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Palliative care for advanced heart failure in a Department of Veterans Affairs regional hospice program: Patient selection, a treatment protocol, and clinical course.

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Published:22nd May 2017
Author: Taylor GJ, Lee DM, Baicu CF, Zile MR.
Availability: Free full text
Ref.:J Palliat Med. 2017 May 22.
DOI:10.1089/jpm.2017.0035.
Palliative Care for Advanced Heart Failure in a Department of Veterans Affairs Regional Hospice Program: Patient Selection, a Treatment Protocol, and Clinical Course


Background:
Palliative care for advanced heart failure (HF) is generally recommended. However, few reports have focused on the particulars of treatment, or the clinical course of HF on a specific treatment regimen.

Objective: Palliation adequate to allow patients to avoid HF admission and die at home.

Methods: Patients from a veterans administration regional practice with multiple, recent hospital admissions were enrolled in community hospice programs. Treatment of HF with reduced left ventricular ejection fraction (HFrEF) included guidelines-directed medical therapy, digoxin, opioids, and oral bumetanide (with metolazone as needed) rather than intravenous diuretics. Levodopa (l-dopa) was added when conventional therapy failed to control symptoms. HF with preserved EF was also treated with bumetanide and opioids.

Results: Thirty male veterans, 23 of them with HFrEF, had 90 HF admissions in the 6 months before enrollment, and 3 HF admissions during follow-up of at least 14 months. Twenty-one patients died, 18 of them at home; 14 died within 5 months, and the rest lived much longer. Failure to improve with initial therapy predicted early death. Results were similar for those with reduced and preserved left ventricular ejection fraction. L-dopa was started in 13 patients and tolerated by 8 patients; functional class improved and B-type natriuretic peptide declined after treatment.

Conclusions: With this treatment protocol, there were few HF admissions and patients were able to die at home. It can be used as a guide to therapy, or as an approach that can be tested with additional study.

 

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