Managing symptoms and complications of heart failure in palliative care

Management of symptoms and complications of heart failure in patients with palliative care needs is individualised; it focuses on subjective assessment of the patient rather than objective measures. The approach depends on the potential benefits and burdens of treatment, and the patient’s prognosis, preferences (including preferred care setting) and goals of care—see Principles of symptom management in palliative care.

Continuing optimised disease-orientated care is important because patients with heart failure commonly have cardiac dysfunction–related complications—see General principles of heart failure management. A number of factors, such as immobility and hypoalbuminaemia, can contribute to generalised oedema (including peripheral and pulmonary oedema). Fluid overload and poor heart function can cause breathlessness. Continuing diuretic therapy is often crucial to decrease pulmonary fluid overload in advancing heart failure, and minimise breathlessness and cough, which often increase as heart function deteriorates. Patients with severe oedema may not absorb oral furosemide (frusemide) because of oedema in the gastrointestinal tract; consider intravenous or subcutaneous administration until symptoms are controlled—see Acute cardiogenic pulmonary oedema. Consider strategies to manage urinary incontinence related to diuresis (see Functional urinary incontinence in palliative care) and serous leakage from oedema.

Heart failure is often caused or complicated by coronary artery disease or cardiomyopathy; patients commonly experience ischaemic chest pain. Ensure preventive therapies are optimised and patients have a chest pain management plan; symptom management includes glyceryl trinitrate (see Treatment of episodes of angina) and opioids.

Patients with heart failure can experience a range of other symptoms that require assessment and management including:

• anorexia
• anxiety or depressed mood
• constipation
• delirium
• distress
• fatigue
• nausea and vomiting, which can be caused by cardiovascular drug toxicity, increasing fluid overload (including oedema in the gastrointestinal tract), or worsening uraemia
• pain, which can be caused by ischaemic chest pain and other causes such as increasing oedema, musculoskeletal pain or metabolic changes from anorexia and cachexia
• sleep disturbance
• uraemic itch caused by chronic kidney disease.

For principles of palliative care in the last days of life, see Principles of care in the last days of life.