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.