From the Guidelines
In this situation, I would recommend not initiating new treatments for the rapid atrial fibrillation in this 82-year-old female palliative care patient who is actively dying and not for escalation of care. The patient's current medication, Bisoprolol, should be continued at the current dose as it may provide some rate control, but adding new medications or increasing the dose is not advisable 1. The focus should be on symptom management rather than rhythm control, as the patient is nearing the end of life. If the patient is experiencing distress from palpitations or shortness of breath related to the AF, consider low-dose benzodiazepines like lorazepam 0.5mg sublingually or midazolam 2.5mg subcutaneously for comfort, as recommended by recent guidelines for palliative care 1. Some key points to consider in managing this patient's condition include:
- Maintaining good hydration if possible
- Ensuring the patient is positioned comfortably, typically with head elevation to ease breathing
- Prioritizing comfort and dignity rather than treating the arrhythmia itself
- Recognizing that new arrhythmias often emerge during the dying process and aggressive management may cause more discomfort than benefit, as highlighted in the 2024 ESC guidelines for the management of atrial fibrillation 1. This approach aligns with palliative goals of care, focusing on the patient's quality of life and minimizing unnecessary interventions.
From the Research
Patient Situation
The patient is an 82-year-old female with a diagnosis of not for Mets but for escalation, indicating a palliative care situation where the focus is on symptom management and quality of life rather than curative treatments. She has recently developed rapid atrial fibrillation (AF) and is currently on bisoprolol, a beta-blocker.
Current Medication and Condition
- Bisoprolol: The patient is already on bisoprolol, which is used for heart rate control in atrial fibrillation.
- Rapid AF: The development of rapid AF in this context may require consideration of heart rate control or rhythm control strategies.
Evidence for Management
Heart Rate Control vs. Rhythm Control
- 2: This study compared digoxin and bisoprolol for heart rate control in patients with permanent atrial fibrillation and found no significant difference in quality of life at 6 months. However, it suggests that decisions about treatment could be based on other endpoints.
- 3: This systematic review supports the use of bisoprolol for the treatment of supraventricular arrhythmias, including atrial fibrillation, particularly for rate control.
Considerations for Palliative Care Patients
- In palliative care, the focus is on symptom management and improving quality of life. The decision to intervene with medications or procedures should be based on the patient's symptoms, preferences, and prognosis.
- 4: While this study discusses various strategies for cardioversion in atrial fibrillation, the context is more applicable to patients where restoring sinus rhythm is a goal. For palliative care patients, especially those near the end of life, the benefits of such interventions must be carefully weighed against potential burdens.
- 5: This older study compared sotalol and bisoprolol for maintaining sinus rhythm after electrical cardioversion of persistent atrial fibrillation, finding them equally effective but with sotalol having more side effects. This may not directly apply to the current palliative care scenario but highlights the importance of considering the side effect profile of medications.
Decision Making
Given the patient's palliative care status and the development of rapid AF, the primary consideration should be symptom management and quality of life. Since the patient is already on bisoprolol, which is appropriate for heart rate control in AF, the decision to adjust medications or pursue other interventions (like cardioversion) should be based on the patient's current symptoms and whether these interventions would significantly improve her quality of life without undue burden.
- Key considerations:
- Symptom burden: Is the rapid AF causing significant symptoms that are impacting the patient's quality of life?
- Prognosis and goals of care: Are interventions aimed at controlling the AF aligned with the patient's overall goals of care and prognosis?
- Potential benefits and burdens of treatment: Would adjusting medications or pursuing cardioversion likely improve symptoms without causing undue side effects or burden?