1. Heart Failure Services at STH: How it works and how End of Life issues are addressed Dr Soon H Song Consultant Diabetologist Acute Medicine Lead for STH Heart Failure Service Clinical Lead for Palliative Care Service in Diabetes/Endocrinology Directorate

2. STH Heart Failure Service Established in 2008 Joint multidisciplinary service between Cardiology and Acute Medicine Directorates Patients admitted with primary diagnosis of heart failure to NGH are triaged to Diabetes/Endocrinology teams Regardless of age including >85 years Transferred to Robert Hadfield 1 and 2 - dedicated heart failure wards General nurses trained in heart failure management Heart failure patients remain under the care of Diabetes/Endocrine consultants who will manage these patients

3. Heart Failure Team is notified of the patient admission Heart Failure Team (Specialist Nurses and Cardiology Consultants) will give input to the clinical management of heart failure Patients who require cardiological intervention will be taken over by cardiology team After discharge, patients will be followed up by STH or Community Heart Failure Teams Unique model – majority of heart failure patients (80%) under medicine and not cardiology, in contrast to other centres Outcome – heart failure mortality in general medical wards STH vs national 9% vs 13% NICE - an example of good model of care for heart failure

4. Palliative care in heart failure STH initiative to improve end of life care in non-cancer patients in hospital Prognosis in heart failure is poor Palliation often not adequately thought through or discussed with patient, relatives and GP especially advanced care planning Clear need to improve on end of life care in heart failure patients

5. Case study: DT 78 year old womannursing home resident Severe biventricular systolic impairment Chronic kidney disease stage 5 - eGFR 15 3 previous hospital admissions with chest pains and heart failure in last 2 months - negative troponin each time Readmitted with exacerbation of heart failure and peripheral oedema

6. Discussion with heart failure team very poor prognosis – 2 major organ failure (heart/kidney) little scope for further treatment escalation palliative symptom control to relieve breathlessness improving oedema not a priority palliative care team input Advanced care planning discussed with patient and daughters discussed prognosis - DNACPR established ceiling of care – symptomatic treatment only wish to avoid hospital admission to discuss with GP about future care hospital readmission vs care at home community palliative input

7. Challenges : Planning end of life care – advanced care planning Effective communication between hospital and GP ICE e-discharge summary – details of ceiling of care DNACPR status and discussion advanced care planning Establishing close links with community teams Importance of primary care team in this co-ordinating role Any facility for intravenous diuretics in the community? Managing patients at home and avoiding admission May be stating the obvious but it is a difficult goal to achieve!