If you would not be surprised that patient died within the next few weeks commence conversations regarding this.
In the dying phase, it will be appropriate to review and discontinue some of the patient’s medication (in consultation with the Cardiology or Specialist Palliative Care Team).
In general continue with medications with symptomatic benefits and stop those aimed at medium to long term reductions in morbidity and mortality.
Consider continuing with following as they may be providing symptomatic benefit:
- diuretics (unless too dehydrated, may be appropriate as CSCI)
- antianginal medication (consider transdermal nitrate if patient is not able to take oral medication
- digoxin (stopping digoxin may worsen heart failure due to the positive inotropic effects of digoxin)
Reassess the value of the following and consider stopping:
- lipid lowering drugs
- spironolactone
- beta-blockers
- ACE inhibitors or ARBs
- antihypertensives (monitor BP initially)
- antiplatelet medication
- anticoagulants
- anti-anginal medication if no symptoms (monitor for symptom recurrence; consider transdermal nitrate if patient is no able to take oral medication)
Consider prescription of anticipatory medications for use if needed
See Chapter: End of life care.
For patients who are in the dying phase and who have an active defibrillator in situ, there is a risk of inappropriate shocking by the device; metabolic or biochemical abnormalities may lead to an agonal cardiac rhythm triggering the defibrillator, a situation which must be avoided in the dying patient.
Proactive deactivation of the defibrillator function of a device according to local guidelines and policy prevents the distress of inappropriate shocks as a patient dies.
It is possible to deactivate the defibrillator function but preserve the pacing mode of CRT-D devices.
For advice about deactivation of ICD devices discuss with cardiology team/pacemaker technicians or palliative care team. In an emergency situation, a strong magnet can be used to deactivate the ICD. Further information can be found here: www.westmidspallcare.co.uk/spagg/
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.