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Community Heart Failure Service Palliative Care Pathway. Potential Triggers Subtle changes Cachexia Increased use of diuretics with poor response Nausea and vomiting Deranged liver function tests Worsening renal failure Increase in frequency of hospital admissions
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Community Heart Failure Service Palliative Care Pathway • Potential Triggers • Subtle changes • Cachexia • Increased use of diuretics with poor response • Nausea and vomiting • Deranged liver function tests • Worsening renal failure • Increase in frequency of hospital admissions • Refer to GSF Prognostic Indicators • www.goldstandardsframework.nhs.uk/content/gp_contract Patient with confirmed heart failure and known to Community Heart Failure nursing team Access to cardiology / medical consultant for specialist heart failure treatment • Heart failure nurse identifies patient with end stage heart failure with a palliative care need • Complex symptom control • Need help with living with uncertainty • Complex end stage management issues • Heart failure nurse instigates general palliative care measures with cardiology / medical team / GP • Optimise medical management of condition • Optimise symptom control • Address end of life issues – Review & start Advance Care Planning • Review preferred place of care • Discuss resuscitation status and liase with GP to document decision • If appropriate, discuss ICD deactivation liase with GP to document decision • Liaise with GP re: Gold Standards Framework & enrolment on Palliative Care Register • Liase with specialist palliative care services for complex palliative needs Consider referral to social services and fast track application for continuing care funding where appropriate Care Home with Nursing Hospice Home / Residential Home Hospital • Discuss with IPC team • Discuss with patient’s GP • Ensure resuscitation and ICD deactivation status is communicated and documented by GP • Referral to hospice according to their criteria • Ensure resuscitation and ICD deactivation status is communicated and documented by GP • Refer to IPC team • Refer to Hospice at Home • Inform the GP and any specialist nurses involved • Ensure resuscitation & ICD deactivation status is communicated and documented by GP • Discuss with cardiology / medical consultant to arrange a planned palliative admission Access Community Heart Failure nurses for heart failure symptom control advice or review if required Tel: 01273 265593 Fax: 01273 265596 Palliative Care Pathway for Community Heart Failure Service Version 1 May 2012
