Congestive Heart Failure

• What it is: CHF develops when the heart's pumping action is weakened or when the heart muscle becomes stiff, preventing it from filling properly. This reduced pumping efficiency means less oxygen and nutrients reach the body's organs, and fluid can build up in the lungs, legs, abdomen, and other tissues, leading to "congestion."
• Causes: CHF can result from various underlying heart conditions, including: 
  • Coronary artery disease (narrowed arteries to the heart)
  • Previous heart attacks (which damage heart muscle)
  • High blood pressure (forces the heart to work harder)
  • Heart valve disease
  • Cardiomyopathy (diseases of the heart muscle)
  • Diabetes
  • Arrhythmias (irregular heart rhythms)
• Progression and Symptoms: CHF is a progressive disease, meaning it tends to worsen over time.11 Symptoms can vary depending on which side of the heart is more affected and how severe the condition is.
  • Left-sided heart failure: Often leads to fluid buildup in the lungs (pulmonary edema), causing shortness of breath (dyspnea), especially with activity or when lying down, and a persistent cough, sometimes with pink, frothy sputum.
  • Right-sided heart failure: Causes fluid buildup in the body, leading to swelling (edema) in the legs, ankles, feet, and abdomen (ascites), and often weight gain from fluid retention.
  • General symptoms (can be from either or both sides): 
    • Fatigue and weakness: The heart can't pump enough oxygen-rich blood to the muscles.
    • Reduced exercise tolerance: Difficulty performing physical activities.
    • Rapid or irregular heartbeat (palpitations).
    • Frequent urination at night.
    • Nausea, loss of appetite, or feeling full quickly.
    • Confusion or decreased alertness (due to reduced blood flow to the brain).
    • Chest pain (especially if caused by coronary artery disease).

Hospice care for CHF is generally considered for patients in end-stage heart failure, where their condition is advanced, and symptoms are persistent and severe despite optimal medical management. The core criterion, as with other conditions, is a prognosis of six months or less if the disease runs its expected course.

Specific indicators often used to determine hospice eligibility for CHF include:

• New York Heart Association (NYHA) Class IV: This is a key indicator. Patients are classified as NYHA Class IV if they experience:
  • Symptoms of heart failure (e.g., dyspnea, fatigue, angina) even at rest.
  • Inability to carry on any physical activity without discomfort.
  • Increased symptoms with any physical activity.
• Optimal Medical Management: The patient must have been optimally treated with standard guideline-directed medical therapy for CHF (e.g., diuretics, ACE inhibitors/ARBs, beta-blockers) or have a documented reason why they cannot tolerate these medications. They should also not be a candidate for, or have declined, invasive procedures like heart transplant or ventricular assist devices (LVADs).
• Recurrent Symptoms and Complications: Despite optimal management, the patient exhibits recurrent, unmanageable symptoms or has had multiple hospitalizations for heart failure exacerbations within the past 6-12 months. These may include:
  • Persistent shortness of breath at rest or with minimal exertion.
  • Recurrent fluid overload/edema unresponsive to increased diuretic doses.
  • Recurrent chest pain/angina unresponsive to nitrate therapy.
  • Treatment-resistant symptomatic arrhythmias (e.g., ventricular arrhythmias, supraventricular tachycardia).
  • History of cardiac arrest or resuscitation.
  • History of unexplained syncope (fainting).
  • Brain embolism of cardiac origin.
• Functional Decline:
  • Progressive decline in functional status (e.g., decreasing Karnofsky Performance Status or Palliative Performance Scale score).
  • Increased dependence on assistance for activities of daily living (ADLs) like bathing, dressing, and eating.
• Co-morbidities: The presence of other serious conditions that further contribute to a limited prognosis (e.g., chronic kidney disease, severe COPD, diabetes with complications, liver failure, advanced dementia, or cancer).
   

While an ejection fraction of ≤20% can support eligibility, it is not an absolute requirement if other criteria strongly indicate end-stage disease. The ultimate decision requires clinical judgment from two physicians, considering the overall trajectory of the illness.

Hospice care for CHF patients is entirely focused on comfort, symptom management, and maximizing the patient's quality of life in their remaining time. The interdisciplinary hospice team works to address the complex physical, emotional, and spiritual needs of both the patient and their family.

Here's how hospice manages CHF:

• Symptom Control (Primary Focus): 
  • Dyspnea (Shortness of Breath): This is a primary and distressing symptom.26 Hospice nurses use: 
    • Oxygen therapy: To improve breathing comfort, even if oxygen saturation levels aren't critically low.
    • Medications: Opioids (like morphine) in low doses can effectively reduce the sensation of breathlessness. Anxiolytics (like benzodiazepines) can help reduce anxiety associated with breathlessness.
    • Positioning: Helping the patient find comfortable positions (e.g., propped up) to ease breathing.
    • Fan therapy: A small fan blowing on the face can provide a sensation of air movement and reduce feelings of breathlessness.29
  • Edema (Swelling): Diuretics are used to manage fluid buildup, aiming for comfort and reduction of swelling without causing dehydration or electrolyte imbalances.
  • Pain (Angina and other pains): Nitrates are used for angina, and other pain medications (opioids, NSAIDs) are used for musculoskeletal pain or discomfort from swelling.
  • Fatigue and Weakness: While not directly reversible, management focuses on conserving energy, assisting with daily tasks, and managing other symptoms that contribute to fatigue.
  • Nausea/Loss of Appetite: Anti-nausea medications and dietary modifications are used to improve comfort. The focus shifts from aggressive nutrition to comfort feeding, allowing the patient to eat what they desire in small amounts.
• Medication Management: Hospice nurses manage all medications related to the CHF diagnosis and other comfort needs. They ensure medications are taken correctly, monitor for side effects, and adjust doses as needed to optimize comfort. A "comfort kit" of emergency medications is often provided at home to manage acute symptom flares.
• Medical Equipment and Supplies: Hospice provides necessary equipment such as oxygen concentrators, hospital beds, wheelchairs, commodes, and incontinence supplies to support comfort and safety in the patient's home.34
• Personal Care Assistance: Hospice aides provide assistance with activities of daily living (bathing, dressing, grooming, hygiene), maintaining the patient's dignity and comfort.
• Emotional and Psychosocial Support: 
  • Counseling: Social workers and counselors address anxiety, depression, fear, and grief for both the patient and family.
  • Spiritual Care: Chaplains or spiritual counselors offer support consistent with the patient's and family's beliefs.
  • Caregiver Education and Respite: Caregivers receive training on how to manage symptoms, provide care, and cope with the demands of caregiving. Respite care offers short-term relief for caregivers.
• 24/7 Support: Hospice teams typically provide on-call support 24/7, meaning a nurse is always available by phone to answer questions or make a home visit if symptoms worsen unexpectedly, helping to prevent unnecessary emergency room visits and hospitalizations.
• Discontinuation of Unnecessary Interventions: The focus shifts away from aggressive life-prolonging treatments (e.g., frequent hospitalizations for IV diuretics, complex medication regimens that cause side effects) towards measures that purely enhance comfort.

By providing this comprehensive, holistic, and comfort-focused approach, hospice care helps individuals with end-stage CHF live their remaining time with the greatest possible dignity, peace, and freedom from distressing symptoms.