Heart failure module 7: end-of-life care for people with heart failure

Released1 November 2017     Expires: 01 November 2019      Programme:

Heart failure learning module 7 - Figure 1
Figure 1. Breathlessness is a particularly distressing symptom for patients with heart failure and their carers (click to enlarge)

Symptom control

Breathlessness (figure 1) is the predominant symptom of end-stage heart failure. Decisions on investigations and treatment must be taken in the context of the patient’s wishes and stage of the disease.

For example, aggressive treatment of pulmonary oedema with diuretics and vasodilators may not be appropriate for someone in the last few days of life whose primary wish is to be kept comfortable.

Palliative management of breathlessness may involve:

  • assessment and treatment of reversible causes dependent upon the patient’s wishes and stage of illness
  • subcutaneous furosemide infusion which may be effective as treatment of congestion and can prevent admission in patients with advanced heart failure21
  • cardiac exercise programmes which also address patient education and psycho-social support are available even for severely limited patients22
  • handheld fans which may ease the sensation of dyspnoea23
  • low-dose opioids which can improve symptoms of breathlessness in patients with heart failure.24
  • a randomised, placebo-controlled trial of low-dose morphine to treat breathlessness in patients with chronic heart failure is underway (IRAS ID 121660)
  • benzodiazepines in the palliative setting, although there is very scant evidence to support their use. They should be used only as second-line agents.25

Despite its widespread use, there is no evidence to support the use of home oxygen as a treatment for breathlessness.26 Home oxygen therapy for patients with with New York Heart Association (NYHA) III or IV class symptoms has no impact on quality of life measures.27

Pragmatic approach to heart failure treatment

Many medications used to treat heart failure lower blood pressure or heart rate yet confer prognostic benefit. Postural hypotension is common among elderly patients,28 and is associated with an increased risk of falls and injury.29 In patients with heart failure who are approaching the end of their lives, continuing high-dose medications such as beta blockers, angiotensin-converting enzyme inhibitors and mineralocorticoid receptor antagonists may cause more harm than long term benefit.


Incorporation of a palliative care approach in response to patient need rather than estimated prognosis will result in better care for patients with advanced heart failure. Interventions to support the patient and family with symptom control and improvement in quality of life can be used alongside optimal heart failure management. Palliative care should be provided by the usual clinical teams in primary and secondary care, with access to specialist palliative care services when needed for persistent or complex problems.

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3. Barclay S, Momen N, Case-Upton S, Kuhn I, Smith E. End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis. Br J Gen Pract 2011;61:e49–62. http://dx.doi.org/10.3399/bjgp11X549018

4. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail 2016;18:891–975. https://doi.org/10.1002/ejhf.592

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8. Hogg KJ, Jenkins SMM. Prognostication or identification of palliative needs in advanced heart failure: where should the focus lie? Heart 2012;98:523–24. http://dx.doi.org/10.1136/heartjnl-2012-301753

9. Haga K, Murray S, Reid J, et al. Identifying community based chronic heart failure patients in the last year of life: a comparison of the Gold Standards Framework Prognostic Indicator Guide and the Seattle Heart Failure Model. Heart 2012;98:579–83. http://dx.doi.org/10.1136/heartjnl-2011-301021

10. General Medical Council. Treatment and care towards the end of life: good practice in decision-making, 2010. Available from: http://www.gmc uk.org/guidance/ethical_guidance/end_of_life_care.asp

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12. Kelner M. Activists and delegators: elderly patients’ preferences about control at the end of life. Soc Sci Med 1995;41:537–45. https://doi.org/10.1016/0277-9536(94)00381-3

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15. Billingham MJ, Billingham SJ. Congruence between preferred and actual place of death according to the presence of malignant or non-malignant disease: a systematic review and meta-analysis. BMJ Support Palliat Care 2013;3:144–54. http://dx.doi.org/10.1136/bmjspcare-2012-000292

16. National End of Life Care Intelligence Network. Deaths from cardiovascular diseases: implications for end of life care in England. NHS National End of Life Care Programme 2013. Available from: http://www.endoflifecare-intelligence.org.uk/resources/publications/deaths_from_cardiovascular_diseases

17. Beattie JM, Connolly MJ, Ellershaw JE. Deactivating Implantable Cardioverter Defibrillators. Ann Intern Med 2005;143:690–1. https://dx.doi.org/10.3238/arztebl.2012.0535

18. Barclay S, Momen N, Case-Upton S, Kuhn I, Smith E. End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis. Br J Gen Pract 2011;61:e49–62. http://dx.doi.org/10.3399/bjgp11X549018

19. Allen LA, Stevenson LW, Grady KL, et al. Decision making in advanced heart failure. Circulation 2012;125:1928–52. http://dx.doi.org/10.1161/CIR.0b013e31824f2173

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21. Zacharias H, Raw J, Nunn A, Parsons S, Johnson M. Is there a role for subcutaneous furosemide in the community and hospice management of end-stage heart failure? Palliat Med 2011;25(6):658-63. https://doi.org/10.1177/0269216311399490

22. Davies EJ, Moxham T, Rees K, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Euro J Heart Fail 2010;12:706–15. http://dx.doi.org/10.1093/eurjhf/hfq056

23. Galbraith S, Fagan P, Perkins P, Lynch A, Booth S. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage 2010;39:831–8. http://dx.doi.org/10.1016/j.jpainsymman.2009.09.024

24. Oxberry S, Bland J, Clark A, Cleland J, Johnson M. Repeat dose opioids may be effective for breathlessness in chronic heart failure if given for long enough. J Palliat Med 2013;16:250–5. http://dx.doi.org/10.1089/jpm.2012.0270

25. Simon ST, Higginson IJ, Booth S, Harding R, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Db Syst Rev 2010;20:CD007354. http://dx.doi.org/10.1002/14651858.CD007354.pub2

26. Cranston Josephine M, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Db Syst Rev 2008;16:CD004769. http://dx.doi.org/10.1002/14651858.CD004769.pub2

27. Clark AL, Johnson M, Fairhurst C et al. Does home oxygen therapy (HOT) in addition to standard care reduce disease severity and improve symptoms in people with chronic heart failure? A randomised trial of home oxygen therapy for patients with chronic heart failure. Health Technol Assess 2015;19(75):1-120. https://dx.doi.org/10.3310/hta19750

28. Ong HL, Abdin E, Seow E et al. Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study.Arch Gerontol Geriatr 2017;72:146-152. https://doi.org/10.1016/j.archger.2017.06.004

29. Finucane C, O’Connell MD, Donoghue O, Richardson K, Savva GM, Kenny RA. Impaired Orthostatic Blood Pressure Recovery Is Associated with Unexplained and Injurious Falls. J Am Geriatr Soc 2017;65(3):474-482. https://doi.org/10.1111/jgs.14563

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