Congestive heart failure end-of-life considerations

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Congestive heart failure end-of-life considerations

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

End of life care in the patient with congestive heart failure is focused on making the patient comfortable. Invasive procedures should be minimized, and patients may elect to have their defibrillators inactivated. The growing number of patients with Stage IV heart failure (intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy) should be considered for palliative care or hospice, according to American College of Cardiology/American Heart Association guidelines listed below.

Some have argued that any patient with NYHA class III CHF should have a palliative care referral. Palliative care can not only provide symptom management, but also assist with advanced care planning, goals of care in the case of a significant decline, and making sure the patient has a medical power of attorney and discussed his or her wishes with this individual.

2013 ACCF/AHA Guideline/2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) [1][2]

Congestive heart failure end-of-life considerations (DO NOT EDIT)[1] [2][3]

Class I
"1. Ongoing patient and family education regarding prognosis for functional capacity and survival is recommended for patients with HF at the end of life. (Level of Evidence: C) "
"2. Patient and family education about options for formulating and implementing advance directives and the role of palliative and hospice care services with reevaluation for changing clinical status is recommended for patients with HF at the end of life. (Level of Evidence: C) "
"3. Discussion is recommended regarding the option of inactivating ICDs for patients with HF at the end of life. (Level of Evidence: C) "
"4. It is important to ensure continuity of medical care between inpatient and outpatient settings for patients with HF at the end of life. (Level of Evidence: C) "
"5. Components of hospice care that are appropriate to the relief of suffering, including opiates, are recommended and do not preclude the options for use of inotropes and intravenous diuretics for symptom palliation for patients with HF at the end of life. (Level of Evidence: C) "
"6. All professionals working with HF patients should examine current end-of-life processes and work toward improvement in approaches to palliation and end-of-life care. (Level of Evidence: C) "
"7. Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life.[4][5][6] (Level of Evidence: B) "
Class III (No Benefit)
"1. Aggressive procedures performed within the final days of life (including intubation and implantation of a cardioverter-defibrillator in patients with NYHA functional class IV symptoms who are not anticipated to experience clinical improvement from available treatments) are not appropriate. (Level of Evidence: C)"

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References

  1. 1.0 1.1 1.2 Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  2. 2.0 2.1 2.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016.DOI:10.1161/CIRCULATIONAHA.109.192064 PMID:19324967
  3. 3.0 3.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline 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 (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235.DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
  4. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA; et al. (2008). "Evidence for improving palliative care at the end of life: a systematic review". Ann Intern Med. 148 (2): 147–59. PMID 18195339.
  5. Qaseem A, Snow V, Shekelle P, Casey DE, Cross JT, Owens DK; et al. (2008). "Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians". Ann Intern Med. 148 (2): 141–6. PMID 18195338.
  6. Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM; et al. (2012). "Decision making in advanced heart failure: a scientific statement from the American Heart Association". Circulation. 125 (15): 1928–52. doi:10.1161/CIR.0b013e31824f2173. PMID 22392529.

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