Palliative Care and Symptom Management

Connie Lewis MSN, ACNP, ANP

Heart failure (HF) is a progressive disease punctuated with symptom exacerbations and an increased risk of sudden death. Patients with heart failure should be transitioned to palliative care, over time, when their clinical status deteriorates and optimal medical therapy is no longer effective or has become inappropriate.⁽¹⁾  These patients have refractory HF symptoms at rest and are classified as Stage D HF according to the American College of Cardiology/American Heart Association(ACC/AHA) guidelines. Symptoms may include marked dyspnea, profound fatigue, cardiac cachexia, and severe limitations in activities of daily living that necessitate repeated and/or prolonged hospitalizations for intensive management. ⁽²⁾ Pain, insomnia, and depression may also be associated with end stage HF. ^(3-4)

The goal of palliative care is to improve the quality of life for the patient and family. Palliative care seeks to prevent, relieve, reduce or soothe the symptoms of disease without affecting a cure. This care is best provided by a multidisciplinary team that focuses on identifying and addressing the physical, psychological, spiritual, and the practical burdens of illness on both patient and family. ⁽⁵⁾ The Hospitalist is in a unique position to lead this team in the acute care setting. Assessment of patient preferences and family needs can be made by the Hospitalist then discussions on prognosis, advanced directives, living wills, and symptom management can be facilitated.

Due to the highly variable clinical course of HF, prognostication is very difficult. To date, functional capacity continues to play a significant role in predicting mortality. The gold standard for assessing functional capacity in HF is the measurement of maximum oxygen consumption with cardiopulmonary testing. This test is limited by availability and the ability of the patient to exercise. In addition, there are several standardized instruments that may be helpful in determining functional capacity. These include the New York Heart Association classification, the Minnesota Living with Heart Failure Questionnaire and the Kansas City Cardiomyopathy Questionnaire. Deterioration in functional capacity suggests a high risk of mortality during the next 6 months. ⁽¹⁾

Specific clinical indicators that are predictive of poor outcomes include intolerance to angiotensin-converting enzyme inhibitors (ACE-I), angiotensin-receptor blockers (ARBs), and/or beta blockers, worsening renal failure, elevated B-type natriuretic peptide, and hyponatremia. ⁽⁶⁾  The classification and regression tree (CART) analysis can be used as a bedside  mortality risk stratification tool. The CART analysis suggest that a blood urea nitrogen level of 43 mg/dL or higher, serum creatinine level of 2.75 mg/dl or higher, and a systolic blood pressure of less than 115 mm Hg on admission are highly predictive of in-hospital mortality. ⁽⁷⁾

The Heart Failure Society of America 2006 guidelines state that end-of-life care should be considered in advanced HF patients that have persistent HF symptoms at rest despite repeated attempts to optimize pharmacologic and nonpharmacologic therapy as evidenced by one or more of the following:

• Frequent hospitalization (3 or more per year)
• Chronic poor quality of life with inability to accomplish activities of daily living
• Need for intermittent or continuous intravenous support
• Consideration of assist devices as destination therapy ⁽⁸⁾

When the Stage D HF patient is identified, the first step in minimizing symptoms is optimizing medical therapies according to established guidelines. The end-of-life treatments are directed toward comfort measures. This would include the gradual withdrawal of ACE-I, ARBs, and Beta Blockers as the patient develops symptomatic hypotension and/or bradycardia. If the patient’s renal function deteriorates, consideration of decreasing or eliminating ACE-I/ARB should be made. If the patient’s oral intake declines, fluid status must be monitored closely and diuretic dosage adjusted accordingly.

Palliative treatments are needed for comfort care in managing the commonly experienced symptoms of dyspnea, fatigue, pain, depression, and anxiety. Oxygen, opioids, and continuous inotropic infusions may be helpful in treating dyspnea. While psychostimulants may be appropriate for fatigue.⁽⁶⁾ Additional clinical recommendations from the Consensus Statement on Palliative and Supportive Care in Advanced Heart Failure are shown in Table 1 . Clinical Recommendations for Care of Patients With Advanced Heart Failure

For more information and CME credit regarding palliative care in patients with heart failure go to – go to The Heart Failure Resource Room CME section and review the Palliative Care for Patients with Heart Failure CME Module.

1. Hauptman PJ. and Havranek EP. Integrating palliative care into heart failure care. Arch Intern Med. 2005;165: 374-378.

2. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guidelines update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

3. Stanek EJ, Oates MB, McGhan WF, Denofrio D, Loh E. Preferences for treatment outcomes in patients with heart failure: symptoms versus survival. J Card Fail 2000;6:225–32.

4. Kutner JS, Kassner CT, Nowels DE. Symptom burden at the end of life: hospice providers’ perceptions. J Pain Symptom Manage. 2001;21:473–80.

5.Clinical practice guidelines for quality palliative care. National Consensus Project. 2004

6. Goodlin SJ, Hauptman PJ, Arnold R, et al. Consensus statement: palliative and supportive care in advanced heart failure. J Card Fail. 2004:10:200-209.

7. Fonarow GC, Adams KF, Abraham WT, et al. Risk stratification for in-hospital mortality in acutely decompensated heart failure. JAMA. 2005:293:572-580.

8. Heart Failure Society of America; Heart Failure Guidelines. Section 8: disease management in heart failure, education and counseling. J Cardiac Failure. 2006;12:e58-e69. Available at: http://www.heartfailureguideline.org/document/2006_heart_failure_guideline_
sec_81.pdf Accessed April 27, 2007.

9. U.S. Department of Health and Human Services. Center for Medicare and Medicaid Services: Medicare Coverage Database—Determining Terminal Status. Updated 4/16/2007

10. Pantilat SZ. and Steimle AE. Palliative care for patients with heart failure. JAMA 2004:291:2476-2482.