Thursday, September 15, 2005
AHA/ACC heart failure guidelines
The American Heart Association and American College of Cardiology have released their revised guidelines for the diagnosis & management of chronic heart failure (free full text .pdf here). There is a brief section at the end on end of life and palliative care for the heart failure patient. It is eminently reasonable & based, of course, on all "level C" evidence; it is also substantially longer than the 2001 guidelines section on end of life. A couple comments.... One is that the idea of inotropes for symptom relief for dying patients is being mentioned (both in the summary below as well in the longer text afterwards). Mentioned but not (yet) endorsed--but I wonder if in the next few years this will become an increasingly utilized (& hopefully critically studied!) intervention especially as it's more & more available in the outpatient and home settings. The other is to note this statement: "Physicians caring for these patients should become familiar with the prescription of anxiolytics, sleeping medications, and narcotics to ease distress during the last days." Perhaps it's careless language (& this language was in the 2001 statements) but one hopes the use of anxiolytics, sleeping medications, and narcotics to ease distress are not viewed as interventions reserved for the last days of people's lives!
Here are the summary Class I recommendations:
Class I
1. Ongoing patient and family education regarding prognosis for functional capacity and survival is recommended for patients with HF at the end of life. (Level of Evidence: C)
2. Patient and family education about options for formulatingand implementing advance directives and the role of palliative and hospice care services with reevaluation for changing clinical status is recommended for patients with HF at the end of life. (Level of Evidence: C)
3. Discussion is recommended regarding the option of inactivating ICDs for patients with HF at the end of life. (Level of Evidence: C)
4. It is important to ensure continuity of medical care between inpatient and outpatient settings for patients with HF at the end of life. (Level of Evidence: C)
5. Components of hospice care that are appropriate to the relief of suffering, including opiates, are recommended and do not preclude the options for use of inotropes and intravenous diuretics for symptom palliation for patients with HF at the end of life. (Level of Evidence: C)
6. All professionals working with HF patients should examine current end-of-life processes and work toward improvement in approaches to palliation and end-of-life care. (Level of Evidence: C)
