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Palliative Care in End Stage Congestive Heart Failure

Congestive heart failure (CHF) is an inability of the heart to supply/pump blood to the body as it needs in normal. CHF is an acute illness and a chronic disease in which the passage of time may cause other physical and psychological diseases that poses a threat to the health of the patient, and may be the cause of life limiting (American Heart Association, 2010). This indicates the poor quality of life of the patient, exacerbating health problem. Hence, those patients need to attend palliative care to improve the quality of life.

Palliative care for CHF patient is very important to relive or prevent the pain which may be able to be cause physical problems such as (respiratory disorder and sleep disorder) or psychological problems such as (depression and anxiety). Palliative care is supportive care which provides physical support, psychological support, spiritual support and social support and that is to provide the best as much as possible to improve quality of life (Davidson, Macdonald & Newton, 2010).

How can you help and support Verner from the palliative care perspective?

From the case Mr. Verner has complaining from several problems related to his state of physical, psychological, social and spiritual. In the beginning I have to consider appropriate place of care either in hospital or at home if there is sufficient support in all ways (Patient UK, 2010). Then I'll start with him a comprehensive assessment for his situation from perspective of palliative care includes the physical and psychological, social, cultural and spiritual (existential). Mr. Verner has advanced heart failure or end stage heart failure where can be identified the stage according to Dunderdale, Thompson, Miles, Beer & Furze (2005) by the New York Heart Association (NYHA). In addition NYHA can assess a variety of the physical symptoms and restrictions. An important aspect of Mr. Verner management is communication and listening, exploring his understanding and feelings about his illness. Exploring concerns about the future can provide opportunities to discuss death and preferences for end of life care (Jaarsma et al., 2009). There are physical and psychological complications caused by CHF. For example Mr. Verner case: he does not sleep at night because he has trouble breathing, probably he has pulmonary congestion/pulmonary edema because according to (American Heart Association, 2010) pulmonary edema is one of the complications of CHF. So, medical intervention is needs in order to address the symptoms experienced by the patient, because medical care is very important to reduce patient stress and anxiety. Providing support through effective communication, skills may lift the moral of the patient. During communication I have to be honest and fidelity also in dealing with this patient must be show kindness, compassion and respect.

In order to helping Mr. Verner from the palliative care perspective I have to provide a good palliative symptom management, psychological, spiritual and social support will provide hope and reassurance. Emotional and social support is very important aspect for CHF patient. Where the presence of family, relatives and friends around of the patient would be a very strong supporter to improve the psychological status of the patient and reduce depression, anxiety, social isolation and loneliness (Jaarsma et al., 2009). I'll ask the provider of Social Work to communicate with family members to provide the counseling and patient needs from social services. Also the family members should be encouraged in participating with palliative care team to more improve in the physical care for the patient. Moreover, he may benefit from a referral to social services and district nursing. Liaison between his primary care team and the local palliative care team is strongly recommended and Mr. Verner could be given contact numbers for the palliative care services. Hospice care for further social support and respite may be beneficial.

Providing spiritual support is one of the important aspect of palliative care whether from family or from clergy, to encourage and support the patient to let him look to the future with optimism and live with his society and daily activities in comfortable manner until he dies (Becker, 2010).

Which problems and needs can you identify?

From the case it shows to me Mr. Verner suffering from physical and psychological problems which include:

Heart disease is the main cause of worsening of his situation and increase physical problems that are:

According to Scherer et al., (2005) lack emotional and social in patients with CHF makes the psychological problems in evolution as experienced by Mr. Verner:

Physical problems

Nausea,Vomiting

Vertigo all the day time

Decreased appetite

Lack of energy

Trouble breathing

Cough in night

Sleeping disorder

Psychological problems

Depression

Anxiety

Social isolation/loneliness

Hopelessness

Fear of death

Nursing diagnosis:

Decreased cardiac output related to decreased myocardial contractility.

Impaired gas exchange related to lung congestion resulting in trouble breathing and cough in night.

Nutrition imbalanced less than body requirements related to nausea and vomiting.

Fatigue related to lack of energy.

Disturbed sleep pattern related to trouble breathing.

Ineffective coping related to chronic illness (Berman, Snyder, Kozier & Erb, 2008).

Patient’s needs:

Information about the disease process, treatment and general advice on what to do and what not to do.

Physical support and managing symptoms to relieve/reduce suffering and improve general health for live comfortably.

Emotional support to reduce the psychological symptoms, where the presence of family around him will be a catalyst for this support.

Social services to provide equipment such as stair lifts, ramps, commodes and information about packages of care.

Enhance the care, improve quality of life and provide end life care with respect culture (customs and traditions), dignity, beneficence, sympathy and empathy.

Make a nursing care plan for Verner. Explain and motivate your suggested nursing interventions in accordance with the four key areas listed in the introduction.

Patient with end stage of heart failure may present with a variety of symptoms, which are similar to patients with advanced cancer (Matzo & Sherman, 2010). A detailed history, physical examination, investigations and establishment of patient priorities will help in the management of their symptoms and improvement of quality of life. An accurate drug history is important due to the nature of complex drug regimens. The difficulties of coping with unwanted drug side effects may cause patients to be afraid to report their non-concordance, which may precipitate hospital admission. Common physical symptoms are fatigue, pain, breathlessness, dizziness, cachexia, anorexia, nausea, insomnia, difficulty in walking, constipation (Jaarsma et al., 2009).

Communication skills are very important part in palliative care between palliative care team and patients and their families. There are small things, but significant that matter to the patient and family such as: a clean, well-pressed uniform; neat and tidy hair; an upright posture; a smile; appropriate eye contact respecting gender, age, culture or disability; a clear introduction of self and most important of all: an attitude that reflect my positive interest in them as a person (Becker, 2010). Also during communicating with the patient must repeat the information. It is possible because poor cerebral blood may lead to confusion and memory problems (Patient UK, 2010).

PHYSICAL SYMPTOMS

SYMPTOM CONTROL

Trouble breathing, Cough in night and Sleeping disorder

INTERVENTIONS (N) AND RATIONAL (R)

Initial

(N) Check vital signs, heart rate, blood pressure and respiratory rate depth. Observe if any wheezes and crackles in lung bases or edema.

(R) This assessment will be noting and presence of fluid in the lung with change in heart and respiratory rate (Lewis et al., 2007).

(N) Administer O2 and put patient on semi follower position.

(R) Over volume is increased in the heart failure patient so, it results in jugular vein distention and increased hepatojugular vein also (Morton, Fontaine, Hudak, Gallo, 2005).

(N) Control pain if any, discomfort feeling.

(R) Patients may experience chronic pain such as oedematous limbs or osteoarthritis, or as a result of previous heart surgery (Morton et al, 2005).

Ongoing Monitoring (N) Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status and urinary output (Berman, 2008).

Nausea, Vomiting, Decreased appetite and Lack of energy

(N) Encourage the patient to eat the liquid food use a small amount of alcohol.

(R) Could be good method to stimulate appetite and improving mood and general self esteem (Berman, 2008).

(N) (Dehydration) Observe skin or mucous membrane dryness and edema. ( Ongoing Monitoring ) Monitor urinary output.

(R) Occurs most often with CHF patients. Hypovolemia fluid shifts and nutritional deficits contribute to poor skin and edematous tissue (Morton et al, 2005).

Ongoing Monitoring (N) Help patient to do daily activities such as using a wheel chair.

(R) Patient needs to fully care of and need someone to help him in accomplishing daily activities at least to feel satisfied (Lewis et al., 2007).

The main symptoms related to the case that require specific interventions of the palliative care team

Causes and effects on CHF patient's

Managing symptom

Fatigue

CHF patient’s feel constantly tired and lacking energy. The main factors contributing to fatigue are: abnormalities in skeletal muscle due to reduced perfusion and neurohumoral changes; the side effects of medications; reduced activity; anaemia; lack of appetite and muscle wasting (Scherer et al, 2005). Fatigue causes reduced quality of life because it severely restricts patient’s activities and creates difficulties in walking and getting out of the house. In the end stages of heart failure even managing personal hygiene and dressing can be difficult. Fatigue can also compound other physical symptoms such as constipation, oedema and pain (Davidson et al., 2010).

Access to exercise programmes may be of benefit to reduce fatigue and can give patients greater sense of well being.

Explanation to the patient and his family about the physiological causes of fatigue can help them understand what they are experiencing and referral to occupational therapy of physiotherapy for advice on energy conservation and exercise can be useful. Education about healthy eating and correcting anaemia can also be beneficial (Jaarsma et al., 2009).

Breathlessness

Commonly caused by pulmonary oedema due to failing left ventricular function or sometimes due to anaemia. Other causes such as chest infection should not be overlooked. Anxiety, depression and inactivity can also contribute to breathlessness (Davidson et al., 2010).

Increasing diuretics is the first line treatment for breathlessness due to increasing congestion and providing by Respiratory Consultant. Home oxygen may be useful for patients with daytime low blood oxygen saturations. The use of breathing and relaxation exercises can help reduce the anxiety, which often accompanies breathlessness (Davidson et al., 2010).

PSYCHOLOGICAL (EMOTIONAL) SYMPTOMS

Causes and effects on CHF patient's

Managing symptom/ Management

Diagnosis of heart failure may make emotional stress. Depression, anxiety, social isolation and loneliness are common symptoms experienced by patient with end stage heart failure. The lack emotional and social support is an important predictor of morbidity and when patient become isolated and lack the ability to cope with his disease this can also be a significant predictor of mortality (Jaarsma et al., 2009). A patient's experience of depression is often compounded by their physical symptoms. Psychological symptoms are can reduce quality of life. Mr. Verner says: "I am not my disease", which can hinder hope for the future. From my experience when I give an opportunity to the patient as Mr. Verner condition, certainly will talk about dying. Fears of how he may die? How of pain?

Emotional support is important for the patient. Effective communication with patient and his carer is needed from diagnosis and throughout the course of the illness. To maintain hope, patients can be offered good palliation of their symptoms and exploration of their preferences for care. Information needs to be available about the disease process, common feelings experienced and local social support services. Referral to psychology services or counselors may be required and some patients may benefit from an antidepressant (Jaarsma et al., 2009). Tricyclic antidepressants are not usually advised due to their pro-arthymic side effects. Selective serotonin reuptake inhibitor antidepressants (e.g. fluoxetine 20 mg once daily) are more commonly prescribed (Morton et al., 2005).

SOCIAL AND FAMILY SUPPORT

Causes and effects on CHF patient's

Management

Social and family support is very important element, which engaging social services are a high priority may affect adversely on some psychological problems such as social isolation, loneliness and sadness etc. Specifically the social aspect may be involved in the following problems: financial status, capacity to self care, adherence with lifestyle and carer burden (Davidson et al., 2010).

Mr. Verner misses his children and grandchildren because he does not have energy to talk on telephone. And that make him in bad condition.

Social services to provide equipment such as stair lifts, ramps, commodes and information about packages of care; District nurses for assessment of symptoms and support. District nurses are often not aware of patients living with CHF until they become hospitalized; Community physiotherapy and occupational therapy for assessment and advice on exercise, energy conservation and home adaptations to aid in activities of daily living; Benefits advice patients may be eligible for disability or attendance allowance (Dunderdale, Thompson, Miles, Beer, & Furze, 2005).

And assist in communicating with family and give advice to family in order to be near Mr. Verner, even if the move to live with his children. The presence of family, relatives and friends around of the patient would be a very strong supporter to improve the psychological state of the patient and reduce depression, anxiety, social isolation and loneliness.

SPIRITUAL (EXISTENTIAL) SUPPORT

Spiritual support is an important aspect in palliative care. CHF reflected a gradual loss of identity and increased dependence and his illness make him incapacitate. Where it feel’s the burden on society and loses a sense of worth and meaning. Some patients have religious beliefs and feel comfortable than other patients who blame the Lord and say, Where is all this time? Why the God made me like this case? (Christian medical fellowship, 2011).

Spiritual support is provided by a clinically certified interfaith chaplain and a qualified by the palliative care team. And chaplain role in this is to restore hope and existential then make the patient to cope the reality (University of Iowa Hospitals and Clinics, 2011). And small things will make Mr. Thomas in happiness or make a huge difference, such as to bring his cat or a visit from a close friend or inspiration in art, poetry, music (Becker, 2010).CONCLUSION

Patients with CHF often experience a multitude of symptoms that affect adversely on their general health therefore it may happen to them to get sudden death. Participation with palliative care team is necessary to reduce the symptoms, provide the best as much as possible to improve quality of life and provide end life care with dignity. Nursing care plays an important role in the teamwork for patients with CHF, which can addressed with a variety of interventions, to relieve physical and psychological suffering, including treatment of pain, breathing difficulties and sleeping disorders. Communication is very important between palliative care team and patients and their families to adoption key work of care approach could improve patients’ access to appropriate palliative care. In addition, good communication between all those caring people for the patient in both primary and secondary care is essential. However, palliative care needs to be accessible early in the disease beginning because in the advanced stages patients may had worsened their health and then the team cannot provide the desired care. Finally I choose this case because I think the palliative care process as a practice in health part just for cancer patients but after dealing with Mr. Verner case I add to my nursing knowledge more specialized skills about the palliative care.


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