Ann is a 78-year-old woman who presents to her GP with acute confusion, fatigue, breathlessness and a history of falls. She has end-stage heart failure (related to inoperable mitral regurgitation and coronary artery disease), chronic kidney disease and atrial fibrillation. She is well known to the local cardiologist, a community heart failure nurse, her GP and local palliative care team. She lives alone but has a supportive family who visit when they can. She has had two recent admissions with exacerbations of her heart failure over the past 3 months.
Her current medications are:
Ann is admitted to her local acute hospital.
-
1. What are the possible causes of Ann’s worsening condition?
Show Answer
Correct answer:
- Exacerbation of heart failure
- Hypoxia
- Worsening renal function/biochemical abnormality, for example, hyponatremia
- Infection
- Intracranial bleed/space occupying lesion
-
2. What investigations might be helpful?
Show Answer
Correct answer:
- Vital signs including BP and oxygen saturation
- Delirium screen – bloods, urinalysis, sputum cultureli>
- CXR
- CT-head
Ann is found to have a urinary tract infection. Her INR is greater than 8. She is also constipated. The CT scan does not show any intracranial haemorrhage or space occupying lesion. Her renal function is stable. She is treated with oral antibiotics and laxatives with some improvement and is transferred to a community hospital for rehabilitation, and planning for discharge home.
However, over the next 2 weeks she continues to deteriorate. She is increasingly fatigued, eating very little, breathless, even at rest and spending most of the day in bed. Investigations reveal no reversible cause for her changing condition. Her blood pressure is low. Her INR readings are unstable.
-
3. What is the most likely diagnosis now?
Show Answer
Correct answer:
- Ann has entered the dying phase of her illness.
-
4. What issues do you now need to consider in caring for Ann?
Show Answer
Correct answer:
- MDT discussion to reach agreement in the diagnosis of the dying phase and explore likely prognosis.
- Communication with Ann (if appropriate) and her family.
- Review of any advance care plans, advance decisions to refuse treatment, preferences and wishes for place of care.
- Review of medications - stopping inappropriate medications, stopping candesartan and reviewing the dose of diuretic, given her low BP. With unstable INRs and requirement to monitor anticoagulation levels it may also be appropriate to discontinue Ann’s warfarin.Domperidone and omeprazole are likely to continue to benefit her symptom control as long as she is able to manage oral medications.
- Anticipatory prescribing of medications for managing symptoms in the last days of life.
- Resuscitation status; if appropriate, this may be communicated with Ann. The need for patients to be part of this discussion must be assessed on an individual basis. As part of communication with Ann’s family about her care in the last few days of life, the issue of resuscitation status should ideally be explored.
-
5. Ann does not have an implantable cardiac defibrillator (ICD), but some patients with heart failure may. What practical issues would need to be addressed if Ann did have an ICD?
Show Answer
Correct answer:
- Ideally the issue of deactivating Ann’s ICD would have been explored as part of earlier advance care planning discussions.
- Be aware of the local cardiology guidelines and contact details for de-activation of ICDs. De-activation of an ICD is usually performed by a cardiology physiologist in a hospital outpatient setting in a planned and timely way. Emergency, temporary de-activation is possible using a special magnet placed over the ICD device. De-programming will still be required once the person has died and removal may be necessary if cremation rather than burial is chosen.
