What is the recommended palliative care plan for a patient with Congestive Heart Failure (CHF) and Chronic Kidney Disease (CKD) stage three?

Palliative Care Plan for Patients with CHF and CKD Stage Three

A comprehensive palliative care approach should be introduced early in the care trajectory for patients with CHF and CKD stage three, focusing on optimizing symptom control, addressing treatment preferences, and improving quality of life while being responsive to dynamic changes in goals of care throughout the disease trajectory. 1

Core Components of the Palliative Care Plan

Symptom Assessment and Management

• Regular and periodic assessment of physical symptoms including pain, dyspnea, fatigue, edema, nausea, and depression should be conducted using validated patient-reported outcome measures 1

• For dyspnea management:

  • Optimize diuretic therapy (intravenous or subcutaneous administration may be considered within home or hospice settings) 1
  • Consider tolvaptan for severe congestion and hyponatremia 1
  • Morphine with an antiemetic (when high doses are needed) can effectively reduce breathlessness 1
  • Intermittent levosimendan in the ambulatory setting may be considered for patients on beta-blocker therapy 1

• For pain management:

  • Neuropathic pain should be treated with non-opioid medications (anticonvulsants, antidepressants) and opioids as needed 1
  • Tramadol, oxycodone, hydromorphone, and fentanyl can be provided orally, intravenously, or transdermally 1, 2

• For gastrointestinal symptoms:

  • Nausea can be managed with metoclopramide (caution with QT prolongation), promethazine, prochlorperazine, ondansetron, or benzodiazepines (caution with sedation) 1
  • Constipation should be addressed with laxatives, stool softeners, and osmotic agents 1

• For fatigue:

  • Address underlying anemia which is common in patients with CHF and CKD 3
  • Adjust medication dosages (diuretics, beta-blockers) and address comorbidities (consider iron supplementation) 1

Medication Management

• Consider deprescribing medications no longer conferring symptomatic benefit such as statins or antiplatelet therapies 1

• Optimize diuretic therapy and consider down-titrating beta-blockers in the face of worsening congestion 1

• For symptomatic hypotension, down-titration of both beta-blockers and renin-angiotensin-aldosterone system inhibitors may be necessary 1

• Engage with and support patients and families during the deprescription process 1

Advance Care Planning

• Systematically take into account patients' and families' supportive needs and preferences for treatment, especially in the terminal phase 1

• Execute advance care directives to improve documentation of treatment preferences, delivery of patient-centered care, and dying in preferred place 1

• Address preferences regarding resuscitation, emergency treatments, and issues related to the patient's specific clinical course 2

• For patients with implantable cardioverter-defibrillators (ICDs), discuss device deactivation options as part of advance care planning 1

Psychosocial and Spiritual Support

• Provide psychological support through open communication, cognitive behavioral therapy, and mindfulness-based stress reduction 1

• Address spiritual needs according to patient preferences 1

• Screen adult caregivers for practical and emotional needs and provide appropriate support 2

• Extend bereavement services to families up to one year after the patient's death 2

Integration of Palliative Care Services

• Introduce palliative care early in the disease trajectory, not just at end-of-life 1

• For patients with advanced CHF and CKD with refractory symptoms, consider formal palliative care consultation 1

• For patients with expected survival <6 months, timely referral to hospice can improve quality of life 1

• Ensure coordination between the heart failure team, nephrology team, and palliative care specialists using a shared care approach 1, 4

Special Considerations for CHF with CKD Stage Three

• Recognize the cardio-renal anemia syndrome where anemia, CHF, and CKD interact as a vicious circle, worsening each other 3

• Consider conservative management approaches for progressive kidney disease in older, frail patients with comorbid CHF, which may preserve function and quality of life with fewer acute care admissions 4

• Address the high symptom burden in this population, which is often greater than in patients with other chronic serious illnesses 5

• Be aware that patients with advanced kidney disease often experience greater intensity of care at the end of life compared with other chronic serious illnesses 5

Common Pitfalls to Avoid

• Delaying palliative care consultation until end-of-life, which can negatively impact patient outcomes 2

• Undertreatment of dyspnea due to concerns about respiratory depression from opioids 2

• Failing to address the multidimensional impact of advanced kidney disease and heart failure on patients 5

• Misconception that palliative care is synonymous with end-of-life care rather than an approach that can be integrated throughout the disease trajectory 1, 5