Chapter 4: Palliative Care for Cardiac and Respiratory Disease
Palliative care for cardiac disease
There are a variety of different cardiac diseases for which a person may receive palliative care - including uncontrolled hypertension, atrial fibrillation, myocardial infarction, valve disease, cardiomyopathies and coronary artery disease. Generally, however, these conditions lead to heart failure. Heart failure is not a single disease, but rather a complex clinical syndrome of structural and / or functional impairment which results in the ventricles of the heart becoming unable to fill with and / or eject blood.
Nurses working in palliative care settings must recognise that patients with heart failure often experience complex comorbidities - including diabetes mellitus (often Type 2), renal disease, sleep-disordered breathing, obesity, pulmonary disease and depression. These comorbidities not only complicate the progression of heart failure, but they may also make its effective management in the palliative care setting more difficult. If heart failure is to be managed effectively, it is essential that a patient's comorbidities are also addressed.
Signs and symptoms of heart failure
A patient with heart failure may present with a variety of different symptoms, which are eventually unrelieved by medical intervention (signalling the patient's impending death). Patients typically present to palliative care settings with the following 'classic' symptoms of heart failure:
- Recent decreased exercise tolerance (e.g. due to dyspnoea and / or fatigue).
- Dyspnoea and orthopnoea. Fluid retention - particularly in right-sided heart failure.
- One or more of the following: abnormal heart sounds, abnormal electrocardiogram (ECG), arrhythmia, hypertension OR hypotension, thrombosis, chest x-ray showing cardiac enlargement, or an acute cardiac event (e.g. a myocardial infarction).
- Cachexia and malnutrition.
- Renal failure, due to decreased blood flow to the kidneys.
Patients with heart failure may also present with general symptoms of decline - such as pain, nausea, limited mobility (often with a history of falls), depression and / or anxiety, insomnia, constipation and loss of appetite.
In patients with heart failure, the following clinical indicators may also be used to predict the person's impending death:
- Recurrent emergency admissions and / or hospitalisations for related problems.
- Need for frequent or continuous intravenous therapy to control symptoms.
- Dependency, partial or complete, with activities of daily living.
- Loss of >10% of non-fluid body weight, often with cachexia.
- Cardiac arrhythmia, particularly if these are symptomatic or 'malignant'.
- Persistent low systolic blood pressure.
- A cardiac ejection fraction of <20%.
- Associated peripheral arterial disease.
- Episodes of syncope.
- Embolic stroke.
- Blood tests with albumin of <2.5g/dL, low sodium, increased blood urea nitrogen, troponin.
- Persistent poor quality of life.
Management of heart failure in the palliative setting
There are two key goals in the management of heart failure in the palliative setting:
- Identifying and treating reversible causes of decline
- Achieving control of symptoms.
Medication therapy is a mainstay in the management of heart failure in the palliative setting. The National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010: p. 18) guideline recommends "the use of angiotensin-converting enzyme (ACE) inhibitors and beta  blockers for first-line treatment" in all patients with heart failure.
As most cases of heart failure are chronic in nature, it is likely that patients in palliative care settings will have been taking ACE-inhibitors and -blockers for some time. It is important for palliative care nurses to check the types and doses of all prescribed medications for their appropriateness to the palliative care setting. Nurses must be aware that some medications may be reduced or even discontinued in patients receiving palliative care, in an attempt to decrease the associated negative symptoms and improve the patient's quality of life.
In addition to ACE-inhibitors and -blockers, there are also a variety of other medications which may be used to treat heart failure in palliative care settings. These include; diuretics, aldosterone agonists (e.g. spironolactone), hydralazine and nitrates and inotropic agents (e.g. dobutamine, digoxin).
Angiotensin-II receptor agonists, calcium-channel blockers (e.g. amlodipine), amiodarone and anticoagulants (including aspirin) are recommended for some patients with heart failure. Many medications - including anti-arrhythmic agents, calcium-channel blockers and non-steroidal anti-inflammatory drugs (NSAIDS) - must be used with caution in patients with heart failure, as they may increase a patient's cardiac risk and / or exacerbate their symptoms.
Palliative care involves assessing and managing a patient holistically - that is, as a whole person. It is important that nurses in palliative care settings consider a variety of other strategies when caring for a patient with heart failure at the end of life.
- Fatigue may be managed using a variety of strategies, such as responding to reversible causes such as anaemia, infection and obstructive sleep apnoea; treating depression; and promoting adequate rest cycles.
- Anaemia is a common problem in patients with heart failure; indeed, up to 50% of patients with heart failure may experience some degree of anaemia. Treating anaemia usually involves correcting reversible causes (e.g. nutritional deficiency, renal dysfunction, haemodilution, etc.).
- Skin care is an important consideration - particularly for patient with heart failure-related oedema and resulting skin ulcers and cellulitis. Compression stockings are often used in patients with severe peripheral oedema.
- Psychological care is crucial, as more than one-third of patients with heart failure may suffer anxiety and / or depression related to their condition.
- Exercise within the limits of their tolerance; this is generally considered a rehabilitative strategy, but in the palliative care context exercise can also help to improve and sustain a patient's quality of life.
- Vaccinated against influenza and pneumococcal disease, as patients with heart failure are likely to be immunocompromised and prone to infection.
It is important for nurses working in palliative care settings to clarify and document each patient's preferences and wishes whilst they are still competent to make choices about their care. The immediate end-of-life period for patients with heart failure can be distressing, particularly if the patient is acutely dyspnoeic. Often, opioids are administered to relieve a patient's dyspnoea by slowing the respiratory drive. It is common for patients and their families / carers to believe that opioids are given with the goal of hastening the patient's death, and it is important for nurses to provide reassurance that this is never the case.
Palliative care for respiratory disease
As with cardiac disease, there are a variety of different respiratory diseases for which a person may receive palliative care. All of these conditions lead to dyspnoea - or 'shortness of breath'.
In palliative care settings, dyspnoea is often accompanied by cough. As described above, dyspnoea is simply 'shortness of breath'. It may be due to a variety of causes - including those which impair pulmonary ventilation, circulation and / or gas exchange. In the palliative care setting, dyspnoea is generally due to; obstructed ventilation, restricted ventilation, reduced perfusion and interstitial disease.
As a patient's condition progressively declines, it is likely that dyspnoea will be provoked at lower and lower exercise thresholds. For example, initially a patient will experience dyspnoea only during exercise, then during activities of daily living (e.g. bathing, dressing, etc.), and eventually they may be dyspnoeic at rest. It is important for nurses working in palliative care settings to recognise that environmental factors - hot air, high humidity, environmental pollutants, anxiety, etc. - may trigger acute dyspnoea in patients with respiratory disease.
Management of terminal respiratory disease in the palliative setting
There are a number of goals for the management of a patient with respiratory disease and dyspnoea:
- Identifying and treating reversible causes of decline.
- Achieving control of symptoms.
As with end-stage cardiac disease, medication therapy is a mainstay in the management of respiratory disease in the palliative setting. One of a variety of different medications may be prescribed, including opioids, corticosteroids, phenothiazines, bronchodilators, benzodiazepines, and diuretics such as furosemide, etc. The type/s and combination of medication prescribed depends on the patient's clinical condition in addition to the symptoms they experience.
For patients who are hypoxic, the administration of oxygen via nasal prongs or a face mask may also be beneficial. Short-term oxygen therapy may be useful in increasing the tolerance of patients when they are completing exercise or engaging in activities of daily living. However, it is important for nurses working in palliative care settings to recognise that excessive oxygen administration can lead to hypercapnoeic respiratory failure in patients with some diseases, including COPD. Furthermore, although it is frequently prescribed, research suggests that if patients are not hypoxic, oxygen probably does not confer any physiological benefit - however, it may be reassuring for dyspnoeic patients.
Nurses working in palliative care settings must recognise that dyspnoea, both chronic and acute, can be one of the most distressing symptoms that a patient will experience. Patients with end-stage respiratory disease often describe feeling 'hungry' for or 'starved' of air, or that they are 'drowning' or 'suffocating'. Patients with dyspnoea often experience significant psychological comorbidity - such as anxiety and panic attacks. The psychological care of a patient with dyspnoea is therefore just as important as their physical care. There are a number of important psychological support strategies that nurses working in palliative care settings can use when caring for patients with dyspnoea; teaching coping skills, educating patients and their significant others, improving the patient's independence and improving the patient's social engagement, and supporting the patient's caregivers.
In caring for a patient with respiratory disease, nurses must also ensure that they prepare the patient for acute episodes of dyspnoea. This may involve the development of a written, stepwise plan for the management of dyspnoeic episodes. This plan must include all the coping strategies available to the patient, prescribed medications and their doses / frequencies, and emergency contact information. This plan can be used as a prompt for the patient and their family / carer / significant others during distressing episodes of dyspnoea.
A patient's dyspnoea often worsens significantly at the end-of-life. Dyspnoea which is severe and frightening should be considered a medical emergency. Opioids (with or without relaxant benzodiazepines) are often administered to relieve a patient's dyspnoea by slowing the respiratory drive. Sedatives such as midazolam may also be administered to relieve a patient's anxiety. In patients with pending respiratory failure, non-invasive positive pressure ventilation may also be administered.
In palliative care settings, dyspnoea is often accompanied by cough. Cough is (usually) an involuntary reflex characterised by the forced expulsion of air from deep within the lungs. In palliative care patients, poorly-controlled cough can be problematic for a number of reasons - particularly as it is associated with issues such as insomnia, exhaustion, musculoskeletal pain, urinary incontinence, anxiety and social isolation. Furthermore, paroxysmal cough - that is, a cough with deep inspirations and multiple forced expirations - may result in an acute exacerbation of dyspnoea in some patients.
In palliative care settings, cough is managed in one of a number of different ways. Medications which may be prescribed to patients with a problematic cough in the palliative care setting include; bronchodilators, anti-inflammatory medications, syrups and lozenges, expectorants, and antitussives.
In addition to medications, there are a number of other interventions which nurses may use in a palliative care setting to assist a patient to manage their problematic cough:
- Educating patients and their significant others. People may be taught about the environmental triggers for cough. Nurses should work collaboratively with allied health professionals - including occupational therapists - to assess and manage a patient's swallowing and aspiration risk (e.g. by providing thickened fluids.).
- Non-pharmacological treatments, for example, upright positioning, humidified air delivered via a nebuliser, chest physiotherapy and breathing techniques.
It is important for nurses working in palliative care settings to recognise that cough is often associated with haemoptysis, or the expectoration of blood. This is most often seen in conditions such as bronchogenic carcinoma and chronic bronchiectasis, as well as other diseases of the airways, lung parenchyma and pulmonary circulatory system, and systemic diseases resulting in impairments to the coagulation cascade. Although haemoptysis is often mild and transient, it may also result in major haemorrhage (typically when a cancerous tumour erodes into a major blood vessel). Aside from emergency surgery, which may or may not be beneficial, there is often little which can be done to manage major haemoptysis; usually, a patient will rapidly lose consciousness (i.e. within 1-2 minutes) before dying.
It is also important to note that many patients in palliative care settings - including those with respiratory disease, may experience ineffective cough. Ineffective cough results in an inability of the patient to clear secretions which accumulate in their upper airway; this increases the risk of dysphagia and aspiration. Nurses must assist patients with ineffective cough to maintain their airway - for example, through suctioning.
Cardiac and respiratory diseases are among the most common reasons that people in the United Kingdom (UK) will be admitted to palliative care settings; it is therefore essential that nurses working in palliative care settings are able to effectively care for patients with cardiac and / or respiratory disease.
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