Is it appropriate to discontinue furosemide (Lasix) for a patient with Congestive Heart Failure (CHF) transitioning to comfort care?

Discontinuing Furosemide in CHF Patients Transitioning to Comfort Care

Yes, furosemide should be discontinued for patients with CHF transitioning to comfort care, as it is not considered essential medication for symptom management in end-of-life care and may cause unnecessary discomfort. 1

Rationale for Discontinuation

• Guidelines for withdrawal of life-sustaining measures specifically recommend that all non-comfort medications, including diuretics, be discontinued when transitioning to comfort care 1
• The American College of Cardiology Foundation/American Heart Association guidelines make no recommendation about the routine use of furosemide to prevent congestive heart failure in patients transitioning to end-of-life care 1
• The primary goal in comfort care shifts from disease modification to symptom management, making diuretics like furosemide non-essential unless specifically needed for symptom relief 1

Potential Benefits of Discontinuation

• Eliminating furosemide reduces medication burden and potential side effects such as electrolyte disturbances, hypotension, and frequent urination 1
• Discontinuing non-comfort medications aligns with the palliative approach that prioritizes quality of life over disease modification 1
• Removing diuretics eliminates the need for frequent laboratory monitoring, which can be burdensome in comfort care 1

Managing Symptoms After Discontinuation

• If fluid overload symptoms (dyspnea, edema) become distressing after furosemide discontinuation:
  • Opioids are the first-line treatment for dyspnea in end-of-life care 1
  • Position changes (elevating the head of bed) can help manage orthopnea 1
  • If severe symptoms persist that significantly impact comfort, consider:
    • Low-dose subcutaneous furosemide as a rescue option for symptom control only 2, 3
    • Intermittent subcutaneous furosemide has been shown effective for managing volume overload symptoms in hospice patients when oral routes are ineffective 2

Special Considerations

• The decision to discontinue should consider:

  • The patient's current symptom burden from fluid overload 1
  • The patient's goals of care and comfort priorities 1
  • The expected prognosis and timeline 1

• If the patient has significant symptomatic fluid overload at the time of transition to comfort care:

  • Consider a short tapering period rather than abrupt discontinuation 1
  • Monitor for worsening dyspnea that may require symptom-directed interventions 1

Implementation Approach

• Discontinue furosemide along with other non-comfort medications when transitioning to comfort care 1
• Focus on symptom management with appropriate comfort medications (opioids for dyspnea, etc.) 1
• Ensure proper communication with the patient and family about the rationale for medication changes 1
• Document the discontinuation as part of the comfort care plan 1

Pitfalls to Avoid

• Continuing diuretics out of habit rather than for symptom management 1
• Failing to have a contingency plan for breakthrough fluid overload symptoms 2
• Not communicating medication changes to all members of the healthcare team 1
• Overlooking the potential for subcutaneous furosemide as a rescue option if severe symptoms develop 3