Congestive Heart Failure Palliative Care Indications

Are you evaluating a patient with end-stage heart disease?

Yes

Age of the patient

years

Unexplained weight loss in the past 6 months (enter 0 if none)

Has the patient experienced a decline in functional status with need for assistance in daily ADL?

Yes

Does the patient require high daily doses of a loop diuretic such as furosemide?

Yes

Resting heart rate

beats per minute

Does the patient have a persistent S3 gallop?

Yes

Has the patient had a ventricular fibrillation/tachycardia arrest ?

Yes

Does the patient have an implantable cardiac defibrillator?

Yes

Serum creatinine

Serum sodium

Serum albumin

Hemoglobin

Does the patient have a documented site of bleeding?

Yes

Worst NYHA status in the past year

Evaluation

Results

Please fill out required fields.

Interpretation and Description

References

Next Steps in Evaluation

Diagnosis

Therapy

Monitoring

Patient Concerns

Objective

ICD-10

Congestive Heart Failure Indications for Considering Palliative Care

Purpose: To identify a patient with end-stage heart failure who should be evaluated for palliative care based on the study of Davidson et al.