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