Should diuretics be continued in patients with end-of-life (EOL) heart failure (HF)?

Diuretics in End-of-Life Heart Failure Management

Diuretics should be continued in end-of-life heart failure patients who have evidence of fluid retention to provide symptomatic relief, even when transitioning to palliative care. 1

Rationale for Continuing Diuretics in End-of-Life HF

Diuretics remain a cornerstone of heart failure management through the end-of-life phase for several important reasons:

• Rapid symptom relief: Diuretics produce symptomatic benefits more rapidly than any other heart failure medication, relieving pulmonary and peripheral edema within hours or days 1
• Unique role in fluid management: They are the only drugs that can adequately control fluid retention in heart failure 1
• Quality of life impact: Reducing congestion directly improves dyspnea, orthopnea, and peripheral edema - symptoms that significantly impact comfort and quality of life in end-stage heart failure 1

Evidence-Based Approach to Diuretic Management in EOL Heart Failure

Assessment for Continued Diuretic Therapy

• Evaluate for signs of fluid retention:
  • Jugular venous distention (most reliable sign)
  • Peripheral edema (legs, abdomen, presacral area)
  • Pulmonary congestion (rales/crackles)
  • Hepatomegaly 2

Diuretic Selection and Dosing

• Loop diuretics remain the mainstay:

  • Furosemide: 20-40 mg once or twice daily (most commonly used)
  • Torsemide: 10-20 mg once daily (better absorption and longer duration)
  • Bumetanide: 0.5-1.0 mg once or twice daily 1

• Dosing approach: Use the minimum effective dose to control symptoms of congestion while avoiding adverse effects 3

Monitoring Parameters

• Daily weight measurements
• Fluid intake/output
• Vital signs
• Clinical signs of congestion
• Electrolytes and renal function 1, 2

Special Considerations for End-of-Life Diuretic Management

Benefits of Continuing Diuretics

• Prevents distressing symptoms of fluid overload (dyspnea, orthopnea)
• Maintains patient comfort
• Reduces need for emergency interventions
• Improves quality of remaining life 3, 4

Potential Risks to Monitor

• Electrolyte abnormalities (particularly potassium depletion)
• Dehydration
• Hypotension
• Azotemia 1

Practical Management Tips

• Consider once-daily dosing to simplify medication regimen
• Adjust doses based on symptoms rather than strict fluid targets
• Balance symptom relief against side effects
• Monitor for signs of overdiuresis (hypotension, dizziness, thirst)
• Maintain electrolyte monitoring but with reduced frequency as appropriate for palliative goals 3, 4

Algorithm for Diuretic Management in End-of-Life Heart Failure

1. Assess for congestion: If present, continue diuretics; if absent, consider maintaining at lowest effective dose
2. Simplify regimen: Convert to once-daily dosing when possible
3. Monitor symptoms: Adjust dose based on dyspnea, orthopnea, and edema rather than strict volume targets
4. Balance comfort vs. side effects: Prioritize symptom relief over laboratory abnormalities unless causing symptoms
5. Reduce monitoring burden: Decrease frequency of laboratory monitoring as appropriate for palliative goals

While there are no long-term studies on diuretic effects on mortality in heart failure 1, the primary goal in end-of-life care shifts to symptom management and quality of life rather than survival benefit. Diuretics remain essential for managing the distressing symptoms of fluid overload that directly impact patient comfort in the final stages of heart failure.