The principles for determining when patients with end-stage cardiac disease require end-of-life care, are actually similar to those for determining prognosis of patients with advanced pulmonary disease.
Disabling Dyspnea or Chest Pain
- Dyspnea or chest pain with rest or minimal exertion and can therefore classified as New York Heart Association class IV (NYHA class IV)
- Ejection fraction less or equal 20%, if available
- Persistent symptoms despite optimal medical management with vasodilators and dialectics, or
- Inability to tolerate optimal medical management due to hypotension and/or renal failure
Other comorbid condition association with a poor prognosis:
- Symptomatic arrhythmias resistant to antiarrhythmic therapy
- History of cardiac arrest and resuscitation
- History of syncope, regardless of etiology
- Cardiogenic brain embolism
- Concomitant HIV disease
Heart failure (HF) is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen. Patients with HF require complex pharmacological and self-care regimens to control symptoms and prevent recurrent hospitalizations.
Congestive heart failure causes a variety of symptoms that can greatly reduce a palliative care patient’s quality of life. Pain is a common symptom, especially chest pain due to myocardial ischemia and extremity pain due to edema and arthritis. Dyspnea is also common in the patient with terminal heart failure, primarily due to pulmonary edema that develops as a result of cardiac pump failure. Other common symptoms include fatigue, depression, sleeping difficulties, and poor appetite.
Opioid pain medications are indicated and effective for the treatment of both pain and dyspnea in the patient with end-stage heart failure. As the patient with heart failure makes the transition to palliative care, the entire treatment regimen (including diet, medications, and implanted cardiac devices) should be evaluated with the patient’s goals for symptom management and end-of-life care dictating the specifics of the treatment plan.