Transcript Co-Joint Management for a Heart Failure Patient at End of Life

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Supporting wellness and independence in
older people living with long term conditions
is the focus of these two days…however
There will come a time when we will need to
use our nursing skills and compassion, to
provide support and ensure a
dignified death
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Heart failure management is difficult with
periods of decompensation and periods of
relative stability.
How do we know when the end of life is
coming?
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When the tablets stop working
More frequent admissions to hospital
Possibly longer length of stay
Patient saying they have had enough
Quality of life deteriorating
This is the time to start talking to the Doctors
patient and family.
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Go back to your workplace
Identify patients who have an ICD in-situ
Where are they on the life continuum?
Is there a “Flag” highlighting that they have
an ICD ?
ICD’s save lives - death at some stage is
inevitable.
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Case study –A dignified death
ICDs –
How they work and save lives.
Controlled and emergency deactivation of the
shocking component
The WDHB Guideline on Deactivation
Cardiologist, GP, CNS Heart Failure
Hospice Nurse
Patient, wife and daughter
2012
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81 years old
Retired school teacher
Enthusiastic lover of life
Wanted to complete the “Bucket List” he and the
love of his life, his wife of 50 years, have
planned
First on his list …. to drive again!
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Dilated Cardiomyopathy Left Ventricular Ejection
Fraction 10-15% (normal 55%)
ICD inserted August 2011 for non sustained
Ventricular Tachycardia
Moderate to Severe Tricuspid Regurgitation
Permanent Atrial Fibrillation
Renal Impairment - Creatinine – 176-186
Starr Edwards Mitral Valve Replacement 1992
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14th-19 April 2005
Heart Failure
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8th - 10th July 2011
Heart Failure
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8th - 21st August 2011
VT, ICD implanted
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Breathless, Haematoma at ICD
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2nd - 6th Sept 2011
insertion site
15th - 16th Sept 2011
Attacks
15th - 30th Nov 2011
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31st Jan - 14th Feb 2012 Heart Failure
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Atrial Fibrillation and Panic
Heart Failure
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Daily contact
Titration of Diuretics
ACE had been stopped secondary to
hypotension
Weekly U&E's
Allowed to drive (no VT 6 months)
Cardiologist set clinical parameters
Intensive surveillance to maintain stability
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Physical deterioration- pt cachexic
More unsteady on feet – falls
GP and HF Nurse discuss deterioration
HF Nurse talks to Cardiologist about ICD
deactivation at some stage
Cardiologist advises treat symptoms
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Deterioration continues, sleeping a lot of day
Oedema difficult to stabilise
GP discusses referral to Hospice with Pt and
wife
Wife calls me crying
I make home visit. I sit on end of their bed and
we talk about death, dying and deactivation of
ICD - and bucket lists
He declined further admission
June 2012
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Meeting at pts home
GP, Hospice, Nurse, HF Nurse, Pt and Wife
Pt declines any further interventions
c/o increased abdominal discomfort and
dyspnoea
GP and Hospice Nurse organise relevant
medications to increase his comfort
HF Nurse to arrange home visit to deactivate
ICD – now imperative
No More Driving
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Home visit by HF CNS and Cardiology
Physiologist
Pt very anxious about deactivation process
Has had no underlying episodes of VT since last
check
ICD shocking component deactivated
This is a significant marker that end of life is
occurring -
Hospice team now leads, initiating appropriate
medications and support to pt, wife and
daughter
Pt passes away peacefully in his own bed at
midnight 17th June 2012
Wife and daughter present
RIP
Never to be forgotten
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