[Monica Zilko]

Can anyone please tell we what to expect at the end of CHF - i am caring for a 75 year old lady, who i might add is lovely and knows she is dying.

She has been rated as end stage for 18 months now, but has gone down hill over the last 6 months. She is always sleeping, vomiting, and had severe SOB - she has oxgen in her house that she uses constantly. She is in so much pain (her feet and legs) uses morphone liquid and S/R tablets amongs other numerous medications. Her kidneys work off and on, has been hospitalised numerous times.

She says she knows the end is near and her doctor said that it would be a blessing if she passes in her sleeep because if she does not she will have a terrible death - can anyone elaborate on this, i just do not know what to expect.

Thank you

[earle58]

it's difficult to give a definitive answer since ea pt can present differently.
however, it is safe to say that in the absence of certain meds to make her comfortable, she will struggle to breathe.

i would certainly encourage this woman to receive hospice care immediately.

with peace,

leslie

[earle58]

another thought.
it 'sounds' like she is in the terminal phase of her disease.
this would be the time for the md to discontinue many of her meds.
it sounds like she needs an increase of her morphine as well.
as long as the aim of tx is to provide comfort, there is nothing illegal in prescribing too much morphine...
just in case this is what the md fears.
it's hard to advise you w/o knowing what she's taking in terms of meds and dosages.
but at this point, she needs the morphine (and ativan!) more than anything else.

leslie

[jmgrn65]

Lungs will probably fill up so in essence she will drown. Morphine as the op mentioned is very important. Breathing will obviously be very diffiuclt not just for the patient but for family to watch.

[Monica Zilko]

Thank you to both of you for replying.

She is receiving palliative care in her home, she does not want to be admitted in hospital anymore. While she is still taking medication for her heart the Dr has decreased the dosages. The morphone is oradine and also a slow release tablet that she has just been prescribed, she has been told to take oradine for breakthrough pain. Her feet are a bluish black colour and that is what causes her so much pain. The dr said she will be gone within 6 months and the main aim is to keep her as comfortable as possible. I would be assuming that as things get worse her care at home will be increased. Her SOB has become worse, even talking is an effort. Her kidney function has been up and down like a yoyo. At times she is very confused and disorientated.

I have listed some of her symptoms;

Shortness of breath (severe, even at rest – her colour in her face changes when she is bad a bluey purplish)
Vomiting (happens out of the blue with no warning and has contained blood once)
Constant runny nose with blood
Swollen tummy, her ankles and legs are not that bad now
Confusion and disorientation
Sleeps off and on most of the day
Very weak
Kidneys are failing
Liver is congested
Her appetite is up and down
Very constipated
She is just skin and bone with a big tummy
She is always very cold
She does have fluid on her lt lung, last time she was in hospital they did try to drain it (loculated)

I will let you know what medication/dosages she is on in my next post

As you can tell, i am very new to caring, the nurses that go to her house are wonderful and so very kind/

Any advice or information is appreciated.

[earle58]

oradine is NOT a type of morphine.
it is an antihistamine and is indicated for allergies.

i'm hoping the palliative care/hospice nurses are in the process of containing her symptoms through liberal use of morphine and anxiolytic.
also something to dry her secretions such as atropine, levsin drops or scopolamine.

also, when is the last time this woman had a bowel movement?
taking any narcotics, these pts need to be on a regular regimen, to prevent secondary and painful complications.
i'm also thinking this could be contributing to her nausea/vomiting.

it sounds much closer than a matter of months:
and am praying that she is getting the meds she needs.

leslie

[NRSKarenRN]

Found @ Medscape Nurses:


From Journal of Hospice and Palliative Nursing

Providing Palliative Care in End-stage Heart Failure

Posted 05/30/2008

Abstract

Heart failure, characterized by the inability of the ventricles to fill or eject blood, is a significant problem for patients and their families. This disease is characterized by periods of exacerbation and remission; patients must cope with the unpredictability and variability of symptoms. Classification systems for patients diagnosed with heart failure assist providers, patients, and families in understanding the chronic and progressive nature of heart disease. In the final stage, patients have refractory symptoms despite optimal medical therapy. At this stage, patients may benefit from hospice and palliative care. This article reviews essential points in the care of patients who are living with-and dying from-end-stage heart failure.

Palliative Care and Medication Use in End-Stage Heart Failure

A Palliative Care Approach to the Advanced Heart Failure Patient

Living with Advanced Congestive Heart Failure: A Guide for Family ...

Fast Fact and Concept #144: Palliative Care Issues in Heart Failure

[earle58]

Originally Posted by NRSKarenRN

Found @ Medscape Nurses:


From Journal of Hospice and Palliative Nursing

Providing Palliative Care in End-stage Heart Failure

Posted 05/30/2008

Abstract

while the link you provided is certainly worthy of consideration, i'm cringing at the thought of this woman being diuresed...
especially if she has hepatorenal syndrome, which is very common w/end stage chf.
even if she doesn't have it, lasix would be contraindicated w/arf or remarkable insufficiency.

my experience is nudging me towards the most basic and liberal usage of morphine, ativan, an anticholinergic for secretions (recognizing this will not help the fluid in her lungs) and if appropriate, stool stimulants.
if she is in the terminal phase, this would be the time to start withdrawing most meds, w/the focus being solely on comfort.

leslie

[jmgrn65]

Originally Posted by earle58

while the link you provided is certainly worthy of consideration, i'm cringing at the thought of this woman being diuresed...
especially if she has hepatorenal syndrome, which is very common w/end stage chf.
even if she doesn't have it, lasix would be contraindicated w/arf or remarkable insufficiency.

my experience is nudging me towards the most basic and liberal usage of morphine, ativan, an anticholinergic for secretions (recognizing this will not help the fluid in her lungs) and if appropriate, stool stimulants.
if she is in the terminal phase, this would be the time to start withdrawing most meds, w/the focus being solely on comfort.

leslie

I agree whole heartedly

[Monica Zilko]

I will get the full list meds/dosages.

As a carer, do i have the right to ask questions and make suggestions?