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

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