Furosemide introduction

Clinical Guideline for the Prescribing and Administration of Furosemide via continuous subcutaneous infusion (CSCI) for Heart Failure Patients at End of Life

Dr Christina Radcliffe, Dr Karen Green

Scope of the Guideline

This guideline sets out the guidance for the assessment and treatment of patients with end stage heart failure who require subcutaneous furosemide at end of life.

The aim of treatment is to provide symptomatic relief.

Furosemide is the drug of choice after all other reversible causes of fluid overload are excluded e.g. uncontrolled atrial fibrillation, bradycardias, sepsis, thyroid disease, anaemia, significantly worsening renal function, and pulmonary emboli.

The guideline can be used in all settings e.g. hospital, hospice, care homes and community.


Prior to starting treatment, the patient and carers/relatives should be made aware that the aim of treatment is symptomatic relief only.

There should be an MDT consensus before initiating treatment.

Blood tests are not always helpful at the end of life but may be considered on an individual patient basis, particularly when increasing doses, or in patients at high risk of electrolyte abnormalities.

Sometimes patients may improve following treatment e.g. if deterioration is due to decompensated heart failure rather than dying, and therefore patient review will be required.


CNS: Clinical Nurse Specialist
CSCI: Continuous Subcutaneous Infusion
MDT: Multi-Disciplinary Team
NYHA: Class IV New York Heart Association Functional Classification
PO: Oral Medication by Mouth
SOB: Shortness of Breath
SC: Subcutaneous
SPC: Summary of Product characteristics


Decompensated Heart Failure

A sudden worsening of signs and symptoms of heart failure typically includes difficulty breathing, pulmonary and peripheral oedema, fatigue and pain.

NYHA Functional Classification

NYHA II no limitation of ordinary physical activity
NYHA II slight limitation of ordinary physical activity by dyspnoea, fatigue or palpitation
NYHA III marked limitation of less than ordinary physical activity by dyspnoea, fatigue or palpitation
NYHA IV severe limitations of physical activity, symptomatic at rest, mostly bedbound

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.