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 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
• ACE inhibitors or ARBs
• antihypertensives (monitor BP initially)
• antiplatelet medication
• 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.
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