Multidisciplinary care of a patient with heart failure. patient with heart failure. Dr Claire Hookey
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1 Multidisciplinary care of a patient with heart failure patient with heart failure Dr Claire Hookey
2 Mr E.S 61 year old gentleman Referred to the hospice by the heart failure specialist nurse May 2010 Heart Failure, Renal Impairment. Pulmonary hypertension, Ischaemic heart disease, Chronic obstructive pulmonary disease, Diabetes Lives with wife and son 2 recent admissions to hospital with decompensated heart failure Communty matron and OT involved
3 Community Palliative Care Nurse Specialist Input Advised oxynorm for breathlessness Visit one week later marked deterioration main problem breathlessness, increased swelling legs and scrotum. Desperate to stay at home
4 Subcutaneous furosemide 50% of patients aware that no further prognostic (life prolonging) treatments are available would prefer to be treated at home if possible (Q J Med 2004;97: ) Iv diuretics safe to administer in outpatient settings or patient s home (Eur J Ht Fail 2008;10:267-72, Lancet 1998;25:446) Evidence of effectiveness of furosemide given subcutaneously (Annals Pharmacotherapy 2004;38:544-9)
5 Overview of pathway for home sc or iv diuretics
6 sc furosemide PCNS arranged: Syringe driver with furosemide Advice to GP to increase oxynorm dose Next day. Weight loss 3 lbs. Legs slimmer. Less breathless. Best night s sleep
7 Ongoing care Following day joint visit PCNS and hospice doctor. wants all care to be at home, no admissions Plan for weekend (24/7 advice line cover) Discussed resuscitation with patient and wife EOL drugs prescribed Following week HF nurse review changed back to oral medication PCNS visit emotional support (tearful and distressed, EOL drugs / DNAR etc brings home his mortality ) Support given and chaplaincy support discussed and accepted, referred to local church leader)
8 Team working Discussed at practice GSF meeting 2 weeks after first referral. Management with sc furosemide reflected on. District nurses happy to undertake again in the future if needed.
9 Ongoing management Stable for periods More episodes of decompensated heart failure. Fluid management with sc furosemide (input from HF nurses and Palliative Care consultant) Symptomatic management with increased opioids, management of nausea and vomiting, anxiety (PCNS and pc Consultant)
10 Prognosis? End July GSF meeting. GP expected prognosis 4-6 weeks
11 Hospital admissions required 1 week admission to hospital with cellulitis August Accidental overdose of insulin Oct
12 Increased care requirements End of Oct - PCNS Refers to hospice at home to Facilitate home death, carer emotional and psychological support Wife very tired, feels guilty not caring for him herself No social care package (had been discussed) HF nurse arranging home oxygen Hospice at home provide a number of shifts at home, day and night over next 3 weeks.
13 Further decompensation Early December HF nurse restarts sc furosemide PCNS provides advice re symptom control Increased anti-sickness Increased opioids Vicar continuing to visit GSF Meeting DN reports patient very poorly but wanting to see Christmas
14 Boxing Day DN phones 24/7 advice line. Patient now unable to swallow oral medications?dying Given advice re converting oral oxycodone dose to sc dose in syringe driver NSUC to visit to prescribe syringe driver Patient died later that day New Year s Eve PCNS phones to offer condolences and explain bereavement support services. Wife says she is grateful for hospice support.
15 Caring for patients at EOL at home Team approach, everyone playing to their strengths GP DN HF nurse Community matrons Community OT Local vicar Hospice PCNS / Doctors / Hospice at home / 24/7 advice line
16 Holistic care Need to address Medical issues / complications hospital admission remains appropriate at times Symptom control Emotional support Spiritual issues Social support Carer support
17 Open discussion DNAR EOL drugs Understanding patient s wishes
18 Ability to respond to change Prognosis very difficult DNAR discussed end of May GP prognosis end July 4-6 weeks Died end Dec Decision making needs senior support at times
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