Palliative care for heart diseases

When treating advanced heart failure, both treatment targeting the disease and palliative care aim to support the patient’s functional capacity and relieve the patient’s symptoms.

As our population ages, heart diseases become more common. While heart diseases are rare in people under 50, one in five people over 85 live with chronic heart failure. Heart failure is not an independent heart disease but a syndrome, and is always the result of heart dysfunction caused by another illness. In heart failure, the heart is unable to maintain circulation to the extent that the body needs.

Most patients with heart failure have had high blood pressure or coronary artery disease for a long time. Other common causes of heart failure include heart valve problems and various conditions affecting the heart muscle. Treating the underlying illness both with medications and, if necessary, with specific procedures is an important part of care for heart diseases.

Although advances have been made in preventing and treating diseases that lead to chronic heart failure, the condition is often incurable, especially in the very oldest population.

Most common symptoms

Unusual shortness of breath on physical exertion is the most common, and often first, symptom of heart failure. In severe heart failure, shortness of breath occurs during light exertion or even at rest. Shortness of breath that gets worse when lying down is typical in heart failure.

Swelling (oedema) in both legs combined with shortness of breath and weight gain may be indicative of developing heart failure, especially if the patient has a pre-existing heart disease. The build-up of excess fluid in the lung tissue causes shortness of breath, and sometimes a dry cough. Swelling in the liver tissue may cause a feeling of pressure in the upper abdomen. There may also be a build-up of excess fluid in the pleural sac around the lungs or in the abdominal cavity around the organs in the abdomen. As the illness progresses, the patient often becomes more and more prone to swelling, and sometimes large doses of diuretics (medicines that remove fluid) are needed.

If the heart’s ability to pump (ejection fraction, EF) is significantly reduced, blood pressure decreases and kidney function is weakened. The patient may experience dizziness, especially when standing up. In late stages of the illness, metabolic changes due to poor circulation may also cause confusion.

In severe heart failure, the patient may experience intense fatigue, pain, constipation, depression, anxiety, or dryness of the mouth.

Palliative care

Finding the cause

In the case of heart diseases, the aim is to find the cause and plan the treatment accordingly. The patient’s symptoms are reviewed, and the patient is examined thoroughly. Examinations such as laboratory tests, an electrocardiogram (ECG or EKG), and a chest X-ray are often needed as well. If the situation is unclear, a heart ultrasound (also called “echo”) may provide more information.

If the cause is identified as a condition that can be treated (such as coronary artery disease or a heart valve problem) and the proper procedure is done in time, interventions such as catheter procedures (angioplasty, valve procedures) or heart surgery (bypass surgery, heart valve surgery) may relieve or even remove symptoms caused by heart disease. If there are abnormalities in the electrical activity of the heart, it may be necessary to adjust medication or have a pacemaker fitted. If procedures that would cure the condition are not an option, the patient is treated with medications and the intent is palliative, with the focus on symptom management.

Treatment

Treatment of heart failure requires regular medication, self-management, and attentive follow-up. It’s advisable to avoid salt, alcohol, and smoking; some patients may be recommended to restrict the intake of fluids. Moderate physical exertion and exercise can also help improve the patient’s functional capacity and quality of life. If there is a build-up of fluid in the body cavities (pleura, abdomen), it’s possible to remove the fluid. The patient’s weight, blood pressure, heart rate, and kidney function should be monitored regularly. The patient should be taught to recognise the signs and symptoms of worsening heart failure. The attending physician makes treatment plans and adjusts medication based on this information.

Progression of illness

If the medication is appropriate and self-management is carried out as planned, incurable heart disease may remain stable for a long time, even for several years. However, the disease will eventually progress, and the symptoms will increase. As blood pressure decreases, so does kidney function, and the doses of heart medications that are otherwise appropriate often have to be reduced.

As the patient’s functional capacity decreases, the need for care increases, and there is more and more need for symptom management alongside heart medications. If necessary, shortness of breath and pain can be managed at home, using symptom-relieving medicines such as strong morphine-like pain medication (opioids), and if needed, anti-anxiety medication. If the patient is low on oxygen, oxygen therapy may be an option. Diuretics are often needed until the end of life.

Care planning

Those with a severe incurable heart disease should always be assigned a unit responsible for their care that the patient or their loved ones can contact at any time. The care should be comprehensive, and it should extend to the mental suffering related to illness, and to the patient’s loved ones. It’s advisable for the patient to think about what to include in a living will and to discuss it with their loved ones and with the attending physician sooner rather than later. With the help of advance care planning made in cooperation with the doctor, as well as home care and home hospital services, it’s more and more often possible to provide care at home, even if the illness is at an advanced stage.