Table 2.

Management of various symptoms of advanced HF

  • Where possible, treat root cause of pain (eg, antianginal agents for ischemic chest pain)

  • For mild pain, prescribe acetaminophen

  • For moderate to severe pain, use opioids as first-line therapy; titrate dose for adequate relief

  • Avoid NSAIDs owing to possible fluid retention, GI bleeding, and renal failure

  • Consider complementary medicine options (eg, physical therapy, massage therapy, hydrotherapy, acupuncture, mindfulness meditation)

  • Remember that causes are multifactorial: volume overload, myopathy and cachexia, pain, dyspnea, sleep-disordered breathing, depression, anxiety, iron deficiency

  • Acknowledge fatigue and consider strategies for energy conservation

  • Using intermittent methylphenidate might be appropriate if tolerated; monitor BP and HR, but HF is not a contraindication to using methylphenidate

  • Remember that causes are multifactorial: dyspnea, anxiety, fear of dying in sleep, pain, sleep-disordered breathing

  • Recommend sleep hygiene practices

  • Using zopiclone might help but it increases risk of falls in older patients

  • Discontinue medications that might be causing nausea

  • Consider a 10-mg oral dose of domperidone 3 times a day or a 10-mg subcutaneous or oral dose of metoclopramide 3 times a day to improve gut motility

Anorexia and cachexia
  • Optimize HF therapy: ACEIs and carvedilol have demonstrated favourable effects on metabolism and cachexia26

  • High-energy nutritional supplements might be useful for malnutrition but there is no evidence that clinical outcomes are improved.26 Also, they can be very expensive for families

  • Avoid dexamethasone for appetite stimulation, as it promotes sodium and fluid retention

  • Prevention is important: use a stimulant (eg, senna) or an osmotic agent (eg, PEG 3350 in low quantity: 17 g in 250 mL of fluid) or a combination of both

  • Do not use fibre if patient is not able to drink sufficient fluid to keep stool soft. With insufficient fluids, fibre can be more constipating

  • Lactulose causes cramps and distention and is less favoured

  • Ensure laxative is included when opioids are prescribed for dyspnea

  • Use low-dose SSRIs as first-line therapy; however, they can induce fluid retention and hyponatremia if there is renal insufficiency. Onset of effect is 1–2 wk or longer, which is a disadvantage at the end of life

  • Recommend cognitive-behavioural therapy, spiritual support, mindfulness-based training, and dignity therapy; these interventions for depression in people with HF are not supported by RCT evidence27

  • Recommend interventions that might help enhance patient’s sense of control (eg, support groups, HF education)

  • For patients who do not respond to these interventions, consider short-acting benzodiazepines (eg, lorazepam); however, use caution when considering benzodiazepines for elderly patients

  • ACEI—angiotensin-converting enzyme inhibitor, BP—blood pressure, GI—gastrointestinal, HF—heart failure, HR—heart rate, NSAIDs—nonsteroidal anti-inflammatory drugs, PEG—polyethylene glycol, RCT—randomized controlled trial, SSRI—selective serotonin reuptake inhibitor.