Patients with advanced chronic heart failure (CHF) can experience 'revolving door' admissions, often for parenteral diuretics, when time at home is precious. Home intravenous diuretic services are patchy. This retrospective review describes 43 consecutive episodes of continuous subcutaneous infusion of furosemide (CSCI-F) in 32 advanced CHF patients; 28 episodes aiming to correct fluid balance and prevent hospital admission and 15 aiming to prevent symptoms in the dying. Overall, 26/28 (93%) avoided hospital admission. Weight loss occurred in 20/28 (70%): a median loss of 5.6 kg [interquartile range (IQR) 0.1-8.9]). The daily dose of furosemide ranged from 40 to 250 mg. The median number of days on CSCI-F was 10.5 (range 2-48; IQR 6-13.8). Site reactions occurred in 10/43 (23%); all of which were mild except two, one of which required oral antibiotics. Symptoms were controlled in all 15 dying patients. CSCI-F for patients with advanced CHF is effective in terms of weight loss and prevention of hospital admission with the heart failure nurse specialist playing a key overall management role in selection and monitoring. As the majority of community and hospice nurses have access to and are familiar with CSCI pumps, this practice should be nationally transferable. The role in the dying patient requires further assessment.

Primary thromboprophylaxis (PTP) is a Department of Health priority in England. The NICE guidelines agree that PTP is inappropriate in the dying patient, but should be considered for those with reversible pathology. In the light of continued variation and uncertainty in UK hospice practice, we assessed PTP prescribing in three hospices. Case notes were reviewed from consecutive patients admitted before (300 patients) and after (350 patients) implementation of the Pan Birmingham Cancer Network (PBCN) venous thromboembolism prophylaxis (VTE) prevention guidelines. Just under half (43%; 40%) of patients had a contraindication to anticoagulation and PTP. Whilst just under a tenth (8.6%; 8.7%) in each group had a temporary increased risk of VTE, considerably fewer (3.6%; 6.3%) had a temporary increased risk of VTE without contraindication to PTP. Patients receiving PTP increased slightly from 1% to 3.6% and documentation of PTP decisions increased from 5% to 81%. Whilst the PBCN VTE tool is a useful tool to tailor an approach for this complex patient group, many questions remain. Clinical trials that include patients with advanced disease with relevant outcome measures are needed to help inform the clinicians who care for them.

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