Marked symptoms of heart failure at rest despite maximal medical therapy.
Refractory heart failure requiring specialized interventions.

Management
Breathlessness: Consider possible causes of breathlessness other than heart failure, such as pharmacological and psychological causes.
Pharmacological management: Humidified oxygen / nebulized saline with bronchodilators / sublingual benzodiazepines, especially if element of anxiety / low-dose opioid.
Non pharmacological management: Breathing retraining / lifestyle adjustments / relaxation / complementary therapies.
Cough: Saline nebules. Cough suppressants: codeine, low-dose morphine. If an ACE inhibitor has been commenced recently and cough is also recent in onset, consider it as a possible cause.
Peripheral edema: May include arms and genitalia as well as lower limbs; diuretics are recommended.
Pruritus/dry skin: Aqueous cream + 0.5% menthol.
Dry mouth: May be due to oxygen therapy, medication, underlying oral thrush. Management: ice cubes / chewing gum / pineapple juice / oral balance gel.
Constipation: May be triggered by reduced intake of fluids and food, diuretics, immobility, and weak or strong opioids. May need stool softener, stimulant laxative, or a combination.
Cachexia and anorexia: For cachectic patients, a high-calorie, high-protein diet with no added salt may be beneficial. Patients may develop low cholesterol levels and in these circumstances statin medication should be discontinued. Consider referral to dietician.
Withdrawal of medication. As the patient’s condition deteriorates and their prognosis is reduced to weeks, it may be appropriate to consider stopping statin agents and warfarin.

Criteria for referral to specialist palliative care
Two or more of the following:
1. Advanced heart failure (New York Heart Association Grade 3 or 4 at discretion of health care team or cardiology team)
2. Anticipated last 12 months of life
3. Three admissions to hospital within the last 12 months with symptoms of heart failure
4. Physical or psychological symptoms despite optimal tolerated therapy (with or without deterioration in renal function)


American Heart Association recommendations
1. Meticulous identification and control of fluid retention.
2. Referral for cardiac transplantation in potentially eligible patients.
3. Referral of patients with refractory end-stage heart failure to a program with expertise in the management of refractory heart failure is useful.
4. Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage heart failure persist despite application of all recommended therapies.
5. Patients with refractory end-stage heart failure and implantable defibrillators should receive information about the option to inactivate defibrillation.

See reference for more information.

Hunt S, Abraham W, Chin H., Guideline update for the diagnosis and management of chronic heart failure in the adult. ACC/AHA American Heart Association. Circulation 2005;112;1825-1852. Internet. Accessed on December 22, 2010.