The iPOS questionnaire may be a useful tool to assist with holistic assessment: https://pos-pal.org/maix/
Optimally treat heart failure and co-morbidities
Assess and manage anxiety / depression
Consider referral for cardiac rehabilitation
Suggest use of hand fan on exertion
FAB (fatigue, anxiety, breathlessness) or similar symptom management programme
Consider slow-release Morphine 5mg-10mg BD & titrate to response (in normal renal function)
For further non-pharmacological and pharmacological management please
- Assess and manage reversible factors
- Consider assessment and treatment of anaemia
- Consider correction of low iron levels with intravenous therapy (50% of patients are not anaemic)
- Encourage appropriate gentle exercise as tolerated.
- Breathlessness management programme or FAB programme.
- Specific causes of pain in heart failure include:
- Angina (consider transdermal nitrate if patient cannot take oral nitrate medication)
- Claudication
- Diabetic neuropathy
- Abdominal bloating (due to e.g. liver capsule distension, gut wall oedema, constipation)
If renal impairment is present, take into account when prescribing analgesia.
For further information see: Chapter: Pain and Chapter: Renal Failure
Consider reversible causes – constipation, blood glucose control, dry mouth, digoxin toxicity.
Consider if gut oedema is affecting absorption of oral agents and if non-oral route may be more effective.
In heart failure, cyclizine is generally avoided due to its antimuscarinic effect.
Constipation is a common and troublesome symptom in advanced heart failure. It can exacerbate other symptoms such as fatigue and breathlessness.
Suggested laxatives:
1st line: Stimulant (e.g. senna, sodium picosulphate); provide routinely to patients on opioids.
2nd line: Softener ( e.g. sodium docusate, polyethylene glycol).
- Review and rationalise medications that might be contributing
- Exclude oral thrush
- Use of saliva substitutes eg Oral balance gel, Oralieve, Biotene
Glandosane - Other practical measures – ice, regular sips of fluid, chewing gum
- Pressure area care
- Soap substitute
- Emollient
- 2% menthol cream for itch
There is a high incidence of depression in patients with chronic illness. Specific tools are available to assess for this eg Hospital Anxiety and Depression Scale (HADS)
www.svri.org/sites/default/files/attachments/2016-01-13/HADS.pdf
Consider referral to appropriate psychological services
If antidepressants are indicated:
- Avoid Tricyclic antidepressants and drugs with many potential drug interactions (e.g. Fluoxetine)
- Consider Sertraline 50mg OD, Citalopram 10-20mg OD, Mirtazapine 15mg OD
- Look for reversible problems e.g. dry mouth, oral candida, untreated nausea or constipation, ill-fitting dentures
- Have small meals
- Help preparing food – if patient too fatigued to cook
- Dietician advice
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.