From the Guidelines
The most appropriate next step in managing this 79-year-old woman with multiple comorbidities presenting with respiratory distress, hypoxemia, and hypotension is to have a goals of care conversation, as her complex medical history and repeated hospital admissions suggest a need to reassess her treatment goals and priorities, considering her reduced ejection fraction, renal impairment, and other comorbidities 1.
Key Considerations
- Her severe symptoms, including respiratory distress and hypotension, require immediate stabilization with supplemental oxygen and careful fluid management.
- The patient's history of heart failure with reduced ejection fraction, severe COPD, and stage 2 chronic kidney disease necessitates a balanced approach to address her acute respiratory distress while considering her other comorbidities.
- The European Society of Cardiology Heart Failure Association position paper recommends considering palliative care throughout the heart failure trajectory, regardless of the stage of the illness 1.
- The patient's repeated hospital admissions and complex medical history suggest a need for a comprehensive management plan that includes discussions about her treatment goals, prognosis, and preferences.
Management Plan
- Supplemental oxygen should be titrated to maintain oxygen saturation between 88-92%, given her COPD history.
- Intravenous diuretics, such as furosemide, should be administered to address fluid overload from heart failure while closely monitoring her blood pressure and renal function.
- A limited fluid challenge of 250-500mL of crystalloid solution may be considered if hypotension persists after initial assessment, but must be done cautiously given her heart failure.
- Diagnostic workup should include arterial blood gases, comprehensive metabolic panel, complete blood count, cardiac biomarkers, chest X-ray, and ECG to differentiate between exacerbation of heart failure, COPD, or other acute conditions.
- Continuous hemodynamic monitoring is essential, and early consultation with cardiology and pulmonology specialists is warranted to guide further management decisions, including potential need for non-invasive ventilation if respiratory status deteriorates.
- A goals of care conversation should be initiated to discuss the patient's treatment goals, prognosis, and preferences, considering her complex medical history and repeated hospital admissions 1.
From the Research
Patient Assessment and Management
The patient is a 79-year-old woman with a complex medical history, including heart failure with reduced ejection fraction, severe COPD, stage 2 chronic kidney disease, diabetes mellitus, and a history of breast cancer. She presents with respiratory distress, hypoxemia, and hypotension, and has had multiple hospital admissions for similar symptoms.
Current Treatment and Response
The patient is currently receiving high-dose intravenous bumetanide and methylprednisolone. However, given her advanced age, multiple comorbidities, and recurrent hospital admissions, it is essential to consider her overall prognosis and goals of care.
Consideration of Next Steps
The following options are considered:
- Evaluation of a left ventricular assist device (LVAD)
- Oral sacubitril-valsartan
- Mechanical ventilation
- Goals of care conversation
Most Appropriate Next Step
Given the patient's complex medical history, recurrent hospital admissions, and current presentation, the most appropriate next step is to have a goals of care conversation. This is supported by studies such as 2, which highlights the importance of early discussions about goals of care in patients with serious illnesses. Additionally, studies like 3, 4, and 5 emphasize the need for palliative care and end-of-life planning in patients with advanced heart failure, including those with LVADs.
Key Considerations
When considering the next steps in management, it is crucial to:
- Assess the patient's prognosis and overall goals of care
- Consider the potential benefits and burdens of each treatment option
- Involve the patient and her family in the decision-making process
- Provide emotional and psychological support to the patient and her family
Palliative Care and End-of-Life Planning
Palliative care and end-of-life planning are essential components of care for patients with advanced heart failure, including those with LVADs. Studies such as 3, 4, and 5 highlight the importance of palliative care in improving quality of life, symptom management, and end-of-life planning. Additionally, 6 provides guidance on how to address potential problems with patients' expectations, plans, and decisions for the future.