The Heart Failure Nurse Service

1. The Heart Failure Nurse Service Managing Patients with Left Ventricular Systolic Dysfunction in Tayside

2. The HFNLS • 3 Nurses • Tayside wide • Managing patients with LVSD who have had a hospital admission with heart failure or presented at clinic with unstable symptoms. • Aim: Promoting Patient Understanding of Their Condition Facilitating Self Management Symptom management Improving prognosis Co-ordinating End of Life Care

3. Self Management • Daily Weighing (to assess fluid retention) • Fluid restriction • Salt restriction • Symptom monitoring • Encouraging Medication Compliance • Managing and Pacing Activity • Management of Breathlessness

4. Symptoms • Common Symptoms • Breathlessness: on exertion, orthopnoea & PND • Ankle & Leg Swelling and/or Abdominal Ascites • Fatigue • Advanced Symptoms • Nausea (caused by gut oedema) • Breathlessness at rest • Itch (renal disease or liver congestion) • Cachexia and poor appetite • Hypoxic Confusion

5. Palliation of HF Symptoms We Have an Array of Proven Medications & Therapies • Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers • Entresto (Sacubitril/Valsartan) • Beta Blockers/Ivabradine • Duiretics: Loop and Thiazide • Aldosterone Antagonists • Digoxin • Cardiac Resynchronisation Therapy Device/ICD

6. End Stage Heart Failure • Frequent Hospital Admissions with decompensated HF • Symptomatic of Heart Failure with Poor response to Standard Heart Failure Medication (particularly high dose IV or Oral diuretics). • Reduction in Functional Capacity • Cardiac Cachexia • Symptoms of End Organ Disease (deteriorating renal function and or liver function)

7. Case Study 1 ICD Deactivation in End Stage Heart Failure 59 year old man, Extensive MI 1 Year previous, CRT-D in situ, Cachexic, Fluid overloaded, BP 82/64mm Hg, pulse 60bpm(paced), Functional Capacity very limited, Breathlessness & Anxiety. • Discussing End of Life, Advanced Care Planning. • Discussing ICD deactivation. • The practicalities: Where and When. • The alternatives (Magnet in the home with instruction). • The outcome a very peaceful death at home

8. Case Study 2 • Palliative Care Team Input 65 year old male, previous coronary artery bypass, Grossly fluid overloaded (no response to IV or oral diuretics). Breathless and nauseated because of gut oedema • Specialist Palliative Care Symptom Control Clinics (Nausea, Itch, Pain, Breathlessness) • Advanced Care Planning; Choice of Place of Death was Hospice • End of Life Care in Hospice a peaceful death achieved.

9. Team Work Is Necessary • Cardiology Team including Heart Failure Nurse • Renal Team • Palliative Care Team • General Practitioner • District Nursing Team • Carers • At end of life it is not possible to achieve a satisfactory outcome for the patient and family without advanced planning and team work. All of the above may have their role to play. At end of life the most important may well be the Team of Carer’s and the District Nursing Team.

10. In Summary • The Trajectory of Disease Progression in Heart Failure is uncertain. • Palliation of Heart Failure Symptoms is through optimisation of Medication/Devices and optimising the environment. • Discussions regarding end of life and defibrillator switch off need to take place in good time. • In latter stages advice may be required regarding medication for symptom control out with standard cardiac medication (Mirtazepine, Haloperidol, Oxycodone etc) • A team approach is required to bring about satisfactory care at end of life for heart failure patients.