The physical and psychological symptom burden in the dying heart failure (HF) patient is similar to that in the end-stage cancer patient. Symptoms includes: pain (78%), dyspnea (61%), depression (59%), insomnia (45%), anorexia, (43%), anxiety (30%), constipation (37%), nausea/vomiting (32%), fatigue, difficulty ambulating, and edema.

Symptom management
• Pain. Common causes: peripheral edema, arthritis, diabetic neuropathy, and post-herpetic neuralgia. NSAIDs are generally contraindicated because they antagonize the effects of diuretics and ACE inhibitors, promoting fluid retention while decreasing glomerular filtration and impairing renal function. Opioids are the agents of choice for nociceptive and neuropathic pain because of efficacy and potential to relieve dyspnea.
• Dyspnea. Reassess/optimize HF medications and assess for reversible causes, e.g. pleural/pericardial effusions, dysrhythmias, COPD exacerbation.
• Depression. Short-term psychotherapy can be helpful for mild-moderate depression. Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice because they preserve ejection fraction, lack hypotensive/arrhythmogenic effects, and have few drug interactions; sertraline in particular may be the agent of choice; psychostimulants may accelerate the treatment response to SSRIs.

Pharmacotherapy
Optimal drug use can improve symptoms and should be continued according to their problems / benefits ratio.
- Diuretic therapy (furosemide O, IV SC, and hydrochlorothiazide O or metolazone O) can be crucial, but diuretic resistance is common.
Inotrope IV therapy (dobutamine, milrinone, dopamine) has a substantial evidence of use and may improve symptoms, but with an increased risk of dysrhythmic death.

Accurate prognostication is virtually impossible in HF. This circumstance may provide a source to:
• Educate patients and families about the unpredictable, but usually terminal nature of HF, and the ever-present danger of sudden cardiac death.
• Establish specific goals of care (e.g. quality of life vs. length of life, living/dying at home vs. hospital)
• Assess options for achieving these goals (e.g. initiating/handling device therapies including when and how to deactivate, hospice vs. serial hospital/critical care unit admissions).
• Assess resuscitation preferences.

See reference for more information about pharmacotherapy.

Adapted from Reisfield GM, Wilson GR. Palliative care issues in heart failure. Palliative Care Network of Wisconsin. Fast facts and concepts #144. Internet. Accessed on December 27, 2018