, and carers during the last stages of illness. They also support patients wishing to die at home through coordination with GPs and hospital teams.

The team is comprised of medical consultants, specialist nurses, physiotherapists, occupational therapists, social workers, a bereavement support officer and a patient and carer advocacy worker

The team can be contacted for referrals Monday to Friday 9.00am to 5.00pm.

Between Monday to Friday 5.00pm and 8.30am, the Out of Hours Telephone Advice line 020 8102 5000 takes calls. Weekends and Bank Holidays 5.00pm to 9.00am.

Referral form for clinician use only.

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

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