Dying phase

Dying phase

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.

Drug rationalisation will need to be tailored to the individual’s situation but the following may be useful guidance to be considered in discussion with the Heart Failure team.

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 ipatient 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)

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.

 

References

1.  Renal Association http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/CKDstages.aspx accessed November 2011.

2.  Ferro C.J. et al. Management of pain in renal failure. In: Chambers J et al. Editors. Supportive care for the renal patient.

2004. Oxford University Press.

3.  Twycross R, Wilcock A (Eds). Palliative Care Formulary: Fourth

Edition. Palliativedrugs.com Ltd 2011.

4.  Joint Formulary Commitee (British Medical Association and Royal Pharmaceutical Company). British National Formulary (BNF 62). bnf.org 2011: chap or pp-pp.

5.  King S, Forbes K, Hanks GW et al. “A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment EPCRC opioid guidelines project” Pall Med. 25 (5) pp525-552.

6.  Douglas C, Murtagh FEM, Chambers EJ, Howse M, Ellershaw J, Symptom management for the adult patient dying with advanced chronic kidney disease: A review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group; Palliative Medicine 2009; (23) 103.

7.   Russon L and Mooney A. “Palliative and end of life care in advanced renal failure”Clin Med 2010 vol 10 no.3; pp279-281.

8.  MacLaran S, Stein A, Bennett-Jones D, Lee R. Supportive Care Guidelines for patients with End Stage Renal Disease. University Hospitals of Coventry and Warwickshire NHS Trust.

9.  Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL. “Symptom distress and quality of life in patients with advanced congestive heart failure”. J Pain Symptom Management. 2008 Jun;35(6):594-603.

10.   “Medical Therapy Guidelines for Chronic Heart Failure”, Coventry and Warwickshire Cardiovascular Network,

multi-professional working group, version 6, 2007, UHCW

e-guidelines 2011 available at http://www.c-a-s-t-l-e.org.uk/

11.    Zacharias H, Raw J, Nunn A et al “Is there a role for subcutaneous furosemide in the community and hospice management of end-stage heart failure?” Pall Med. 25 (6) pp658-663.